Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance

doi:10.1016/j.urology.2019.02.037

Urology

Volume 130, August 2019, Pages 99-105

https://doi.org/10.1016/j.urology.2019.02.037 Get rights and content

Abstract

Objective

To characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. mpMRI has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established.

Methods

Using Surveillance, Epidemiology, and End Results registry data linked to Medicare claims data, we identified men with localized prostate cancer diagnosed between 2008 and 2013 and managed with active surveillance. We classified men into 2 treatment groups: active surveillance without mpMRI and active surveillance with mpMRI. We then fit a multivariable logistic regression models to examine changing mpMRI utilization over time, and factors associated with the receipt of mpMRI.

Results

We identified 9467 men on active surveillance. Of these, 8178 (86%) did not receive mpMRI and 1289 (14%) received mpMRI. The likelihood of receiving mpMRI over the entire study period increased by 3.7% (P = .004). On multivariable logistic regression, patients who were younger, white, had lower comorbidity burden, lived in the northeast and west, had higher incomes and lived in more urban areas had greater odds of receiving mpMRI (all P < .05).

Conclusion

From 2008 to 2013, use of mpMRI in active surveillance increased gradually but significantly. Receipt of mpMRI among men on surveillance for prostate cancer varied significantly across demographic, geographic, and socioeconomic strata. Going forward, studies should investigate causes for this variation and define ideal strategies for equitable, cost-effective dissemination of mpMRI technology.

Section snippets

Study Population

The SEER-Medicare data files were used to identify men with nonmanaged care Medicare coverage age 66 years or older, and localized prostate (International Classification of Diseases ninth Edition code 185) between 2008 and 2013. Methods for cohort identification closely adhered to prior work using SEER-Medicare data to study prostate cancer active surveillance.¹¹ We included patients 66 years or older who were continuously enrolled in Medicare Parts A and B during the 12 months prior and after

Results

We identified 9467 male Medicare beneficiaries diagnosed with prostate cancer and managed with active surveillance between 2008 and 2013. Of these, 1289 (14%) received mpMRI. The demographic, socioeconomic, and clinical information for the men in the prostate cancer surveillance cohort is summarized in Table 1. Overall, most of the men in the cohort were under 75 years, white, married, had low comorbidity burden, Gleason score 3 + 3, lived in higher educational attainment areas, higher income

Discussion

In this population-based study we characterize patterns of mpMRI utilization for men on surveillance for localized prostate cancer between 2008 and 2013. There are several key implications from this analysis. First, mpMRI was uncommon, with only 14% of men on surveillance receiving mpMRI. Second, the uptake of mpMRI in active surveillance was relatively slow with an increase of only 3.7% over the 5 years analyzed. Finally, use of mpMRI varied significantly across geographic regions and among

Conclusion

From 2008 to 2013, the use of mpMRI in prostate cancer active surveillance in the Medicare population increased incrementally, but significantly. The overall rate of mpMRI use was 14% and increased by a mere 3.7% over the 5 years analyzed. Receipt of mpMRI among men on surveillance for prostate cancer varied significantly across demographic and socioeconomic strata. This may represent provider uncertainty and access disparities and is a potential target for future work determining ideal

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Active Surveillance for Prostate Cancer: Expanding the Role of MR Imaging and the Use of PRECISE Criteria
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Imaging Utilization Patterns in the Follow-Up of Extremity Soft Tissue Sarcomas in the United States
2023, Current Problems in Diagnostic Radiology
This study aimed to describe patterns of imaging utilization after resection of extremity soft tissue sarcoma in the United States, assess for potential disparities, and evaluate temporal trends. A retrospective cohort study using a national database of private payer claims data was performed to determine the utilization rate of extremity and chest imaging in a 5-year postoperative follow-up period for patients with extremity soft tissue sarcoma treated between 2007 and 2019. Imaging utilization was assessed according to patient demographics (age, sex, race and ethnicity, and region of residency), calendar year of surgery, and postoperative year. Associations of demographic variables with imaging use were assessed using chi-square tests, trends in imaging use were analyzed using the Cochran-Armitage trend test or linear regression, and associations of postoperative year with imaging use were evaluated with the Pearson Correlation coefficient. A total of 3707 patients were included. Most patients received at least 1 chest (74%) and extremity (53%) imaging examination during their follow-up period. The presence of surveillance imaging was significantly associated with age (P < 0.0001) and region (P = 0.0029). Over the study period, there was an increase in use of extremity MRI (P < 0.05) and ultrasound (P < 0.01) and chest CT (P < 0.0001) and a decrease in use of chest radiographs (P < 0.0001). Imaging use declined over postoperative years (decrease by 85%-92% from year 1-5). In conclusion, the use of surveillance imaging varied according to patient demographics and has increased for extremity MRI and ultrasound and chest CT over the study period.
Which men with non-malignant pathology at magnetic resonance imaging-targeted prostate biopsy and persistent PI-RADS 3-5 lesions should repeat biopsy?
2022, Urologic Oncology: Seminars and Original Investigations
To assess predictors of clinically significant (cs) prostate cancer (PCa) in men who had a non-malignant Multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and persistent Prostate Imaging-Reporting Data System (PI-RADS) 3 to 5 lesions in subsequent mpMRI.
We retrospectively analyzed MRI-targeted biopsy database in three centers. Inclusion criteria: persistence of at least one PI-RADS ≥3 lesion found negative for cancer in a previous MRI-targeted plus systemic biopsy (baseline biopsy). Exclusion criteria: downgrading to PI-RADS 1-2. A logistic regression analysis was performed to estimate the predictors of csPCa.
Fifty-seven patients were included. Median interval between biopsies was 12.9(2.43) months. Median age was 68.0(12) years. Median PSA was 7.0(5.45) ng/ml. At follow-up, 24.6%, 54.4%, and 21% of patients had a PI-RADS score 3, 4, and 5 index lesion (IL), respectively. At re-biopsy, 28/57(49.1%) men were found to harbor PCa. Among these, 22(78.6%) had csPCa. csPCa was found outside the IL in only 2 patients. Eleven, 13, and 5 patients with PI-RADS 3, 4, and 5, respectively, had no cancer. Three patients with a PI-RADS 3 lesion had cancer (2 with Gleason score 3+3, 1 with Gleason score 3+4). 14/43 men with a PI-RADS 4/5 lesion harbored Gleason score ≥3+4 PCa. Logistic regression analysis found that PSA (HR 1.281, 95% CI: 1.013–1.619, P = 0.039) and IL size (HR 1.146, 95% CI: 1.018–1.268, P = 0.041) were the predictors of csPCa at re-biopsy.
Patients with non-malignant pathology from PI-RADS ≥3 lesions targeted biopsy should be follow-up with mpMRI, and those with persistent PI-RADS 4 to 5 lesions should repeat MRI-targeted and systematic biopsy.
Variation and Disparity in the Use of Prostate Cancer Risk Stratification Tools in the United States
2022, European Urology Focus
In this review we summarize evidence from US studies examining variation in the use of prostate magnetic resonance imaging (MRI) and tissue-based gene expression tests (genomic tests), focusing on sources of regional and racial variation. Large observational studies indicate that prostate MRI and genomic testing vary significantly at the regional level as measured across multiple geographic boundaries. Similarly, there is lower use of prostate MRI among Black versus White-identified patients Black in comparison to those who are White, as well as evidence of less use among Hispanic and Asian versus White patients. These findings indicate opportunities to address modifiable sources of practice variation in localized prostate cancer.
In this review, we found that use of prostate magnetic resonance imaging (MRI) scans and genetic testing differed by region, and race, with less prostate MRI use among Black versus White patients. These findings can help raise awareness about gaps in access to new prostate cancer tools.
Influence of Enema and Dietary Restrictions on Prostate MR Image Quality: A Multireader Study
2022, Academic Radiology
To evaluate the effect of enema and dietary restrictions on prostate MR image quality metrics and to assess inter-reader agreement for these metrics.
This retrospective study included 195 men divided into groups based on their compliance with preparation instructions before prostate MRI (Enema + Diet, n = 98; Enema, n = 42; Diet, n = 35; Control [no compliance], n = 20). Four readers independently assessed six image quality metrics on a 5-point scale. Between-group comparisons were made using Wilcoxon rank sum test. Inter-reader agreement was calculated using Fleiss’ kappa.
Compared with the Control group, image quality with respect to rectal stool/gas, distortion of diffusion-weighted images, overall image quality, and confidence in assessment was higher in the Enema + Diet, Enema, and Diet groups (p  < 0.05 for all comparisons). The Enema + Diet and Enema groups had significantly higher scores than the Diet group for rectal stool/gas (p < 0.001 and 0.005, respectively). The Enema + Diet and Diet groups had higher scores than the Control group for rectal peristalsis (p = 0.027 and 0.009, respectively), but there were no significant differences in motion artifacts on T2-weighted images. Agreement among readers was fair, with kappa values ranging from 0.25 to 0.37.
Enema and dietary restriction can improve the quality of prostate MRI by decreasing rectal distension and distortion of diffusion-weighted images and by increasing reader confidence in image assessment. Inter-reader agreement using subjective criteria for analysis of MRI quality is fair.
Cost-Effectiveness Analysis of Prostate Cancer Screening in Brazil
2021, Value in Health Regional Issues
Citation Excerpt :
The introduction of periodically MRI, however, has been supported in the literature,50-53 as seen in the National Collaborating Center of Cancer–National Institute for Health and Care Excellence (NICE) in the United Kingdom,54 with the advantage of more accurately monitoring PCa patients, despite a modest increase in spending.55 To date, there is considerable amount of published evidences of mpMRI benefits in the selection and monitoring of AS patients,56-59 but few studies supporting rebiopsy replacement by this imaging method.60,61 The present study was carried out in the city of Sao Paulo, the largest economic center in the country, reaching the population of the metropolitan region that covers almost 10% of the total Brazilian population (Brazil = 211 million inhabitants/Sao Paulo = 21.9 million inhabitants).28
Introduction: Prostate cancer is one of the most common malignancies among men worldwide. Prostate-specific antigen (PSA) screening shows uncertain benefits and harms from clinical and economic perspectives, resulting in an important impact on healthcare systems. Because of nonstandardized studies and substantial differences among populations, data are still inconclusive.
The objective of this study was to carry out long-term cost-effectiveness and cost-utility analysis on the PSA-screened population from the service provider’s perspective in the Brazilian population.
We performed a cost-effectiveness and cost-utility analysis using clinical outcomes obtained from 9692 men enrolled in the PSA screening program. Prostate cancer treatments, 5-year follow-up outcomes, and all related costs were examined. Data were compared with a nonscreened prostate cancer population to calculate incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). ICER and ICUR were compared with the Brazilian-established willingness-to-pay (WTP) threshold (WTP = R$ 114 026.55).
A total of 251 of 9692 men had a diagnosis of prostate cancer (2.6%), of which 90% had localized disease. Two hundred and five patients were treated as follows: surgery (45.37%); radiation therapy (11.22%); radiation plus androgen deprivation therapy (21.95%); active surveillance (13.17%); exclusive androgen deprivation therapy (7.32%); and watchful waiting (0.98%). Two simulated cohorts were compared based on screening and nonscreening groups. Values obtained were—ICER of R$ 44 491.39 per life saved and ICUR of R$ 10 851.56 per quality-adjusted life year (QALY) gained—below the Brazilian WTP threshold and showed cost-effectiveness and cost-utility advantages.
According to the Brazilian WTP, PSA screening is a cost-effective policy from a hospital and long-term perspective and should have more standardized studies developed in different populations and economies.

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: Funding/Disclosures: Mina M. Fam is supported in part by the Shadyside Hospital Foundation. Liam C. Macleod is supported in part by the Shadyside Hospital Foundation and in part by the Conquer Cancer Foundation. Bruce L. Jacobs is supported in part by the University of Pittsburgh Physicians Academic Foundation, P30CA047904 from the National Cancer Institute and the Henry L. Hillman Foundation.

: The other authors declare no conflict of interest.

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OncologyIncreasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Study Population

Results

Discussion

Conclusion

European urology

Eur Urol

J Urol

Urology

J Clin Epidemiol

Lancet

Does the introduction of prostate multiparametric magnetic resonance imaging into the active surveillance protocol for localized prostate cancer improve patient re-classification?

BJU Int

Incidental findings on multiparametric MRI performed for evaluation of prostate cancer

Abdom Radiol

INNOVATE: A prospective cohort study combining serum and urinary biomarkers with novel diffusion-weighted magnetic resonance imaging for the prediction and characterization of prostate cancer

BMC Cancer

Current beliefs and practice patterns among urologists regarding prostate magnetic resonance imaging and magnetic resonance-targeted biopsy

Urol Oncol

Small area variations in health care delivery

Science

Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project

Prostate Cancer Prostatic Dis

Variation in use of active surveillance among men undergoing expectant treatment for early stage prostate cancer

J Urol

National trends in active surveillance for prostate cancer: validation of Medicare claims-based algorithms

Urology

Oncology
Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance