
Am Fam Physician. 2022;105(6):665-666
Author disclosure: No relevant financial relationships.

Test | Indication | Population and frequency | Cost* |
---|---|---|---|
Multiparametric magnetic resonance imaging | Risk stratification for targeted biopsy; active surveillance of low-risk prostate cancer | Patients 50 years or older with suspected or known prostate cancer, frequency of test varies | $275 to $444 |
Accuracy
The prostate imaging reporting and data system, second revision (PI-RADSv2) provides standardized interpretation and reporting of mpMRI.1 A score between 1 and 5 is assigned by a radiologist (1 suggests that a clinically significant cancer is highly unlikely, and 5 suggests that it is highly likely). In a systematic review of 21 studies including 3,857 patients, the PI-RADSv2 tool (using a threshold score of 3 or 4) had a pooled sensitivity of 0.89 (95% CI, 0.86 to 0.92) and specificity of 0.73 (95% CI, 0.60 to 0.83) for the detection of prostate cancer.4
Inclusion of mpMRI information into a multivariate risk-prediction calculator improves the accuracy of cancer risk assessment and can assist in shared decision-making regarding management options.5
Benefit
In a randomized controlled trial of 1,532 patients with prostate-specific antigen levels of 3 ng per mL (3 mcg per L) or greater, clinically significant prostate cancer was diagnosed in a similar percentage of patients who had mpMRI plus targeted biopsy as those who had TRUS-guided systematic biopsy alone (21% vs. 18%; risk difference = 3%; 95% CI, −1% to 7%). Additionally, clinically insignificant cancer was detected less often in the mpMRI plus targeted biopsy group compared with the TRUS-guided systematic biopsy group (4% vs. 12%; risk difference = −8%; 95% CI, −11% to −5%).7
A prospective cohort of 172 patients in whom cancer was suspected despite previous negative biopsies underwent mpMRI plus targeted biopsy and TRUS-guided systematic biopsy. Targeted biopsy detected clinically significant prostate cancer (Gleason score of 7 or more) more often than systematic biopsy (16% vs. 9%; P = .01).8
Harms
In 2017, the U.S. Food and Drug Administration started requiring a warning with gadolinium-based contrast agents because they may be partially retained in brain tissue for months to years after use.10 The only established complication of gadolinium-based contrast is nephrogenic systemic fibrosis, which affected up to 0.07% of patients with stage 4 or 5 chronic kidney disease in one large meta-analysis.11 The long-term consequences of gadolinium retention are otherwise unknown and require further safety studies.
Cost
Studies suggest that mpMRI could be cost-effective at $23,483 per quality-adjusted life-year, although this conclusion depends on the assumption that a negative mpMRI result could be used to safely avoid biopsy.12
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