Improving Prostate Cancer Detection Using MRI-Targeted TRUS-Guided Biopsy

NCT ID: NCT02488096

Last Updated: 2020-01-21

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 40 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2015-12-31
• Study Completion Date: 2019-01-31

Brief Summary

The purpose of this study is to determine if using MRI can improve cancer detection by identifying potential cancer targets prior to TRUS-guided biopsy in populations that have previous inconclusive results from TRUS-guided biopsies.

Detailed Description

Accurately diagnosing clinically significant prostate cancer at a time when the benefits of treatment outweigh the harm continues to elude clinicians because of the complex nature of prostate cancer. When patients are found to have a high prostate specific antigen (PSA) blood test, an abnormal digital rectal exam, or they have prostate cancer but are delaying treatment (active surveillance), they are referred for transrectal ultrasound (TRUS) guided biopsy. The sensitivity of TRUS with 12-core biopsies is only 53-68% so cancers can be missed, particularly in the anterior region of the prostate. In some cases, TRUS can be used to rule out other causes of abnormal test findings, however the specificity of TRUS is also fairly poor making it difficult for a man to know for certain if he is cancer free. Unfortunately, biopsies also cause serious side effects including incontinence, bowel dysfunction, infection and pain. Increasing the number of cores taken during biopsy does not typically translate to better detection rates.

Magnetic resonance imaging (MRI) has much greater resolution than TRUS and can therefore, detect changes in the prostate more accurately. If conducted prior to a targeted biopsy, MRI can also reduce the number of cores taken compared to a standard biopsy (e.g. 2-4 cores vs. 12 cores), which could reduce biopsy side effects while simultaneously increasing detection of clinically significant cancer compared to routine 12-core biopsies and saving health care system dollars. Technology that combines MRI at the same time as biopsy (MRI-TRUS fusion biopsy) is increasingly being used, with some promising results. However, these techniques require expensive equipment and specially-trained personnel, and are more time-consuming and restrictive in when the procedure can occur. Utilizing MRI prior to a TRUS-guided biopsy could provide the same benefits in terms of cancer detection, but at a more reasonable cost and shorter wait-times as MRI alone can be done in a variety of settings and times.

If the results of this study demonstrate that MRI-targeted biopsy improves detection of clinically significant cancer over TRUS-guided biopsy alone, it would suggest that this protocol may be a more practical solution. Moreover, if the results show that MRI-targeted biopsy could reduce the number of cores taken without missing clinically significant cancers, the local biopsy protocol could be adjusted in the future to minimize unnecessary harm in these populations of men. In summary, this study will have practical merits in minimizing costs and patient morbidity associated with unnecessary prostate biopsies and treatments across Canada.

The primary objective of this study is to determine if using MRI can improve cancer detection by identifying potential cancer targets prior to TRUS-guided biopsy in populations that have previous inconclusive results from TRUS-guided biopsies.

The secondary objectives are to:

• Determine the sensitivity, specificity, positive and negative predictive value of MRI in predicting clinically significant prostate cancer
• Identify areas of the prostate that would benefit most from MRI
• Estimate Type 1 and Type II errors of using MRI-targeted biopsy samples compared to both MRI-targeted and standard 12-core.
• Estimate cost savings by using MRI-targeted biopsy samples only compared to both MRI-targeted and standard 12-core.
• Compare cost-effectiveness of using MRI prior to TRUS-guided biopsy compared to MRI-fusion biopsy used in other centers

This is a prospective, single institution randomized clinical controlled trial.. Participants will be randomized in a 1:1 ratio to one of the following groups:

1. Control Group: TRUS-guided systematic 12-core biopsy (standard care)

2. Experimental Group: prostate MRI later followed by systematic 12-core TRUS-guided biopsy + targeted biopsy of additional MRI-detected cores

Conditions

Prostate Cancer

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: DIAGNOSTIC
• Blinding Strategy: NONE

Study Groups

TRUS-Guided Biopsy

Transrectal Ultrasound (TRUS)-guided biopsy systematic 12-core biopsy (standard care)

Group Type: ACTIVE_COMPARATOR

TRUS-Guided Biopsy

Intervention Type: DEVICE

The standard care TRUS-guided biopsy is a schematic 12 core biopsy scheme with 2 cores taken from each of standard 6 zones. In some cases, the radiologist may take additional cores beyond 12 if suspicious areas are suspected from clinical findings or TRUS. TRUS-guided biopsies will be performed by a designated group of radiologists. An overall score out of 5 of likelihood of clinically significant prostate cancer will be recorded for each individual patient. The biopsy will be scheduled within 1 week of referral.

MRI + TRUS-Guided biopsy

Prostate MRI later followed by systematic 12-score TRUS-guided biopsy + targeted biopsy of additional MRI-detected scores.

Group Type: EXPERIMENTAL

MRI + TRUS-Guided Biopsy

Intervention Type: DEVICE

A designated radiologist will perform all MRI exams. The radiologist will identify locations of the prostate gland of the standard 12 cores to be taken and any additional lesions deemed to be suspicious for cancer.

The procedure for the MRI-targeted biopsy will be exactly the same as the TRUS-guided biopsy except that an additional 2 cores per area may be taken beyond the standard 12 cores in areas that were previously identified by MRI on the map. The systematic 12-core biopsy will always be performed first. The radiologist performing the MRI-targeted biopsy will review the MRI targets prior to the biopsy as per standard of care, and he/she will also perform the TRUS-guided biopsies for this group. Patients will be scheduled for their biopsy ~ 1 week after the MRI.

Interventions

TRUS-Guided Biopsy

The standard care TRUS-guided biopsy is a schematic 12 core biopsy scheme with 2 cores taken from each of standard 6 zones. In some cases, the radiologist may take additional cores beyond 12 if suspicious areas are suspected from clinical findings or TRUS. TRUS-guided biopsies will be performed by a designated group of radiologists. An overall score out of 5 of likelihood of clinically significant prostate cancer will be recorded for each individual patient. The biopsy will be scheduled within 1 week of referral.

Intervention Type: DEVICE

MRI + TRUS-Guided Biopsy

A designated radiologist will perform all MRI exams. The radiologist will identify locations of the prostate gland of the standard 12 cores to be taken and any additional lesions deemed to be suspicious for cancer.

The procedure for the MRI-targeted biopsy will be exactly the same as the TRUS-guided biopsy except that an additional 2 cores per area may be taken beyond the standard 12 cores in areas that were previously identified by MRI on the map. The systematic 12-core biopsy will always be performed first. The radiologist performing the MRI-targeted biopsy will review the MRI targets prior to the biopsy as per standard of care, and he/she will also perform the TRUS-guided biopsies for this group. Patients will be scheduled for their biopsy ~ 1 week after the MRI.

Intervention Type: DEVICE

Other Intervention Names

Transrectal Ultrasound Guided Biopsy; Magnetic Resonance Imaging + MRI-Targeted TRUS-guided Biopsy

Eligibility Criteria

Inclusion Criteria

• Referred for an ultrasound-guided prostate biopsy
• Indication 1: Men without a history of prostate cancer referred to the PAC for a biopsy who have a history of 1 negative biopsy who are being referred for a follow-up biopsy
• Indication 2: Men who have a history of diagnosis of prostate cancer and are currently on active surveillance under the care of an oncologist who are referred to the PAC for a follow-up biopsy

Exclusion Criteria

• Are unable to consent on their own behalf
• Less than 3 months since previous biopsy (to avoid inflammation and hemorrhage confounding MRI image)
• A history of treatment for prostate cancer (including surgery, chemotherapy or radiotherapy)
• Emergent/urgent biopsy referrals
• History of urinary tract infections or prostatitis in the last 3 months
• Contraindications to MRI:
• Ferromagnetic or otherwise non-MRI compatible aneurysm clips
• The presence of an implanted pacemaker or implanted defibrillator device
• Contraindication to receiving Gadolinium containing contrast for the which may include past or current kidney disease or injury or kidney transplant
• Severe claustrophobia

• Minimum Eligible Age: 18 Years
• Eligible Sex: MALE
• Accepts Healthy Volunteers: No

Sponsors

Saskatchewan Health Authority - Regina Area

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Jennifer St. Onge, PhD

Role: PRINCIPAL_INVESTIGATOR

Research, Regina Qu'Appelle Health Region

Ashok Verma, MB

Role: PRINCIPAL_INVESTIGATOR

Radiology, Regina Qu'Applle Health Region

Locations

Regina Qu'Appelle Health Region

Regina, Saskatchewan, Canada

Countries

Canada

Other Identifiers

REB15-27

Identifier Type: -

Identifier Source: org_study_id