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 up to four different types of image. These images give your doctor information about whether or not there is any cancer inside your prostate, and how quickly any cancer is likely to grow.
Before having an mpMRI scan, you will be injected with a Gadolinium-based contrast agent. The gadolinium (a metal ion) in these dynamic contrast agents has been chemically adapted to make it safe to use as part of an mpMRI scan. The injection of a contrast agent is an essential part of this type of imaging. We, and NICE recommend that men have an mpMRI scan prior to biopsy for diagnosis and as part of ongoing monitoring on an active surveillance protocol. 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.
Until now, the only way to diagnose prostate cancer and determine whether or not it needs treating, has been based on the results of a TRUS biopsy. This involves one needle inserted numerous times to sample tissue across the prostate, to see whether or not it contains any cancerous cells.
On occasions, the needle, which inserted numerous times can miss significant cancer if the section of the prostate where its located isn't sampled. Also 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. 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.
What we're doing
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
Help improve the accuracy when taking biopsy samples, targeting directly any suspicious areas seen on the MRI
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 initially undertook a first UK-wide Freedom of Information Act Request(FOI) in 2016 so that we could understand the implementation challenges that Trusts in England and Health Boards in Wales and Scotland might face. In early 2018, we undertook a second FOI to know the extent to which its availability has increased and to pinpoint where more work is needed. We are responding to these challenges and variations in mpMRI pre-biopsy availability by working collaboratively with relevant bodies including NHS England, Cancer Alliances and the Welsh Cancer Network.
We recognise that mpMRI before biopsy is a complex scanning technique which is why we have worked together with relevant professional bodies and experts to develop resources and guidelines to support healthcare professionals to roll out this technique to a consistent, high-quality standard which delivers the greatest benefit for men.
This includes funding a Clinical Research Fellow at University College Hospitals London to build a Clinical Consensus of experts that outlines best practice for its implementation.
Adoption in progress
The 2018 UK-wide Freedom of Information Request has found that large parts of the UK still don’t have access to mpMRI scans for prostate cancer. However, there has been a significant increase in access overall. In particular, some areas in Wales and Northern Ireland do not offer scans at all, while their availability and quality in England and Scotland varies hugely. Prostate Cancer UK want all men across the UK who could benefit to have access as soon as possible. We are calling on NHS decision makers to make pre-biopsy mpMRI scans available without delay and to address variation in access and quality.
Implementation in England
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 are also working with other Trusts and Cancer Alliances to support them to use this funding to implement mpMRI before biopsy.
Implementation in Wales
Some areas in Wales do not offer access to mpMRI before biopsy yet. This is in large part due to the complexity of the technique and lack of resources to achieve widespread adoption. Wales is a top priority for us and we've been supporting the Welsh Government, Welsh Planned Care Programme team and Welsh Urology Board to provide solutions to the barriers to adoption of high-quality mpMRI across the Health Boards.
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.
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 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 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.
The Clinical Consensus 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.
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.
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 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. Our 2016 Freedom of Information Act data showed that half of mpMRI scanners will need to be updated 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 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?
Promote the use of mpMRI before biopsy to your Clinical Commissioning Group, if it is not available to a high-quality in your area. To find out which areas are providing it or not, check out our map.
The National Institute for Health and Care Excellence has recommended pre-biopsy mpMRI scans and a host of other improvements to diagnosis and treatments for prostate cancer become standard NHS practice across the UK. While we back the proposals, we're calling for enough scanners and trained staff to deliver them.