Adoption in progress
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 and referral-to-treatment time to 20 days. We will soon also be 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 provide an mpMRI scan 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.
While one of these Trusts is yet to use this technique to rule some men out of a biopsy, they have begun to use MRI scans to better target biopsies when the scan shows a suspicious area in the prostate. Soon, they will enable some men to avoid an invasive biopsy, especially when these men have scans that show there is nothing suspicious in the prostate and there are no other clinical factors suggesting prostate cancer. One Trust will be exploring how to incorporate Dynamic Contrast Enhancement, a technique used in the PROMIS trial and one that is an important safety net for ruling some men out of a biopsy.
Read about these five Trusts' experiences of implementing mpMRI before biopsy.
Implementation in Wales
The Welsh Urology Board, with support from the Welsh Programme of Care Board have made the implementation 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 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 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 builds on the one 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. It aims to achieve set standards that can be applied consistently across the UK. It will be published in Spring 2018.
High-quality mpMRI scans rely on an effectively optimised scanner. 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 their 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. Both workshops and the elearning 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 can mean 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 digital platform that will enable radiologists to compare their reporting results with the experts. Radiologists new to mpMRI before biopsy will be able to interpret and report a bank of validated cases 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 work 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 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.
Making the case?
Last year we worked with a group of clinicians to develop a ‘checklist’ which can be downloaded that sets out what we believe should be in place to commission mpMRI before biopsy effectively.
We believe that the checklist we produced can also be adapted for use to 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.