Preoperative MRI shows benefit in men with prostate cancer, but use varies by race, region
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Preoperative MRI led to significantly fewer postoperative complications among men undergoing prostatectomy for prostate cancer, according to study results.
However, findings of the population-based retrospective study, published in Journal of Urology, showed marked variations in use of preoperative MRI according to geographic region, as well as race.
Rationale and methods
“Large academic centers have dramatically increased the use of prostate MRI in recent years and have achieved good outcomes both pre-biopsy and pre-surgery using MRI,” Alexander P. Cole, MD, assistant professor of surgery at Harvard Medical School and associate surgeon in the division of urological surgery at Brigham and Women’s Hospital, told Healio. “The problem is that studying MRIs is expensive, time-consuming and very technique- and radiologist-dependent. We did not know how good the outcomes are when we step back and look at the country as a whole, so we wanted to assess how MRIs are being used throughout the country and to assess their association with surgical outcomes.”
Cole and colleagues used SEER-Medicare linked data to identify 19,369 men (mean age, 70.2 years) undergoing prostatectomy for prostate cancer between 2003 and 2016. They characterized the proportion of men receiving preoperative MRI during each year and each hospital referral region, and then performed a two-stage instrumental variable analysis to assess the association of preoperative MRI with margin status, surgical complications and additional cancer-directed therapies.
Key findings
The proportion of men who underwent preoperative MRI increased from 2.9% to 28.2% during the study period and varied from zero to 28.8% across the different hospital referral regions.
Results of the two-stage instrumental variable analysis showed associations of preoperative MRI with lower odds of positive surgical margin (OR = 0.84; 95% CI, 0.72-0.97) and lower odds of blood transfusions at 30 days (OR = 0.56; 95% CI, 0.38-0.83) and 90 days (OR = 0.58; 95% CI, 0.41-0.84), but higher odds of further treatment (OR = 1.49; 95% CI, 1.32-1.7). Of note, almost twice as many white men underwent an MRI before surgery compared with Black men.
“MRI provides surgeons information about the prostate size, shape and the location of the cancer within the prostate gland,” Cole said. “Regarding the uptake of MRI, we know that this is an important tool for improving cancer outcomes but when we looked at the uptake of MRI, we found that the chance of receiving a preoperative MRI increased during the study period, but also varied substantially from region to region and according to race in the United States.”
Implications
This study supports what many surgeons have thought for a long time: Preoperative MRI helps improve surgical outcomes, Cole said.
“This makes sense because for most cancers, imaging is a critical tool for planning surgery. Prostate cancer was one of the few cancers where surgeons would proceed with surgery simply based on an exam and biopsy without having cross-sectional imaging of the organ they are removing,” he added. “If we have the option of an MRI before surgery, it probably will help a surgeon perform this surgery. What is also striking in this paper is that the chance of getting MRI varies significantly, so we still have a long way to go in terms of making sure men can receive this test.”
Cole said there is a lot of ongoing, exciting research in this area.
“These types of high-tech diagnostic tests, like prostate MRI, along with other forms of advanced imaging and molecular testing are routinely used in high-resource settings,” he said. “But we have a long way to go in terms of disseminating these tools in a way that is equitable and fair. This is where a lot of the next steps are going to be focused — we need to address the quality gap that we have identified in this paper.”
References:
- Cole AP, et al. J Urol. 2022;doi:10.1097/JU.0000000000002736.
- Preoperative MRI may lead to better surgical outcomes for prostate cancer patients (press release). Available at: https://medicalxpress.com/pdf574601402.pdf. Published June 16, 2022. Accessed July 6, 2022.
For more information:
Alexander P. Cole, MD, can be reached at apcole@bwh.harvard.edu.
Perspective
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Samuel C. Haywood, MD
MRI allows urologists to accurately view prostate anatomy, as well as the potential location and extent of prostate cancers. The increasing access and quality of this imaging modality over the past decades has improved biopsy accuracy and surgical planning.
Cole and colleagues demonstrated benefits of obtaining MRI prior to surgery. The results show significant increase in utilization of MRI over the study period. They proceed to associate the use of preoperative MRI with decreased odds of positive surgical margins (OR = 0.84) and blood transfusions (OR = 0.56 at 30 days). Taken together, these findings provide hard data that using MRI helps the surgeon with preoperative planning.
However, the authors also demonstrated that use of preoperative MRI is associated with increased odds of additional prostate cancer treatment within 12 months (OR = 1.49). This suggests that preoperative MRI may be associated with an overall package of cancer care with higher use of resources. Unfortunately, the study showed significant variation of preoperative MRI by both geography and race.
If the use of MRI and other technological resources translates into improved clinical care (eg, do higher-quality surgeons order more MRIs, or is the additional cancer treatment noted leading to improved outcomes?), this could exacerbate health care inequalities across prostate cancer treatment in our country.
Notably, since the study period, several trials have emerged showing the benefit of MRI prior to prostate biopsy. Combined with the trend in this study, we expect continued rise in the use of MRI. If preoperative MRI indeed translates into better surgery and is associated with improved care, then it is important that we as a field ensure that these advantages are equally available to all patients.
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