Intended for healthcare professionals


NICE recommends MRI for suspected prostate cancer to reduce biopsies

BMJ 2018; 363 doi: (Published 13 December 2018) Cite this as: BMJ 2018;363:k5290
  1. Jacqui Wise
  1. London

Men with suspected prostate cancer should be offered multi-parametric magnetic resonance imaging (mpMRI) to reduce the number of invasive and unnecessary biopsies, says draft guidance from the UK National Institute for Health and Care Excellence.1 The technology produces a detailed image of the prostate that will help clinicians decide whether a biopsy or subsequent treatment is needed.

Many hospitals already offer mpMRI, but a freedom of information request carried out for the charity Prostate Cancer UK earlier this year found that only half of men with suspected prostate cancer were being offered the scan before biopsy.

Currently, men with suspected prostate cancer are offered a blood test to look for raised concentrations of prostate specific antigen. If these are raised, men may be offered a biopsy, which involves inserting a needle numerous times to sample tissue across the prostate. However, biopsy can miss significant cancer if the section of the prostate where it is located isn’t sampled, and it carries a risk of serious infection. It can also be uncomfortable and unnecessary for men with low risk cancer.

The new draft guidance says that mpMRI scanning should be offered as a first line investigation for men with suspected clinically localised prostate cancer. This will not be replacing standard first line tests such as the PSA test, and people who are not going to have radical treatment should not be routinely offered the scan, the guidelines say.

Men for whom the scan results in a score of 1 or 2 on the 5 point Likert scale are not likely to need a biopsy, the guidance says, although it recommends that specialists discuss that decision with the patient.

NICE said that mpMRI will be cost effective as it will reduce the number of biopsies. In addition, cancers are more likely to be detected and identified earlier, so reducing the need for further treatment.

The incidence of prostate cancer in England was 40 488 cases in 2016, said NICE. From 1 April 2015 to 31 March 2016 in England 21 730 people with a new diagnosis of prostate cancer underwent mpMRI. Last year 15 243 transperineal template biopsies and 35 267 transrectal ultrasound guided biopsies were performed.

Paul Chrisp, director of NICE’s Centre for Guidelines, said, “This diagnostic method aims to improve survival, reduce unnecessary biopsies, and benefit both patients and the NHS in the long term.”

Heather Blake, director of support and influencing at the charity Prostate Cancer UK, said, “Now that NICE has endorsed this breakthrough diagnostic technique as being both clinically and cost effective, there should be no further delay in making sure all men can benefit from the increased accuracy of diagnosis it can provide.”

She added, “It’s vital that there is increased scanner capacity, training, and workforce so that all men can benefit from this guidance.”

The guidelines also recommend that all men with low risk, localised prostate cancer should be offered active surveillance as a treatment option, as well as radiotherapy or prostatectomy, with a compulsory mpMRI scan beforehand.

Another new recommendation is that radiotherapy for localised prostate cancer will be given at a lower dose over a shorter period of time, which has been proved to provide equal benefit with fewer visits to hospital. Men whose PSA levels are stable after prostate cancer treatment and have no complications should be offered a supported self management programme, the guidelines recommend.

The draft guidelines are out for consultation until 16 January 2019 and are expected to be finalised early next year.