Fusion biopsy: A view from the trenches

Like many U.S. urologists, I have been intrigued by the wealth of articles and presentations by urology’s academic leaders on the use of magnetic resonance imaging-ultrasound fusion targeted biopsies in prostate cancer. In fact, one of my goals at the 2016 AUA annual meeting was to learn more about this potentially game-changing technology.

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My conclusion? Jay Bishoff, MD, the proctor at a plenary session on fusion biopsy, nailed it when he stated that MRI fusion biopsy was the future of prostate biopsy; it’s just not quite prime time yet. The data behind its use in the setting of a rising PSA after a negative biopsy is impressive, but I’m unsure how a small practice justifies the six-figure cost when there is no reimbursement for it.

I also am not sold on its use on first-time biopsy patients, although I concede that the ability to get an MRI after the fact and then fit your biopsy tracts onto the image to see if you missed a suspicious area is fascinating. I also can see how a large, vertically integrated system such as a university would love the technology because if it increases the use of MRIs and increases the number of biopsy specimens being done, that certainly would defray the cost of the machine.

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As for me, I intend to follow the white paper that was introduced at the AUA (“MRI-Targeted Prostate Biopsy After Prior Negative Biopsy: An SAR-AUA Consensus Statement”), which allows for cognitive fusion to be used for now. If and when the AUA changes its opinion on the technology, I likely will too.

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On a different note, one of the more intriguing concepts that came out of my AUA courses on fusion biopsy was an attendee question at Eric Klein, MD’s course on new diagnostics for prostate cancer. The attendee asked if it was appropriate to move straight to definitive treatment simply based on a PI-RADS 5 lesion on prostatic MRI. I thought this was a great question because if the accuracy of prostatic MRI approaches 80% to 90% for clinically significant cancer in a PI-RADS 5 lesion, that is similar to the accuracy of a contrast-enhanced CT for renal masses and no one would fault me for removing a 5-cm enhancing renal mass without biopsy, would they?

So why can’t I remove a prostate for a PI-RADS 5 lesion on prostatic MRI? A question for my academic friends.