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UPJ Insight: Diagnostic Imaging in Low-Risk Prostate Cancer: More Harm Than Good?
By: Justin Loloi, MD; Joshua M. Eccles, MD; Grant Owens, MD; Erik Lehman, MD; Matthew G. Kaag, MD; Jay D. Raman, MD; Suzanne B. Merrill, MD | Posted on: 01 Mar 2022
Loloi J, Eccles JM, Owens G et al: Diagnostic imaging in low-risk prostate cancer: more harm than good? Urol Pract 2021; https://doi.org/10.1097/UPJ.0000000000000288.
Study Need and Importance: Among patients diagnosed with very low-risk (VLR) and low-risk (LR) prostate cancer (PCa), there is significant overutilization of imaging at the time of diagnosis. This occurs despite American Urological Association (AUA) and National Cancer Comprehensive Network® (NCCN®) recommendations against routine use for staging. The potential consequences and impact of potentially unnecessary imaging in these LR patients are considerable, notably with respect to overuse of resources and the potential for incidental findings with resultant workup and treatment burden.
What We Found: Despite recommendations against its use, a majority of patients diagnosed with VLR and LR PCa underwent staging imaging at time of diagnosis. Not surprisingly in these patients, all bone scans and greater than 90% of computerized tomography scans did not reveal any significant PCa specific findings. Furthermore, magnetic resonance imaging noted few PCa significant findings. The table shows the imaging use for each risk category according to scan type and the significance of the findings.
Table. Imaging use according to scan type and significance of findings
| No. Computerized Tomography (%) | No. Magnetic Resonance Imaging (%) | No. Bone Scan (%) | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total No. | Normal | Nonurological Findings | Urological | PCa Significant | Normal | Nonurological Findings | Urological | PCa Significant | Normal | Nonurological Findings | Urological | PCa Significant | |
| AUA risk group: | |||||||||||||
| AUA VLR | 58 | 21 (77.8) | 0 (0) | 5 (18.5) | 1 (3.7) | 14 (40.0) | 0 (0) | 17 (48.6) | 4 (11.4) | 17 (85.0) | 3 (15.0) | 0 (0) | 0 (0) |
| AUA LR | 67 | 25 (78.1) | 3 (9.3) | 2 (6.3) | 2 (6.3) | 22 (46.8) | 0 (0) | 22 (46.8) | 3 (6.4) | 22 (88.0) | 3 (12.0) | 0 (0) | 0 (0) |
| NCCN risk group: | |||||||||||||
| NCCN VLR | 51 | 16 (76.2) | 0 (0) | 4 (19.0) | 1 (4.8) | 14 (43.8) | 0 (0) | 16 (50.0) | 2 (6.2) | 14 (93.3) | 1 (6.7) | 0 (0) | 0 (0) |
| NCCN LR | 74 | 30 (78.9) | 3 (7.9) | 3 (7.9) | 2 (5.3) | 22 (44.0) | 0 (0) | 25 (50.0) | 3 (6.0) | 25 (83.3) | 5 (16.7) | 0 (0) | 0 (0) |
Limitations: Our study is limited by its retrospective nature and relatively small patient cohort. Furthermore, we did not distinguish between imaging tests ordered at our institution or at a different institution. The specific indication for imaging was not captured, although we presume it was based on the diagnosis. In that regard, such observations plausibly depict real life practice habits commonly encountered by patients with PCa.
Interpretation for Patient Care: These findings offer insight into the potential overutilization of resources at time of diagnosis of LR PCa. By recognizing that overutilization of imaging occurs in these LR patients, we can explore underlying reasons and necessary education to decrease its occurrence.