It’s not often that the release of a NICE guideline results in two headline stories in as many days. You will have probably heard on the radio, read in the paper or seen on television the initial discussion around active surveillance raised by the release of guidelines on diagnosing and treating prostate cancer. The NICE recommendation to consider active surveillance for low risk prostate cancer – a way of monitoring through regular check-ups rather than treating it straight away – is good news. For many men this could be a successful avenue that avoids the unpleasant side-effects such as erectile dysfunction and incontinence, which are risks associated with invasive forms of treatment such as surgery.
For me, the most exciting news the guideline contained – and which has made the headlines today – is the recommendation to use MRI as a diagnostic tool. NICE recommend the use of multiparametric MRI – a particularly accurate method of imaging – after one negative prostate biopsy. If you’ve had a prostate biopsy, you’ll know the last thing you want is another one, but multiple biopsies are not uncommon. A prostate biopsy is not the first port of call when checking for prostate cancer; to get this far along the diagnostic pathway – a minefield for both men and clinicians – a man will have had his PSA level checked (a simple blood test) and found it to be higher than normal. A biopsy of the prostate generally involves inserting a needle into the gland (guided by ultrasound through a probe inserted up your bottom) and taking 10 to 12 tissue samples. It can be a deeply unpleasant process and one that comes with risks of infection. And here’s the rub: one negative biopsy result doesn’t necessarily mean the prostate is wholly cancer free. Taking 10 to12 very small tissue samples from a gland the size of a walnut cannot always give a fully accurate picture. If a man’s presentation and previous tests suggests he has prostate cancer, but his initial biopsy is negative, he may face further invasive biopsies to ensure his doctors get the diagnosis correct. And let’s be clear: once you’ve heard that prostate cancer may be on the cards, you want to be damn sure if you’ve got it or not. Introducing multiparametric MRI into this diagnostic pathway after the first negative biopsy will allow doctors to get an accurate image of the whole of the prostate in one go. This imaging will then either confirm that the gland is free from cancer, or help confirm the location of the tumour for subsequent biopsies and speed up the whole process. This is great news for men. This imaging is such a useful and accurate diagnostic tool, it begs the question why not do it before taking a prostate biopsy? This question is being rigorously tested in clinical trials right now, and the results are due very soon. Hopefully missing the deadline for this guideline won't result in a hold up in pre-biopsy MRI entering clinical practice if it indeed proves beneficial to men.