Breaking news--and some cautions--on biparametric MRIs to avoid gadolinium and claustrophobia

Plus a reader survey on MRIs: The Elephant in the tube and other tales of the MRI.

By Howard Wolinsky

I have been advocating for a switch to biparametric MRIs to help patients like us avoid exposure to gadolinium contrast and its potential side effects, reduce tube time to lessen the risks of claustrophobia, and cut costs while increasing the capacity of MRI machines as we face a doubling of PCa cases by 2040.

I even managed in July to undergo my first prebiopsy MRI in eight years. These MRIs typically reduce tube time 45 minutes to 15, fast enough to help many of us avoid that closed-in feeling. Mine was a breeze—and results showed no lesions. I have only had lesions seen in a biopsy and an MRI 15 years ago as part of Active Surveillance.

Veeru Kasivisvanathan, MD, PhD, of University College London, London, England, and the lead researcher of the PRIME trial, said the landmark study shows that biparametric MRIs without contrast and multiparametric with gad contrast diagnose the same proportion of prostate cancers. That’s huge.

The PRIME study was published today in JAMA.

Kasivisvanathan told me in an exclusive interview for Medscape: “You avoid injection, avoid gadolinium, have a shorter scan, there is no risk of allergic reactions or rare side effects, such as systemic nephrogenic fibrosis.”

Todd Morgan, MD, chief of urologic oncology at the University of Michigan, in Ann Arbor, Michigan, said the study “makes a very strong case for moving toward biparametric MRI at centers where high-quality MRI is performed.”

(Michigan (Go Blue!) has switched virtually all of its AS patients to biparametric MRIs.)

But he noted in a JAMA editorial, “Biparametric Prostate MRI Is Safe and Effective if Image Quality Is Excellent,” with his colleagues from the University of Michigan, that there are some issues we patients face as we consider biparametric MRIs.

In an ideal world, all centers would easily adapt and perform excellent biparametric MRIs. But the reality is some centers do better than others in making MRI images, so, as Morgan et al. point out, some centers should continue with contrast. They’re not ready for PRIME time, right?

So high-quality images are a must for biparametric MRIs. GIGO: garbage in, garbage out.

I asked Morgan how a patient can learn a center's ability to perform high-quality biparametric MRIs.

He told me: “It's an important question, and really the answer is no different than gauging expertise with any aspect of clinical care--which is to say, it is difficult for patients to gauge this accurately. The best advice is to be seen at experienced, high-volume centers/practices and ask questions that help you (the patient) assess your own comfort level with that practice/provider. In the absence of public reporting of data, which is rare in the U.S., there is a lot of trust on the part of the patient that they feel they are being cared for by an expert team.”

Randall Jones, PhD/MBA, is an MRI researcher and founder and CEO of Bot Image Inc. in Omaha, which has developed AI interpretation of MRIs. He said the advantages of biparametric over multiparametric MRIs have been established over the past decade in radiology.

Jones said he expects the adoption of biparametric MRIs to be “very slow. My belief is that radiologists use DCE (dynamic contrast-enhanced imaging) as a crutch to help them diagnose - this is because the vast majority still lack a great deal of experience and biopsy feedback on how they are interpreting MRIs. Until the monetary aspect of their practice forces them to change, they will continue to be reluctant.”

Kasivisvanathan said he expects guideline writers to adopt recommendations favoring nonparametric MRIs.

Insurance companies are not expected to be an obstacle: bpMRI costs about $700 less than an mpMRI in the U.S.. Plus, avoiding an mpMRI contrast agent saves about $1,000 each in the U.S.

(See info below on the upcoming AnCan webinar with Dr. Jones.)

The Elephant in the Tube and other tales of the MRI: What you have to say about MRIs in a reader survey

(Image by Perplexity AI.)

At TheActiveSurveillor.com, we're bringing the realities of prostate cancer screening and monitoring out into the open. Recently, nearly 160 men with prostate cancer—mainly on Active Surveillance—shared details of their diagnosis, MRI experiences, and tips for coping with the anxiety and challenge of this vital scanning technology.

The MRI Journey: Purpose and Practice

For these men, MRI is central. Most commonly, MRI was used for pre-biopsy clarification and ongoing monitoring. The vast majority underwent multiparametric MRI (mpMRI)—once but no longer the gold standard scan with and without contrast—though a significant number received biparametric MRI (bpMRI), which omits the contrast agent gadolinium.

New Research: Is Contrast Always Needed?

Emerging evidence from recent extensive international studies, including significant work in the UK and at the University of Michigan, shows that biparametric MRI is noninferior to multiparametric MRI in detecting clinically significant prostate cancer. The PRIME trial and other recent head-to-head studies have confirmed that both approaches offer similar rates of cancer detection, sensitivity, and specificity, with no significant difference in false positives or biopsy recommendations. For many, this means avoiding contrast agents and reducing scan time to minimize risks associated with claustrophobia without compromising diagnostic accuracy.

Patients are not yet being offered the choice of a biparametric MRI. Only 5% of respondents said they were offered biparametric as an option.

Is organized urology ready for reform? The days should be numbered for most patients undergoing multiparametric MRIs. Time for the docs to wake up and smell the coffee, as my old colleague, advice columnist Ann Landers, used to say.

And patients need to ask for biparametric by name.

The Gadolinium Dilemma

Despite these advances, only 8% of respondents said they’d been explicitly offered biparametric MRI as a means to avoid contrast and potential gadolinium-related side effects. Notably, 32% remain concerned about potential side effects, highlighting a need for broader awareness of contrast-free alternatives now validated by the latest evidence.

Claustrophobia: The Elephant in the Tube

The most significant emotional hurdle wasn’t side effects, but claustrophobia:

• Nearly three-quarters of the participants denied any problem with feeling trapped inside the scanner.

• But 27% admitted to claustrophobia, and 3% (five men) had actually abandoned a scan. BTW, that’s almost double the national average of 15%. Are TAS readers more honest about fear and loathing of MRI tubes? This is a safe place.

I had a biparametric MRI this summer, my first MRI of any kind in eight years. The test found nada. I couldn’t even score a PI-RADS. Good news.

Read about my MRI adventures and mishaps and eventual success here: https://howardwolinsky.substack.com/p/part-ii-how-i-stopped-worrying-dismissed?utm_source=publication-search

Hard-Won Strategies for Coping

Asked for their “secrets” to surviving the MRI experience, this community delivered honest and creative answers:

• Medication: “Valium,” “Ativan,” and “Xanax” featured repeatedly.

• Sensory strategies: “Keep my eyes closed,” “Music, think about a movie, TV series or book.”

• Mental techniques: “Visualize sunning at a noisy beach,” “Count songs,” “Prayer and sing songs to myself,” “Mind over matter.”

• Physical tips: “Ask to go in feet first,” “Blanket for warmth,” “Wide bore MRI is better.”

• Humor and resilience: “Bare knuckle!!!” and “Man up guys. It's a painless diagnostic test.”

Many simply said: “Just relax. It doesn't take long.” Still, for some the noise and confinement were challenging—“I was terrified I would not be able to make it, but I found that the noise the MRI made was very musical... Each short test had a different song, and I spent the 40+ minutes in the tube singing along.”

Some guys who don’t have this problem ridicule those of us who do. It’s real so give us some slack. At Evanston Hospital, which is located outside Chicago, they don’t yet receive many requests for biparametric imaging. My hospital system offers to put men out who can’t tolerate the MRI experience. Yeah, it can be that difficult.

Techs at Evanston told me only 5% of patients ask for biparametric. Change is coming. At U Mich. (Go Blue!), multiparametric with 45 minutes to an hour in the tube has been replaced by about 20 minutes in the tube. The procedure eliminates $1,000 + in expenses for gadolinium and spares us from risks posed by deposition in the brain of gadolinium.

Technologist Ratings: High Marks

MRI techs got glowing reviews. A majority (43%) gave their MRI technologist a perfect “10” for professionalism and attentiveness, and only a handful expressed dissatisfaction. Techs can make a difference in this experience. I had one who I reported for torturing me at the University of Chicago. I call her Torquemada the Tech

Who Answered the Survey?

Survey participants reflected the spectrum of prostate cancer grades:

• Grade Group 1 (Gleason 3+3=6): 74 respondents

• Grade Group 2 (Gleason 3+4=7): 48 respondents

• Grade Group 3 (Gleason 4+3=7): 11 respondents

• Grade Group 4 (Gleason 4+4+): 9 respondents

• Unsure: 13 respondents

Nearly half fell into the most favorable category: Grade Group 1, regarded as "very low-risk." Some 78% of respondents are on Active Surveillance—close monitoring, rather than immediate treatment. Most (48%) have been on this watchful waiting path for one to five years, though a notable few have been under surveillance for more than a decade.

Final Thoughts: How to Make MRI Better

When asked how the MRI experience might be improved, participants highlighted the importance of:

• A high-quality sound system and music selection can help distract patients

• Clearer pre-scan instructions, especially for those with urinary or mobility issues

• Extra attention to temperature, with options for blankets and hats. I got a bolster to help me avoid back stress.

• More patient choice in scan type and comfort measures—especially in light of validated contrast-free MRI options.

• Empathetic, communicative technologists. I find it helpful for the tech to tell me how much time is left.

MRI is a high-stakes, high-anxiety experience for many living with prostate cancer, but open conversation and shared wisdom from those who have been there can make the difference between dread and resilience—now with growing confidence that less can sometimes be more, especially when it comes to the role of contrast agents in modern prostate imaging.

Some of your comments on your MRI experience:

I was suffering from BPH issues at the time and had to 'leave the tube' and urinate about 30 minutes in. Just a circus, and if I had known, I would have worn a pad. I don't know if this affected the scan, but the results were consistent with my biopsy. Yes, the MRI was AFTER the biopsy--that was another circus.

Temperature inside the tube is more important than temp. in the room. The fan in the tube can be cold. A cotton hat and a scarf cover it.

I had no challenges with the MRI procedure other than concern about the possible side effects of gadolinium.

Claustrophobic concerns were handled with Valium and the procedure was a breeze.

Provide a high-quality sound system and user choice of music

It seems I might be allergic to gadolinium as immediately after dosing I become exceedingly enraged for several minutes

Disappointed in the transcription - said I had "Fentanyl effacement" - my doc thinks it was an error in the voice-to-text software. No suspicious lesions found. Now I have to get them to change the report!

The big issue was reading the scan, I don't trust that all radiologists have the same level of skill.

Virtual reality goggles would be great!

Better hearing protection. If the noise level was significantly reduced, it would make the experience more pleasant and take away some of the claustrophobia issues. Yes earplugs were given, but they were inadequate.

It's "Mind over matter. If you don't mind, it doesn't matter."

Well, punk, do yah wanna live? The get on with it! (In your best Clint Eastwood accent!)

A little empathy for a few moments will help calm down nerves.

Look at it as an opportunity for a nice semi-nap!

If alternative approaches are available, such as biparametric, it would be helpful to have comparative information.

A list of questions and concerns that I may want to be aware of before an MRI, or any other procedure concerning prostate issues—biopsy, follow-ups, results, etc. A list of patients' rights....

Procedure was no big deal - results with pictures were made available to me within the week

Music readily available. (Why does each successive MRI seem worse than the previous one(s). You would think it gets easier, but it's the opposite.

Is the requirement to have an enema prior to the MRI standard?

The biggest issue for me is the use of the contrast material. I have concerns about the safety of it in my body, especially as I age.

Use Northwestern Med as the provider- almost all MRI machines are wide/ large bore.

Suggest some form of medication for anxiety if you think you need it.

My next MRI will be biparametric-discussed with my doc.

The report also listed PSA, but found out that came from a different doctor blood test done previously.

Bled for 3 weeks after transperineal biopsy ,,, will agree to MRI and PSA in the future.

No masks which limit the airflow around the face. It only increases the anxiety and panic if there is no cool fresh air to breathe.

Read up on the scan you're going to have and the procedure of the actual MRI scan before you go in.

Speak to the technician about issues.

I think an information video and a practice routine would help.

Explanation about the loud noise would be helpful. Too many of us have experienced poor headphones and volume control to deal with the loud noise. The issue of hearing damage never gets addressed. No one discusses the use of gadolinium, questions to ask and what to do after receiving gadolinium. Some are told to drink more water but mostly, there is nothing stated.

Was not offered feet first.

Guess I need to do some research into MRI contrasts and biparametric MRI. Maybe that will take my mind off the claustrophobia. :-)

I always like it when the tech talks to me with progress updates as the scan goes along.

Had an open MRI once, liked that better. I am 6'1" and weigh approx 250. I feel like a wiener in a hot dog bun!

I’ve had 3 MRIs, all with general anesthesia. Only one was for PCa.

It's a painless diagnostic test. Get over it guys. It can help you avoid a biopsy and surgery.

The next time I have an MRI, I am definitely going to make sure I have some sort of sedative or medication to lower my anxiety. Otherwise, I don’t think I can get back into that tube.

Having experienced at the start of my PCa journey an endorectal coil MRI in a dimly lit baron room but only 4 years ago, to now a modern 3T MRI in a much brighter environment or room with options such as a headset and music, is already like night and day.

It was difficult to stay still (breathing causes movement); tight space and loud.

The shorter the better. My first one was at the University of Pennsylvania Hospital, and my second was at Memorial Sloan Kettering in New York, which was a lot shorter; maybe their equipment is better.

Issues getting a high-quality MRI. Gas in the rectum and operator error.

Xanax gets me through.

I had to pee halfway through. They stopped the scan, I hopped out in the gown, had to leave the van (parked outside the imaging center!), run to the restroom through the waiting area. Next time I will wear a pad (I'm a pilot so I have lots of them). I won't do an MP again, just takes too long, and I don't want the Gd exposure.

I find it difficult to lie still for so long and it becomes uncomfortable

Sedatives should be offered as an option as a matter of course.

I’ve had 2 MRIs. The first was 1.5T with an endorectal coil. The 2nd was 3T with no coil. I was not aware of the difference before the first MRI. The detection results were quite different. The first MRI was clean. The 2nd MRI found a pretty large PIRADs 4 lesion 1 year later. The first MRI definitely missed it. It’s essential to be well-informed about the MRI details up front.

Unclear understanding of the side effects of contrast injection.

An armrest behind your head, a legrest under your knees, and the removal of footwear are very helpful in avoiding stress on the muscles and joints during the scan

The machine requires a lot of sound insulation inside.

Open MRI is capable of sufficient detail, so closed MRI becomes a thing of the past.

Given uncertainty in the safety of the contrast, I think bi- parametric MRI is the my choice now.

Make sure you discuss MRI with your urologist before they biopsy you

I had an MRI to see if there was a need for a biopsy. Thankfully, there was not. Just a giant prostate, but no sign of cancer!

For me, the more information during the procedure, the better, e.g. this sequence will be 10 minutes

3+3=6, 3+4 =7 low%4 = GG1; or simply 3+3 pre MRI Enema(s) recommended; received Glucagan to slow bowel movement? Clear liquids 8 hrs before MRI?; no sex or ejaculation 72 hrs before recommended ( can impact accurate seminal vesicles reading)

The medication puts me to sleep. I have no more fear or anxiety before the procedure.

Issues with rectal gas caused the need for a repeat. I took all precautions, but still had an "artifact" that interfered with interp. Apparently, some facilities inject a gel into rectum. My hospital does not.

bpMRI will help with costs and time.

Have had bi- and multi-. Much prefer the bi- and will never have the contrast MRI again.

I’ve had 3 MRI’s. Different places and machines. One was feet first.(most comfortable for me)

My first MRI resulted in an overheating problem. Had to abort. I firmly believe it was a lazy tech.

I’m not anxious or claustrophobic, so nothing about that issue applies to me. However, I try to be well-informed and, in addition to being prepared for what to expect physically during the procedure, I would have appreciated an explanation of what’s being tested, how the machine works, what the results are, how to understand them, how and by whom they’re interpreted, what they mean for me, etc. I know Dr’s time is limited and I trust and respect him, but I’d like to be better educated and informed - more than just ‘now I’m scheduling you for this test’ and ‘the results showed nothing new of concern.’ I know not everyone with PCa would be interested, but for those of us who are, educational handouts, glossaries, web videos, etc., would be appreciated, both before and after.

I don't have a problem with MRIs. However, the shorter the better.

BP MRIs only, much shorter & quality 3T matters. ALWAYS get a second opinion!

More room and ability to have my head out of the tunnel

Most difficult part was holding my breath during portions of the exam.

Your secrets of coping with that closed-in MRI feeling:

Thinking about how to tackle a project at home

Drugs. Possibly Ashwaghandha.

Relax.

Keep eyes closed

Valium

Music, think about a movie, tv series or book.

Keep my eyes closed the whole session. Focus on nature images. Don't have canned music.

I keep my eyes closed.

Listen to loud rock music

Eyes covered - headphones on listening to music!

Close your eyes and don't think about it. It is necessary for your continued health. Get on with it. It doesn't take long.

Staying calm. My favorite music helps a lot.

Just relax and realize there's an opening at both ends, then take a semi-nap!

Eye cover, cool air

Stay calm! The new generation of open MRIs is much more forgiving than the narrow tube-like structure of the 1990s, where elbows would barely fit in along side the body

Quiet yourself even before the MRI begins. Keep setting what causes your claustrophobia aside again and again. It can be difficult (whether for claustrophobia or anything else) if you have never practiced doing so.

Mind over matter

Try to focus mostly on being somewhere pleasant, like at the beach.

Prayer and singing songs to myself.

Sedation, cotton in ears and headphones with new age music.

Wide bore MRI - no problems

Focus on the music. I also count the number of songs I have heard, which allows me to track the time that has passed. I assume 3 minutes a song--and go from there. Being in the machine, it is really easy to lose track of time--I like to know how far into the procedure I am.

I had them put me in feet first so my head was closest to the entrance

My son-in-law said to go in feet first, keeping your head at the entrance, where there is better ventilation. He is the manager of a research lab.

Headphones with rock music - counting songs. Figure that when I get to 8-9, I'll be close to being done.

I was a volunteer firefighter for 37 years and am accustomed to working in confined spaces.

Ativan one hour before

Never open eyes

Being able to see the ceiling of the room, breathing, Xanax last time. Asking to stop before going complain to be able to adjust.

Medication did help, I think an information video and a practice routine would help.

Ativan

Close my eyes, listen to music, and know if I HAD to, I could get out of the scanner.

Pray, meditate, and breathe.

I just relax and think about something I am working on.

General Anesthesia

None. Man up guys. It's a painless diagnostic test.

Bare Knuckle!!!!!

For me, there was a sense of rhythm during the machine’s operation. A heartbeat to the machine, so to speak. I just visually pictured myself sitting by a stream in meditation, listening to the tempo of a Buddhist monk tapping on a wooden temple block or drum. As the machine got louder or the tempo increased, so did the striking of the hammer during the practice of a state of meditation. I found it relaxing to feel all of the various sensations throughout your body, including the flushing warmth of the contrast as it entered throughout your bloodstream.

Close my eyes and think about anything else

Just relax

Close your eyes and listen to the words in any music.

I count the seconds while breathing

"Headphones" that transmit music via plastic tubes, keep eyes closed, plan a mental journey.

Stay calm and carry on

Triazolam and wearing a mask

Keep your eyes closed at all times and while in the tube

Be tired

Close your eyes, listen to music

Anti-anxiety meds (Xanax, etc.)

If I had it, I'd take a relaxant. It was offered, but then I would have had to have my wife with me. Frankly, I have no issue with the machine.

Meditation

I have them play music, close my eyes (I have dozed off before)

Look up out of the tube

Close your eyes and meditate

Music

Keep eyes closed always

Close your eyes and take a nap

Ask if you can go in feet first allowing your head to be less inside the “tunnel.”

Headphones playing Bruce Springsteen. The Boss made it possible to get through!

I would opt for music via headphones if available

Earplugs are a must; I also like to request a warm blanket (I’d rather be too warm than cold), and I prefer to close my eyes. I’m a writer and musician, and I try to write a little ditty in my head to pass the 45 minutes (when I can manage to ignore the cacophonous noise)… when I can’t ignore it, I start imaging I’m listening to a (very strange, loud, experimental, bad) electronic “song” being made from all the crazy noises

Listen to the MRI sounds on the internet, get used to it. The head is not in the tunnel anyway.

I was terrified I would not be able to make it, but I found that the noise the MRI made was very musical. It had tone, and rhythm. Each short test had a different song and I spent the 40+ minutes in the tube singing along with and adding to each different musical piece. It was very surprising to me that it worked out that way. I also found the announcement that "the next test will last for 5 mins" very helpful

Praying, in my case, the Hail Mary

Mindfulness practice

Focus on music and breathing

Close eyes

Anti-anxiety medication and cannabis

I count to know how much longer. One to 100. Keep track of 100’s on my fingers.

close eyes and hopefully hear the music requested

Close your eyes and imagine yourself in wide-open spaces.

Xanax

Towel over eyes, praying and listen to music

Close my eyes and visualize sunning myself at a noisy beach.

IV sedation

Sleep

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At AnCan on Sept. 17: MRI 2nd Opinions..... ProstatID solves the challenge

Getting second opinions is essential in PCa care.

It's easy to find a medical 2nd opinion, and you can get your pathology reread by the best. But MRIs - that's been challenging.

Now there's an affordable AI-validated option that's proven very reliable* - ProstatID from Omaha-based Bot Image. Medicare covers ProstatID.

Join AnCan on Wed. Sep 17th at 6.30 pm Eastern in the AnCan Barniskis Room https://www.gotomeet.me/AnswerCancer Free & drop-in, precdeing AnCan’s weekly virtual support session for patients on Active Surveillance.

Founder and Developer of Bot Image, Randall Jones, PhD , MBA,explains the technology and its uses. Hosted by AnCan Advisory Board Member and prostate cancer peer, Cdr. Mike Crosby, who is chief commercial officer at Bot Image.

ProtatID is licensed to medical groups and also is available from Precision Prostate Consulting, in which Jones is a partner.

You can get a preview of Bot Image in The Active Surveillor:

Has the time come for AI and MRIs?

Howard Wolinsky

·

Aug 13

(Editor’s note: We’ve heard a lot about AI and pathology reports.

Read full story

Up next At ASPI: What’s up with BPH

By Howard Wolinsky

Patients with low-risk prostate cancer are no strangers to BPH (benign prostatic hyperplasia), an enlarged prostate.

The percentage of men with low-risk prostate cancer who have (BPH) is not precisely stated in the medical literature. But autopsy and epidemiological data suggest that more than 20% of men with prostate cancer also have BPH, with some older studies showing this co-occurrence in up to 83% of prostate cancer cases overall.

Since BPH prevalence rises with age, and most low-risk prostate cancer patients are older, overlap is common. Many men diagnosed with low-risk prostate cancer are found through PSA testing, which BPH often also elevates.

BPH has been a focus of a lot research, such as water vapor ablation, which also is under study as a prostate cancer treatment.

(Dr. Brian Helfand)

Learn more at the next webinar by Active Surveillance Patients International, “BPH: What’s New, What’s Next,” featuring Brian Helfand, MD, PhD, who researches prostate cancer, AS, and BPH.

The program will be from noon to 12:30 p.m. Eastern on Saturday, September 27.

Register here.

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In other news

• Share how you found your prostate cancer specialist:

  https://forms.gle/Hhhdds7rSFz1NcgP6

• New Research Study at NYU Langone Health for Hispanic Patients with Prostate Cancer: Dr. Stacy Loeb and Colleagues are conducting a new study “Perspectives on Genetic Testing for Prostate Cancer” for Hispanic patients with prostate cancer. Participation involves an anonymous 40-minute virtual interview, in English or Spanish, to share perspectives about genetic testing. A $40 honorarium is provided for participation. For more information, please contact the study coordinator Tatiana Sanchez Nolasco (Tatiana.Sancheznolasco@nyulangone.org or 646-501-2550).