A standard MRI scan creates an image of an internal organ. But unfortunately, it is rarely clear enough to confidently diagnose early prostate cancer. That’s where mpMRI, or multi-parametric magnetic resonance imaging, is different. By combining up to three different types of scan, we can get a clearer picture of what’s going on in the prostate. Also, an injection of a contrast agent means that scan images can be enhanced making it clearer to see if cancer is present or not.
Why do we need a new diagnostic?
For over 30 years, the only way to diagnose prostate cancer and determine whether or not it needs treating, has been based on the results of a random TRUS biopsy. This involves using a series of needles that randomly sample tissue across the prostate, to see whether or not it contains any cancerous cells.
The problem is that because there are gaps between the needles, sometimes significant cancers can be missed if that section of tissue isn’t sampled. The other problem is that although biopsies are a key part of diagnosis, they are invasive and painful, and can sometimes lead to serious infections – so we only want men to have them if they need them. Finding a way to improve the number of aggressive prostate cancers that get caught in time, whilst reducing the number of men who have biopsies unnecessarily, is really important. Multi-parametric MRI can do both of these things as well as ensuring that the biopsies that do happen are able to be much more targeted to where the cancer actually is in the prostate.
About the project
Here at Prostate Cancer UK, we believe mpMRI before biopsy offers the potential for a step-change in prostate cancer diagnosis. Results of the PROMIS trial have shown that mpMRI before biopsy can:
Be significantly better at identifying clinically significant prostate cancer compared to TRUS (trans-rectal ultrasound) biopsy
Reduce 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.
We have been working since January 2016 to make sure that, by 2020, every man with suspected prostate cancer can get access to mpMRI scan before a biopsy.
To do this we undertook a UK-wide Freedom of Information Act Request (last updated 2016, to be updated April 2018) so that we could understand the implementation challenges that Trusts in England and Health Boards in Wales and Scotland might face. We are responding to these challenges in partnership with NHS England and the Programme of Care Board in Wales and hope to soon work with Cancer Networks in Scotland.
We recognise that mpMRI before biopsy is a complex scanning technique and so we are also developing several resources that can build the expertise needed to ensure mpMRI before biopsy is high-quality and delivers the best outcomes for men.
Adoption in progress
Our activities have encouraged NHS England to make funding from the National Cancer Transformation Programme available to Trusts that want to transform their prostate cancer diagnostic pathway.
To support this initiative, we are working closely with the Royal Marsden and the Trusts in the West Midlands to use this funding to pilot what is being called a RAPID pathway. This will use mpMRI before biopsy to reduce average prostate cancer diagnosis time to just eight days and referral-to-treatment time to 20 days. We will soon also be working with other Trusts to support them to use this funding to implement mpMRI before biopsy.
Implementation in Wales
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 with suspected of having prostate cancer gets an mpMRI scan before a biopsy as standard practice. Progress is being made in North Wales too.
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 in the Spring to get their backing for the widespread adoption 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 2016, to be updated April 2018) to see which ones.
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.
That is why we have funded a Clinical Research Fellow at University College Hospitals London to build a clinical consensus among expert mpMRI before biopsy radiologists, radiographers, urologists and medical and clinical oncologists that sets standards for how mpMRI before biopsy should be conducted.
This clinical consensus will aim to ensure that men experience the same high-quality approach to mpMRI before biopsy no matter where in the UK they live. It will do this by setting standards that can be applied consistently across the UK and will be published in Spring 2018.
It will also be 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.
High-quality mpMRI scans rely on MRI scanners being configured in a specific way. With several MRI makes, Tesla strengths and models, it can be challenging to know which protocols to apply to get the highest quality image.
We are working with the Society of Radiography to develop a set of scanner protocols that can be applied to relevant scanner 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. The protocols will be available in Spring 2018.
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 next one is scheduled for March 2018.
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 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 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 will be working with the Royal College of Radiologists to work out how many radiologists are needed in the future, if a 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. Our 2016 Freedom of Information Act data showed that 51% of MRI scanners either needed to be updated or replaced by 2026.
We plan to investigate just how many MRI scanners are needed for every man with suspected prostate cancer to have access to a 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.