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Backing Prostate MRI
Cincinnati radiologist and co-creator of ACR PI-RADS® continues to push for high-quality MR imaging for prostate cancer.
Aug. 28, 2024
Cincinnati radiologist and co-creator of ACR PI-RADS® continues to push for high-quality MR imaging for prostate cancer.
Each September, the medical community celebrates Women in Medicine Month, a time to acknowledge and honor the significant contributions of women to the field of healthcare. In observance of Women in Medicine Month and Prostate Cancer Awareness Month, the Bulletin talks to University of Cincinnati Professor of Radiology Sadhna M. Verma, MD, MBA, FSAR, one of the earliest proponents of using MR to evaluate prostate cancer, on the evolution of the technique, current prostate MR programs within the U.S. Department of Veterans Affairs (VA) and what’s next for prostate imaging.
During Prostate Cancer Awareness Month, the Bulletin talks to University of Cincinnati Professor of Radiology Sadhna M. Verma, MD, FSAR, one of the earliest proponents of using MR to evaluate prostate cancer, on the evolution of the technique, current prostate MR programs within the U.S. Department of Veterans Affairs (VA) and what’s next for prostate imaging.
At the Cincinnati Veterans Center, we were the first center, nationally, to have the MR ultrasound fusion biopsy device, where we can fuse our MRI scans to the ultrasound images to target cancer. That was almost 16 years ago now. So we’ve been at the forefront of prostate cancer care in terms of detection of clinically significant cancer.
Also, within the VA in conjunction with our urologist, we developed a comprehensive prostate cancer program. The VA has something called Veterans Integrated Services Networks (VISN), regional systems of care. These are partnerships between a group of VA systems to use shared resources. As the regional prostate cancer center of excellence, all patients in our VISN could be scheduled to receive prostate MRI as per clinical indications. These patients would be sent a prep prior to the MRI. They would also have transportation to the Cincinnati VA. So they’d come in all prepped and get the MRI and then the biopsy on the same day. It was quite an undertaking considering all of the logistics.
Our initiatives have expanded since that first comprehensive program, and we’ve been involved in consulting with other VA centers to help them develop and start a prostate MRI program. I’ve also done reviews for them, troubleshooting anywhere from acquisition of MRI and all the protocols, troubleshooting with reads, and discrepancies between pathology and imaging.
Our initiatives have expanded since that first comprehensive program, and we’ve been involved in consulting with other VA centers to help them develop and start a prostate MRI program.
What’s really cool about the VA is that it’s a very diverse population, and since everyone is contained within this VA group, you can easily study many issues. One of the biggest issues that I have been working on for a while now is the elevated risk for prostate cancer in the Black male population. The incidence of prostate cancer among Black men is 64% higher than among White men, and the mortality rate of prostate cancer is 2.3 times higher.
So it's important that we address this. It’s been suggested that lack of insurance may play a part in the higher risk. But in the VA system, everyone has insurance, so we can eliminate that as a variable.
The University College of London Group published a study last year. It was studying a prostate MRI exam for over 2,000 patients. The study authors used MRI to evaluate for prostate cancer as well as prostate-specific antigen (PSA) density to see if patients needed any other tests. In that group, almost half of the patients that had clinically significant disease did not have a high PSA. They found only 1 of 5 Black men opted to do MRI as opposed to non-Black men. This is an important aspect to consider — equitable access. A study in 2021 by the Harvey L. Neiman Health Policy Institute® also showed similar concerns.
Typically, when we do MRI, we include sequences to evaluate anatomy and some functional sequences, such as diffusion and dynamic contrast enhancement, that together creates the multiparametric exam. In 2019, the ACR first came out with Prostate Imaging Reporting & Data System (PI-RADS®), and I’ve been involved with that since the beginning. The new version, 2.1, includes very specific protocols as to how to do the diffusion and all of the sequences. In fact, most places globally are now using the PI-RADS protocol. What we are dealing with are issues of quality. Not all scanners are state-of-the-art, and older scanners cannot perform the diffusion the way we would like, so the quality of imaging is subpar. The ACR has been at the forefront with guidelines and quality, so the ACR’s initiative to create ACR Prostate Cancer MRI Centers of Excellence, where at least one accredited MR unit meets the minimum requirements for quality, is important.
I was planning to do women's imaging during my training at Johns Hopkins, and hardly anyone was doing prostate MRI then. When I started at the University of Cincinnati, I led the genitourinary (GU) tumor board, and I was surprised that imaging played no role in prostate cancer detection. Traditionally, prostate cancer workup involved PSA, digital rectal exam, and ultrasound-guided biopsies. Since ultrasound cannot detect prostate cancer, these were basically blind biopsies. Sometimes men with high PSA could get multiple biopsies and up to 20 to 80 cores during each biopsy session that would still be negative for cancer. Eventually, they could have one core positive for intermediate-grade cancer. Interestingly, many of the prostatectomy pathology specimens would either have low-grade disease when high-grade cancer was a concern or very high-grade cancer that was not known prior to treatment.
I started to research to see how imaging could help in prostate cancer detection, and I learned that only two academic institutions had publications on prostate MR. I started working remotely with physicists from the University of California San Francisco on using MR spectroscopy to image the prostate. I learned MR spectroscopy, but around that time there was a large ACRIN® trial on the use of prostate MR spectroscopy for prostate imaging that showed the technique totally failed. I learned that MR spectroscopy has to be done just right — with a trained technologist, physicist and physician lead. So at the GU tumor board, another urologist was interested, and he and I started this MR spectroscopy program at the University of Cincinnati. At first, we didn’t have any patients, but it grew with word of mouth. It went from two people showing up to a lecture at the Society of Abdominal Radiology to at RSNA 2–3 years later where I was wondering how I was going to get through a huge line to get coffee before my lecture on prostate MRI, and it turned out that was the line to get into my lecture!
Everyone needs to work in this space. Prostate cancer is the number one cancer in men and isn't going anywhere. The prostate sits very internally in the pelvis, and imaging can easily be affected by gas or bowel. The foundation of all of this is quality. We can only be as good as what we can replicate and need to do better with pathology. As it has happened in other cancer imaging such as in the breast, once imaging was available everywhere, quality became an issue that required government mandates. We’re working on how to establish that quality and be able to reproduce the same results at places besides just big academic centers.
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