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FOCAL THERAPY Multiparametric MRI Fusion Prostate Biopsy and Cryoablation in Minority and Vulnerable Populations
By: Connie Wolf, MD, Denver Health Medical Center, Colorado; Ian McComb, PA, Denver Health Medical Center, Colorado; Fernando J. Kim, MD, MBA, FACS, Denver Health Medical Center, Colorado | Posted on: 09 Jun 2023
Prostate cancer is a prevalent cancer in men, and early detection and treatment are crucial for improved survival rates.1 Ethnic minorities, especially Black men, have a higher incidence of prostate cancer and are often diagnosed at a later stage, resulting in poorer outcomes. Therefore, early detection is particularly important for these populations.2 This article aims to discuss the importance of diagnosing prostate cancer, especially in ethnic minorities, and the benefits of outpatient MRI fusion prostate biopsy and targeted cryoablation treatment (TCT) resulting in fewer side effects from the treatment.
Prostate cancer diagnosis typically involves a digital rectal exam, PSA testing, and a transrectal ultrasound−guided biopsy. However, the transrectal ultrasound biopsy method can miss up to 30% of significant cancerous lesions, leading to underdiagnosis and undertreatment.3 In contrast, multiparametric MRI (mpMRI) can accurately detect and locate prostate cancer lesions, allowing for more precise and targeted biopsies. mpMRI involves a combination of T1- and T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement, providing a detailed visualization of the prostate and surrounding tissues.4
MRI fusion prostate biopsy is a technique that combines the use of MRI with real-time ultrasound imaging during biopsy. This method allows for accurate targeting of the suspicious lesions identified on the MRI, increasing the detection rate of clinically significant prostate cancer. Additionally, this method reduces the number of biopsy cores required, resulting in fewer complications and improved patient satisfaction.
TCT is a minimally invasive treatment option that involves the destruction of cancerous tissue using temperatures <20 °C.5 This treatment method has shown promising results in the management of localized prostate cancer, without the need of Foley catheterization after the treatment, and fewer side effects than traditional treatments such as radical prostatectomy or radiation therapy. Additionally, TCT can be performed in an outpatient setting, resulting in faster recovery times and reduced health care costs.
The use of mpMRI fusion biopsy and TCT can be particularly beneficial for ethnic minorities and vulnerable populations of patients who may not have access to newer technology or techniques, leading to underdiagnosis and undertreatment. In a study conducted from September 2022 to April 2023, 54 men underwent MRI fusion prostate biopsy and TCT, including 21 Caucasian, 16 Hispanic, 13 Black, and 4 Asian men (Table 1). Interestingly, the majority of Black patients had Prostate Imaging Reporting & Data System (PI-RADS) 3 lesions, while Hispanic patients had PI-RADS 4 or 5. Asian patients had a lower incidence of significant lesions, and Caucasian patients had a higher incidence of PI-RADS 4 and 5 (Table 2).
Table 1. Magnetic Resonance Imaging Fusion Biopsy Demographic, Insurance Status Data
| Overall (n=54) |
Black (n=13) |
Hispanic (n=16) |
Asian (n=4) |
Caucasian (n=21) |
|
|---|---|---|---|---|---|
| Age, mean±SD, y | 63.4±7.5 | 61.8±7.2 | 61.5±9.1 | 68.8±5.7 | 64.8±6.1 |
| Insurance status, No. (%) | |||||
| None | 1 | 0 | 1 (100) | 0 | 0 |
| Indigent | 5 | 3 (60) | 2 (40) | 0 | 0 |
| Medicaid/Medicare | 39 | 7 (18) | 12 (31) | 4 (10) | 16 (41) |
| Private | 9 | 3 (33) | 1 (11) | 0 | 5 (56) |
| BMI, mean±SD, kg/m2 | 28.4±4.7 | 31.1±5.3 | 28.9±5.0 | 24.2±1.2 | 27.1±3.7 |
| Abbreviations: BMI, body mass index; SD, standard deviation. | |||||
Table 2. Prostate Size, Prostate Imaging Reporting & Data System Scores, Gleason Score
| Overall | Black | Hispanic | Asian | Caucasian | |
|---|---|---|---|---|---|
| Prostate size, median (IQR), cm3 | 60.3 (12.4-326.5) | 51.5 (14.2-97.5) | 68.1 (12.4-326.5) | 68.4 (49.1-90.7) | 59.0 (18.4-118.9) |
| PI-RADS scores, No. (%) | |||||
| 3 | 3 | 2 (67) | 1 (33) | 0 | 0 |
| 4 | 25 | 7 (28) | 5 (20) | 1 (4) | 12 (48) |
| 5 | 18 | 2 (11) | 6 (33) | 2 (11) | 8 (44) |
| Gleason score, No. (%) | |||||
| 3 + 3 | 21 | 5 (24) | 5 (24) | 0 | 11 (52) |
| 3 + 4 | 8 | 3 (37.5) | 1 (12.5) | 0 | 4 (50) |
| 4 + 3 | 3 | 1 (33) | 2 (67) | 0 | 0 |
| 4 + 5 | 1 | 0 | 1 (100) | 0 | 0 |
| Abbreviations: IQR, interquartile range; PI-RADS, Prostate Imaging Reporting & Data System. | |||||
The use of targeted cryoablation focal treatment for PI-RADS 4 and 5 lesions in 1 setting can decrease the number of visits and anxiety of patients while waiting for pathology results. In this study, 6 patients (1 Caucasian, 2 Hispanic, 3 Black) had a simultaneous MRI fusion prostate biopsy and TCT. All patients had excellent patient satisfaction with no urinary incontinence, no Foley drainage, or change in sexual function (Table 3). Interestingly, 1 patient with PSA of 10.5 ng/mL and a Gleason 3+ 3, PI-RADS 4 lesion with extension beyond the capsule and perineural invasion. After TCT the patient had a reduction of PSA to 0.3 ng/mL and resolution of PI-RADS 4 lesion (see Figure).
Table 3. International Prostate Symptom Score, Quality of Life, and Erectile Dysfunction Before and After Targeted Cryoablation Treatment
| Overall | Black | Hispanic | Asian | Caucasian | |
|---|---|---|---|---|---|
| IPSS pre-TCT | 8 | 7.5 | 8.9 | 15 | 6.3 |
| IPSS post-TCT | 8 | 7.5 | 8.9 | 15 | 6.3 |
| IPSS QoL pre-/post-TCT | 2.3 | 2.2 | 2.8 | 3 | 1.7 |
| PSA preoperatively, mean±SD, ng/mL | 8.1±5.4 | 10.3±6.4 | 6.6±3.2 | 5.5±3.6 | 8.4±6.1 |
| Erectile dysfunction pre-TCT/post-TCT | 20/26 | 4/7 | 8/9 | 1/1 | 7/9 |
| Abbreviations: IPSS, International Prostate Symptom Score; PSA, prostate-specific antigen; QoL, quality of life; SD, standard deviation; TCT, targeted cryoablation treatment. | |||||
In conclusion, the use of mpMRI fusion biopsy and targeted cryoablation focal treatment can improve the accuracy of prostate cancer diagnosis and reduce the side effects associated with traditional treatments. TCT can be particularly beneficial for ethnic minorities and vulnerable populations of patients who cannot afford or have access to lengthier modes of treatment with longer recovery time. Future studies may demonstrate the advantages of simultaneous diagnosis and TCT treatment, resulting in decreased clinical visits, improved patient access and flow, and faster social and clinical recovery, ultimately leading to an improvement in the quality of life of these patients.
- Centers for Disease Control and Prevention. Prostate Cancer Statistics. 2022. Accessed April 12, 2023. https://www.cdc.gov/cancer/prostate/statistics/index.htm.
- Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2018. 2021. Accessed April 12, 2023. https://seer.cancer.gov/csr/1975_2018.
- Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003;349(3):215-224.
- Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging-Reporting and Data System: 2015, Version 2. Eur Urol. 2016;69(1):16-40.
- Maccini M, Sehrt D, Pompeo A, Chicoli FA, Molina WR, Kim FJ. Biophysiologic considerations in cryoablation: a practical mechanistic molecular review. Int Braz J Urol. 2011;37(6):693-696.
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