About the project

Here at Prostate Cancer UK, we believe mpMRI before biopsy offers the potential for a step-change in prostate cancer diagnosis. In January 2016, the results of the Prostate MRI Imaging Study (PROMIS) were published in the Lancet and showed that giving a man a multi-parametric Magnetic Resonance Imaging (mpMRI) scan before a biopsy can radically improve the accuracy of the diagnostic process for prostate cancer.

We have been working since January 2016 to make sure that, by 2020, every man with suspected prostate cancer can get access to an 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 availability of mpMRI before biopsy at that time and the implementation challenges that Trusts and Health Boards might face.In early 2018, we undertook a second FOI to find out 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 pre-biopsy mpMRI 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 commissioners and 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.

We worked with the MRC Clinical Trials Unit at University College London to produce a series of short films on how mpMRI scans can improve prostate cancer diagnosis.

 

Making it happen

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. 

Securing funding

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.

Support men in their calls for the Welsh Assembly to make pre-biopsy mpMRI available across Wales by signing our petition.

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.

Setting standards

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.

Scanner optimisation

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.

- Darren Walls, PET/MRI Research Radiographer, Institute of Nuclear Medicine UCLH

 

Radiologist training

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.

Quality assurance

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. 

How you can help

  • Tell us about the barriers or challenges that are preventing you from implementing mpMRI before biopsy.
  • Tell us how many new radiologists you need to transform your prostate cancer diagnostic pathway to include mpMRI before biopsy.
  • Share your implementation story so that we can use it to help others.
  • Contact us if you would like our support to implement mpMRI before biopsy.

Contact us at policy@prostatecanceruk.org

 

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