Adoption in progress
The 2018 UK-wide Freedom of Information Request has found that there has been a significant improvement in access to mpMRI before biopsy since 2016. The greatest increase has been seen across England where rollout of this technique has been prioritised by health commissioners. However, it has also found that 56% of areas across the UK do not provide mpMRI scans to the highest evidence-based standards. And further, there are areas with no access at all, in particular in North and West Wales, Northern Ireland, North West England and parts of Scotland.
NHS England has made funding from the National Cancer Transformation Programme available to numerous Cancer Alliances that want to transform their prostate cancer diagnostic pathway. To support this initiative we are working closely with the Royal Marsden Cancer Vanguard and the West Midlands Cancer Alliance to use this funding to pilot a RAPID pathway that will use mpMRI before biopsy to reduce average prostate cancer diagnosis time to just eight days (compared to a target of 31 days) and referral-to-treatment time to 20 days (compared to a target of 62 days). We are also working with other Cancer Alliances to support them to use this funding to implement mpMRI before biopsy.
Providing peer to peer support
We have asked Trusts in England who have already transformed their prostate cancer diagnostic pathway to include mpMRI before biopsy to share their experiences. Five Trusts from across England have outlined some of the challenges they faced and the ways they overcame them.
Read about these five Trusts' experiences of implementing mpMRI before biopsy.
Implementation in Wales
Some areas in Wales do not offer access to mpMRI before biopsy at all. This is in large part due to a lack of resources needed to achieve widespread adoption. However, our activities have encouraged the Welsh Urology Board, with support from the Welsh Programme of Care Board, to make the adoption of mpMRI before biopsy a top priority.
Two centres in Wales are already leading the way, with Cwm Taf providing a one-stop shop service – like the RAPID pathway being piloted in England – and Aneurin Bevan transforming its diagnostic pathway so that every man suspected of having prostate cancer gets an mpMRI scan before a biopsy as standard practice. Progress is being made in north Wales too.
We are working in collaboration with the Welsh Planned Care Programme team and Welsh Urology Board to support Welsh Health Boards in the adoption of high-quality, pre-biopsy 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 plan to bring these clinicians together to get their backing for the widespread implementation of mpMRI before biopsy. We then hope to support them to make this a reality.
Some Health Boards have already put mpMRI before biopsy into the prostate cancer diagnostic pathway. Use our map (last updated in June 2018) to see which ones.
Falling behind in Northern Ireland
Northern Ireland does not have access to the latest diagnostic scans for prostate cancer as the Freedom of Information request in 2018 found. It is lagging behind much of the UK and puts Northern Irish men at disadvantage.
We want Northern Ireland to make pre-biopsy mpMRI available to a high standard for all men who could benefit from it. Prostate Cancer UK is ready and willing to provide support and insight to help make this happen.
Overcoming barriers to adoption
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.
The Clinical Consensus that we funded among radiologists, radiographers, urologists and medical and clinical oncologists with extensive experience in mpMRI before biopsy aims to ensure that men experience the same high-quality approach to mpMRI before biopsy no matter where in the UK they live.
It builds on the consensus undertaken in 2013 to outline how mpMRI scans should be undertaken and reported, the criteria needed to rule some men out of a biopsy and the best practice management of these men in primary care. By setting these standards, the technique can be applied consistently across the UK.
High-quality mpMRI or multiparametric MRI (mpMRI) scans are critical to making sure that mpMRI before biopsy delivers the best outcomes for men, especially when some of these are men could be ruled out of an immediate biopsy because of these images. But achieving high-quality images requires MRI scanners to be optimised, sometimes in ways that expand on the pre-set scanner protocols. With several MRI makes, models and different magnetic field strengths in use across the UK, it can be challenging to achieve the right level of optimisation to get the highest-quality images.
This is why we’ve joined forces with the Society of Radiographers, who have developed a set of scanner protocols that can guide radiographers to calibrate and optimise their specific MRI scanner for use in prostate MRI before biopsy. There may be additional protocol tweaks required – and radiographers should always look to test the quality of the images their MRI scanner produces with expert centres and physicists - but for any radiographers newly adopting mpMRI before biopsy, these protocols provide a good starting point for the high-quality images they’ll need.
High quality MR images are crucial to help doctors diagnose and manage men with newly diagnosed prostate cancer. The protocol strives to provide some consensus on the need for small field of view T2 images, diffusion weighted imaging and dynamic contrast enhanced T1 images of the prostate in light of the recent UK consensus document that has been published.
Earlier this year we launched an e-learning module to support radiologists to get to grips with the basics of mpMRI before biopsy.
We have also worked in collaboration with the Royal College of Radiologists to create two, one-day workshops. One was held in January 2018 and was over-subscribed, the other in March 2018. Both workshops and the e-learning resource provide CPD points. Any radiologists wanting to undertake advanced mpMRI training should visit the British Society for Urogenital Radiology website.
mpMRI before biopsy courses are also available for urologists and provided by University College London.
We are now developing plans to create radiologist training opportunities in expert centres across the UK.
The complexity of interpreting and reporting mpMRI before biopsy scans means that some centres continue to biopsy every man. To ensure the benefits of mpMRI before biopsy are realised everywhere, we are investing in the creation of a digital platform that will enable radiologists to compare their reporting results with more experienced radiologists. Radiologists new to mpMRI before biopsy will be able to interpret and report a bank of validated practice cases to see how their conclusions compare to radiologists who 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 at another centre. 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. We will be working with the Royal College of Radiologists to work out how many radiologists are needed in the future, if mpMRI before biopsy is to become 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. Including through supporting scans to be checked or reported at another centre.
MRI scanners are 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. Our 2016 Freedom of Information Act data showed that half of mpMRI scanners will need to be replaced in the next few years.
We 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 biopsy. We plan to use this information to work with Cancer Alliances and Health Boards to make the case for the equipment they need.
Making the case?
Last year we worked with a group of clinicians to develop a downloadable ‘checklist’ that sets out what we believe should be in place in order to commission mpMRI before biopsy effectively.
The checklist we produced can also be adapted to help develop local business cases and for national commissioners or health board procurement teams to put in place what is needed to make sure this diagnostic imaging technique delivers the best outcomes for men.