mpMRI: Early action to get a new diagnostic adopted by UK healthcare systems

What is mpMRI?

A multi-parametric magnetic resonance imaging (mpMRI) scan is a special type of scan that creates more detailed pictures of your prostate than a standard MRI scan. It does this by combining four different types of image. These images give your doctor information about whether or not there is any cancer inside your prostate.

During the mpMRI scan, you will be injected with a Gadolinium-based contrast agent which is an essential part of this type of imaging. It allows for a clearer picture of the prostate. The gadolinium (a metal ion) in these dynamic contrast agents has been chemically adapted to make it safe to use as part of a mpMRI scan. Part of the quality control for mpMRI involves using the lowest possible effective dose of the contrast agent. There is not yet any clinical evidence that gadolinium causes any harm when used as a contrast agent for mpMRI, however, we will continue to monitor the situation carefully. The contrast agent will not be administered if it's clinically contraindicated, for example, when dealing with kidney problems.

*Please be aware this map was constructed with 2019 data which we received from individual hospitals and may not be accurate to the current situation. If you are concerned, please contact your local hospital for the latest information.

Why mpMRI is better than previous diagnostic methods

Until recently, the only way to investigate suspected localised prostate cancer and determine whether or not it needs treating was based on the results of a TRUS (trans-rectal ultrasound) biopsy. This involves needles inserted into sample tissue across the prostate, to see whether or not it contains any cancerous cells.

On occasions, the needle can miss significant cancer if the section of the prostate where its located isn't sampled. Although biopsies are a key part of diagnosis, they can be invasive for men and come with a risk of serious infection. Finding a way to improve the number of significant prostate cancers that get caught in time, whilst reducing the number of men who have biopsies unnecessarily, is really important.

In 2017, the results of a new study called PROMIS were published. The study involved hundreds of men and examined whether mpMRI before biopsy can provide a more accurate diagnosis for men with suspected prostate cancer and can rule some men out of unnecessary biopsy. The study has shown that mpMRI:

is significantly better at identifying clinically significant prostate cancer compared to TRUS biopsy
reduces the number of men having biopsies unnecessarily by a quarter (27%) because the scan will only pick up cancers which could cause men harm and need further tests
helps improve the accuracy when taking biopsy samples, targeting directly any suspicious areas seen on the MRI

Our ambition for 2020

Since the publication of the PROMIS study in 2017, it has been our ambition to make sure that, by 2020, every man with suspected prostate cancer can get access to a mpMRI scan before a biopsy.

We recognise that mpMRI before biopsy is a complex scanning technique which is why we have worked together with experts and relevant professional bodies to develop resources and guidelines to support healthcare professionals and Hospital Trusts to roll out this technique to a consistent, high-quality standard which delivers the greatest benefit for men.

We also engaged with NICE, the National Institute of Clinical Excellence, to ensure mpMRI before biopsy is recommended in their guidelines as standard practice for suspected prostate cancer diagnosis.

Implementation across the UK

Over the previous 3 years, we have launched several Freedom of Information Requests (FOI) to monitor the availability of mpMRI pre-biopsy across the UK. Overall, the data shows that progress has been made and more men are able to access it. Our latest FOI conducted in 2019 has found that 72% of areas across the UK are now offering these types of scans to PROMIS trial standard.

Implementation in England

In England, we worked with NHS England to develop an optimal timed diagnostic pathway for prostate cancer. It outlined how Hospital Trusts can introduce pre-biopsy mpMRI to rapidly and more accurately diagnose prostate cancer. Alongside this, there was an expectation from NHS England, that Hospital Trusts would implement pre-biopsy prostate mpMRI by March 2020. Since the document’s publication in April 2018 we have been offering support to Trusts to ensure that pre-biopsy mpMRI is widely available including radiologist training and implementation events.

Implementation in Wales

In Wales, adoption of pre-biopsy MRI began at a slower pace due to the complexity of the technique and lack of resources to achieve widespread adoption.

At Prostate Cancer UK, we worked closely with the Welsh Government, the Welsh Planned Care Programme team and the Welsh Urology Board to provide solutions to the barriers to adoption of high-quality mpMRI across the Health Boards.

Over the last 18 months we have seen substantial progress in Wales as Health Boards across the country have transformed their diagnostic pathways to provide mpMRI before biopsy.

Prostate Cancer UK will continue to work with the National Imaging Academy of Wales and groups such as the Prostate Cancer Diagnostic Pathway Group in order to support Health Boards to provide high-quality mpMRI.

Making progress in Scotland

Clinical transformation in Scotland requires agreement among relevant clinicians (urologists and radiologists) that the evidence for change is strong enough. We brought clinicians together from across Scotland’s Health Boards to get their backing for the widespread adoption of mpMRI before biopsy.

Prostate Cancer UK was fully engaged in the process to update NHS Scotland’s prostate cancer Quality Performance Indicators (QPI) and helped to secure the first ever QPI covering prostate MRI before biopsy. The latest QPIs were agreed in early 2020.

We will continue to work with the Scottish Government, via our mpMRI Roundtable to reach agreement on how best to take forward high-quality mpMRI services across the nation.

Some Health Boards have already put mpMRI before biopsy into the prostate cancer diagnostic pathway. Use our map (last updated 2019) to see which ones.

Availability in Northern Ireland

Pre-biopsy MRI scans are widely available across Northern Ireland. However, they are not to PROMIS standard. While the PROMIS standard is more accurate, if there is any uncertainty around the result of the MRI scan in Northern Ireland then clinicians will keep a close eye on patients to ensure they do not require further scans or require treatment.

Prostate Cancer UK's support offer

A complex technique

The expert radiologists we work with tell us that it took them time to develop the skills needed to interpret and report mpMRI scans. It also took them time to have the confidence to recommend not to biopsy some men. We have been offering support to radiologists to train and build their confidence.

Setting standards

We worked with several clinicians to publish a Clinical Consensus which aims to ensure that men experience the same high-quality approach to mpMRI before biopsy no matter where in the UK they live. It does this by setting standards that can be applied consistently across the UK.

It is also clear about when some men can be ruled out of an immediate biopsy and will set best practice guidelines for GPs so that they effectively monitor men who are not biopsied.

Scanner optimisation

High-quality mpMRI scans rely on MRI scanners being configured in a specific way. With several MRI brands, Tesla strengths and models, it can be challenging to know which protocols to apply to get the highest quality image.

We worked with the Society of Radiographers to develop a set of scanner protocols that can be applied to relevant scanners to produce high-quality images. We are also exploring digital ways for radiographers to be able to share scans with expert centres to have their quality validated.

Radiologist training

We launched an e-learning module to support radiologists to get to grips with the basics of mpMRI before biopsy.

We have worked in collaboration with the Royal College of Radiologists and the National Imaging Academy Wales to create several one-day workshops.

We have also established local expert training centres across the East of England to train local radiologists on the interpretation of mpMRI scans and increase their confidence to rule men safely out of a biopsy. We are hoping to make available this innovative training approach to other areas in the UK too.

Quality assurance

The complexity of interpreting and reporting mpMRI before biopsy scans can mean that some centres continue to biopsy every man.

To ensure that those men who do not need an immediate biopsy can avoid this potentially uncomfortable procedure, we are investing in the creation of a digital platform that will enable radiologists to compare their reporting results with experts.

This means that radiologists new to mpMRI before biopsy will be able to see how their conclusions compare to radiologists that have been practising mpMRI before biopsy for a long time.

There will also be opportunities made available for further training, the chance to obtain a mentor, and in time, the means to upload scans and have them reported by an expert. We believe this last opportunity could help Trusts and Health Boards that are struggling with radiologist capacity.

Addressing capacity issues

We know that the radiologist workforce is struggling to keep pace with demand for MRI. We have worked with the Royal College of Radiologists to determine how many radiologists are needed in the future, if an mpMRI scan before a biopsy is to be a reality for every man with suspected prostate cancer.

We will also be investigating how technology could provide an answer to radiologist workforce shortages in the shorter-term.

MRI scanners are also in high demand and can be used to diagnose conditions that affect the brain, spine and nervous system, heart conditions, liver or kidney disease and conditions or injuries that affect bones and joints. They are also expensive and regularly need to be replaced.

We developed a model that helps Trusts and Health Boards plan to investigate just how many MRI scanners are needed for every man with suspected prostate cancer to have access to an mpMRI scan before a biopsy. We plan to use this information to work with Cancer Alliances and Health Boards to make the case for the equipment they need.

What can men/supporters do?

Following the release of data obtained through a Freedom of Information request, Prostate Cancer UK has launched a campaign to make sure that diagnostic services across the UK are equipped to meet increasing demand. We need you to contact your local health decision-maker to share our Diagnostic Pathway Demand Model and help your local area plan for future provision of mpMRI.

Contact your local health decision maker now to share our planning tool so they can calculate the resources needed in your area over the coming years.

mpMRI before biopsy – a step change in prostate cancer diagnosis for men