He began by showing that research attending regarding prostate fusion biopsy has almost exponentially increased since the first published articles in 2002. There were 8 fusion biopsy platforms in 2015, and this has increased to over 12 platforms in 2019. He acknowledged that given the data regarding the efficacy of fusion biopsies and the sheer number of prostate biopsies performed globally each year, there is ample money to be made by the technology companies who market these devices.
He next showed the “hype cycle” a term branded by information firm Gartner which shows how a group regards a new technology (Figure 1). After a new technology is introduced, there is commonly an initial peak of inflated expectations about what the technology can offer. This is often followed by a period of disillusionment after it is realized that the technology cannot likely offer all that was initially hoped. As the technology matures, however, it reaches a plateau, which is somewhere in between the inflated expectations and any disillusionment. He applied this analogy to fusion biopsy devices, showing how technology has improved in the prostate biopsy, from initial digital-guided biopsies to transrectal ultrasound-guided (TRUS) biopsies, to improvements in technology for ultrasound-guided biopsies, to MRI-fusion biopsies.
Figure 1 – Hype Cycle
He reviewed results of the PROMIS trial which showed that utilization of MRI-fusion biopsies can improve the diagnosis of clinically significant prostate cancer over standard TRUS biopsy and improve the negative predictive value of biopsy.
Van Melick then discussed the three main types of MRI fusion biopsies: In-bore MRI fusion biopsy, MRI/US fusion biopsy, and cognitive fusion biopsy. Each modality has pros and cons to consider including cost, time required, learning curve, office-based versus hospital-based, and urologist-performed versus radiologist-performed. He then reviewed the data from the FUTURE trial comparing the three main types of fusion, which is admittedly limited, but shows that for clinically significant prostate cancer detection, none of the three methods appears to be superior. He discussed the limitations of the trial including the fact that it was underpowered, particularly for subgroup analyses. He reminded the audience that the brain is also a powerful fusion system and that cognitive fusion and MRI/US fusion may mutually benefit one another to increase accuracy.
He concluded that image-guided biopsies improve prostate cancer detection but require a high-quality MRI and an experienced radiologic interpretation. He believes that the search for the best targeting technique is ongoing, but that each of the techniques has pros and cons. He again stressed that he believes that MRI/US fusion and cognitive fusion likely work to improve one another. While he didn’t explicitly say so, it appears that he believes that the fusion biopsy devices are a true improvement, when used in the correct setting by an experienced operator.
Presented by: Harm van Melick, MD, PhD, FEBU, Urologist at St. Antonius Hospital Utrecht Nieuwegein, Nieuwegien, Netherlands
Written by: Brian Kadow, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.