Faculty Bibliography

PURPOSE: The purpose of this review is to summarize the available data about the clinical and economic effectiveness of MRI in the diagnosis and management of prostate cancer and to provide practical recommendations for the use of MRI in the screening, diagnosis, staging and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians with expertise in the diagnosis and management of prostate cancer evaluated the current published data regarding the use and effectiveness of MRI in the management of prostate cancer. For those clinical scenarios where adequate studies are available for analysis, recommendations are made on the basis of data; where such studies are not available; recommendations are made on the basis of expert consensus. RESULTS: At this time the data support the use of MRI for patients with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. The data regarding the utility of MRI for initial biopsy suggest a possible role for MRI in an initial biopsy in some circumstances. There is currently insufficient evidence to recommend MRI for screening, staging or surveillance of prostate cancer. CONCLUSION: MRI offers superior anatomic detail, the ability to evaluate cellular density based on water diffusion and blood flow based on contrast enhancement. MRI-targeted biopsy may increase the diagnosis of clinical significant cancers by identifying specific lesions not visible on conventional ultrasound. MRI adds cost to the management of prostate cancer. The clinical indications for the use of MRI in the management of prostate cancer are rapidly evolving.

BACKGROUND AND OBJECTIVE: Small kidney cancers are a heterogeneous group with varying malignant potential. Pathologic information obtained from a renal biopsy may guide decision-making for small kidney cancers. We sought to assess the effect of pathologic information from renal biopsy on the nonsurgical management of small kidney cancers in a population-based cohort of patients over 65 years of age. METHODS: In the Surveillance, Epidemiology and End Results-Medicare dataset, we identified patients >/=66 years diagnosed with a kidney cancer<4cm between 2002 and 2011. Diagnostic biopsy was defined by a Medicare claim within 1 month prior through 6 months following cancer diagnosis or before surgery. Nonsurgical management was defined by the absence of a claim for partial or radical nephrectomy or tumor ablation in the first 6 months following diagnosis. The relationship between patient and tumor characteristics and the likelihood of nonsurgical management by receipt of diagnostic biopsy was assessed by multivariable logistic regression models. RESULTS: From 8,933 patients, 2,782 (31%) had a diagnostic renal biopsy of whom 616 (22%) were managed nonsurgically. Controlling for patient, disease, and provider specialty, biopsy was associated with nonsurgical management (adjusted odds ratio = 1.61, 95% Cl: 1.43-1.82) in patients with low-grade tumors but also with more aggressive histology (clear cell renal cell carcinoma). Older age (85+) and geographic region were significantly associated with greater odds of diagnostic biopsy. Patients whose initial renal tumor diagnosis was made by a urologist (vs. other type of provider) were less likely to receive a biopsy (adjust odds ratio = 0.73, 95% Cl: 0.60-0.89). CONCLUSIONS: Although the use of renal biopsy has increased over time and is associated with the use of nonsurgical management of small kidney cancers, the use of the pathologic findings remains limited. Further advances, particularly with prognostic markers, are necessary before renal biopsy can be routinely implemented for treatment decision-making for small kidney cancers.