Southend University Hospital NHS Foundation Trust serves a local population of 338,000 and is the surgical centre for uro-oncology in South Essex. 294 men were diagnosed with prostate cancer in this Trust’s area in 2017.
In 2011, Southend transformed their prostate cancer diagnostic pathway and made multi-parametric MRI (mpMRI) scans available before biopsy.
Their route to implementation
“We found teamwork between urologists, radiology and pathology to be essential. Regular attendance at multi-disciplinary team (MDT) meetings allowing for clinical-radiological-pathological feedback is key to improving diagnostic accuracy.
“There was an initial substantial increase in the numbers of MRIs needing to be reported with no increase in the number of trained radiologists to read the scans. We went from 10 MRIs per month to now performing 60 per month.
“In order to perform dynamic contrast enhanced (DCE) MRI prostate imaging without delay, it is wise to ensure renal function tests are available on the examination date prior to administration of gadolinium. We now have processes for all patients to have up-to-date renal function prior to MRI referral. This means that all patients with normal renal function now have mpMRI at their first appointment. Without this arrangement some patients would be recalled at a later date and this could delay the total length of the patient pathway. We have found that if suitable renal function status is available prior to referral we can now image all patients within 48 hours of request.
“There was also an increase in the study time for the MRI, meaning fewer patients were scanned in a day. It is critical to educate radiologists by ensuring they attend courses and read articles on the Prostate Imaging – Reporting and Data System (PI-RADS™). We have also provided MRI safety training and referral guidance for nurse referrers.
“It is critical to educate the referrers with regard to basic MRI safety. This avoids lost capacity by referring patients who are contraindicated for imaging.
“Although initial delays occur, the benefits soon come into play as the service is streamlined. For example, an increase in the number of biopsy specimens to process and report, with transperineal as default, was offset by a reduction in the number of repeat biopsies (patients who had a prior negative TRUS biopsy but continued suspicion) and now in patients with normal MRI and PSA density.
“Patient focus groups are very helpful in shaping the service. Better patient experience, safety and clinical quality are all in favour of this approach.”
What they’ve achieved
Southend University Hospital have been performing pre-biopsy MRI in all patients since 2011. A diagrammatic as well as a standard verbose report is produced incorporating a PI-RADS™ score. Patients go on to have a transperineal prostate biopsy via cognitive fusion. This is done under general anaesthetic but will be switched to local anaesthetic soon. Patients with a low PSA density and no lesion on their MRI are offered surveillance rather than biopsies.
Well over 1,000 patients have passed through the diagnostic pathway and been biopsied in this manner. Occasionally, patients with advanced disease suitable for chemotherapy and with a palpable lesion will have a limited core biopsy digitally-guided.
Southend initially started off doing bi-parametric (T2, DWI b-1400) and in the last 2 years have added DCE.
They have recently introduced a nurse-led PSA telephone clinic where all GP referrals with an increased PSA on two separate occasions get an mpMRI booked and reported before the first consultant outpatient clinic. This allows the patient to be counselled appropriately at the first meeting and also shortens the pathway. Very limited numbers of TRUS biopsies are now performed, usually for patients with locally advanced disease on MRI to get 1-2 cores for treatment.
Patient and service outcomes
mpMRI has improved the detection of clinically significant cancer and provides a road map for the surgeon to biopsy. Furthermore it potentially avoids unnecessary biopsies in those with PI-RADS™ ≤2 and low PSA density.
Initially determining appropriate biopsy has allowed better use of resources e.g. trans-rectal vs transperineal, targeted vs systematic.
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