Implementing mpMRI before biopsy: learning from those that have succeeded
The big idea
The results from the PROMIS trial make it clear that giving men with a raised PSA a multi-parametric MRI (mpMRI) scan before a biopsy can help increase the number of aggressive cancers detected whilst reducing the number of unnecessary biopsies for men – potentially removing the need for biopsy in around one quarter of cases of suspected cancer.
We have asked Trusts in England who have already transformed their prostate cancer diagnostic pathway and are providing an mpMRI scan before biopsy to share their experiences. These five Trusts 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 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 (DCE), a technique used in the PROMIS trial and one that is an important safety net for ruling some men out of a biopsy.
In Profile: Leeds Teaching Hospitals NHS Trust
Leeds Teaching Hospitals NHS Trust is one of the largest teaching hospitals in Europe and a national centre for specialist treatment. 427 men were diagnosed with prostate cancer in this Trust’s area in 2017.(1)
Leeds recently set out to transform their prostate cancer diagnostic pathway using multi-parametric MRI (mpMRI) before biopsy, overcoming challenges to achieve a fast-track service.
Their route to implementation
“Despite issues with MRI capacity, equivocal MRI findings and huge demands on radiology departments, this is without a doubt the best service to offer this cohort of patients. The PROMIS trial has proven that for those patients with Prostate Imaging – Reporting and Data System (PI-RADS™) v2 Assessment Categories 1 or 2, we can avoid unnecessary biopsies.
“We would implore you to get your urology colleagues on board and highlight the huge benefits to the service this brings. Be persistent, approach local teaching hospitals for help and advice setting up protocols, attend British Society of Urogenital Radiology (BSUR) and European Society of Urogenital Radiology (ESUR) study days and embrace the change.”
What they’ve achieved
Patients at Leeds Teaching Hospitals NHS Trust have a pre-biopsy MRI and, based on DRE, PSA and PI-RADS™ score, are stratified for biopsy accordingly. They perform mpMRI with contrast – and obtain axial and coronal narrow field of view type-2 weighted image, axial type-1 weighted image, dynamic weighted image (up to b value 1400), apparent diffusion coefficient (ADC) and dynamic contrast enhancing (DCE) sequences. This is performed on 1.5 tesla Siemens MRI with surface coil.
Patient and service outcomes
- Benefits to patients: mpMRI allows them to risk stratify their patients and, based on clinical suspicion, PSA etc, some patients with low PI-RADS™ MRI (1 and 2) can avoid biopsy. For others, they offer a targeted biopsy within a standard 10 core biopsy regime. They can also select out those patients who would be best served by a transperineal biopsy.
- A very streamlined service: Patients are seen in the suspected prostate cancer clinic, with MRI +/- biopsy performed on the same day. The MRI is performed within a week, reported in less than a week and acted on accordingly.
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In Profile: Royal Cornwall Hospitals NHS Trust
The Royal Cornwall Hospitals NHS Trust is the main provider of acute and specialist care services in Cornwall and the Isles of Scilly. It serves a population of around 430,000 people. 345 men were diagnosed with prostate cancer in this Trust’s area in 2017.(1)
Royal Cornwall recently set out to transform their prostate cancer diagnostic pathway using multi-parametric MRI (mpMRI) before biopsy, overcoming challenges to achieve a fast-track service.
Their route to implementation
“We implemented fully in July 2017 when our 3rd MRI scanner was installed, so had increased capacity.
“The costs associated with mpMRI before biopsy can and should be set against reduced numbers of biopsies. These are made possible by adopting the PROMIS trial findings/European Society of Urogenital Radiology (ESUR) guidelines to high standards and not biopsying Prostate Imaging – Reporting and Data System (PI-RADS™) v2 score 2s.
“It is advisable to double report or review at least a percentage of cases with a Radiology colleague, as these can be quite challenging scans to report.
“There will be increased scan time and cost with administering Gadolinium as part of mpMRI. Our solution has been to follow the following criteria: <70 years, PSA <30, suspicion of prostate cancer, fit for radical treatment, American Society of Anesthesiologists (ASA) I & II. Ultimately, reduced numbers of biopsies may offset increased costs of MRI scans.”
Please note: Eligibility in other centres can be defined as: Any man aged 50-69 who is advised to have a prostate biopsy for whatever clinical indication.
What they’ve achieved
Royal Cornwall have implemented mpMRI before biopsy to great success.
They have reduced waiting times, as previously MRI was done with a 4-week wait post biopsy to let the haemorrhage resolve.
It has affected the 62-day wait by shortening waiting times.
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In Profile: Southend University Hospital NHS Foundation Trust
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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In Profile: University Hospitals of North Midlands NHS Trust
University Hospitals of North Midlands NHS Trust (UHNM) provides a full range of general acute hospital services for approximatively 700,000 people living in and around Staffordshire and beyond. 415 men were diagnosed with prostate cancer in this Trust’s area in 2017.(1)
UHNM use multi-parametric MRI (mpMRI) before biopsy, overcoming scanner time challenges.
What they’ve achieved
“For the last couple of years, we have performed mpMRI of the prostate on almost all patients before they have a prostate biopsy. Mostly these are patients with a raised PSA but a minority have an abnormal-feeling prostate on digital rectal examination (DRE) and some have an established diagnosis of prostate cancer and are on active surveillance.
“We perform a large field of view axial T1 sequence from aortic bifurcation down to groins. Smaller field of view T2 weighted sequences are obtained of the prostate in the axial, sagittal and coronal planes. Axial diffusion weighted images are obtained with a B value of 800. Dynamic contrast enhanced (DCE) T1 weighted fat saturated sequences are also obtained using an 8 second interval between sequences.”
Their route to implementation
“The pre-biopsy MRI has been fitted into the patient pathway without delaying the biopsy. The result is a shorter time to having all the information required to make decisions about management and to start treatment if appropriate for many of our patients. Importantly, pre-biopsy MRI removes the delay that previously occurred when biopsies were positive but the staging MRI had to wait weeks for the post-biopsy haemorrhage to reduce to allow meaningful MRI assessment of the prostate.
“A challenge was to perform the MRI in advance of the biopsy, without causing delay. To achieve this, we needed to ensure the MRI was requested when the patient was seen for the first time in the urology clinic and that the patient was contacted quickly by the radiology department to make them aware of their MRI appointment time.
“Another challenge was to make sure there was available scanner time to perform the MRI scans prior to biopsy. This was addressed by reserving a number of MRI appointments each week for prostate patients.
“Reporting the scans before the biopsy lists has been another challenge. The urology secretaries have responsibility for checking that MRI scans are reported for all the patients on any biopsy list. They email the radiologists several days before the reports are required if the scans are not already reported.
“Ensure prompt referral for MRI from the urology clinic and a rapid robust system for vetting, protocolling and appointing the scans.
“Try to nurture a small number of MRI radiographers who become expert in performing these scans.
“Plan reporting capacity not only in terms of an increased workload of prostate MRI reporting but in terms of timely reporting so as to guide the biopsy.”
Patient and service outcomes
The prostate is imaged without post-biopsy haemorrhage or capsular disruption that can be caused by biopsy and can influence the detection and staging of cancer on MRI. More accurate detection and staging of prostate cancer results in more appropriate management plans for the patients.
The MRI can identify targets to sample at the time of biopsy. This results in fewer false negative biopsies and biopsies that better represent the most aggressive disease present. Anterior cancers are more likely to be sampled by biopsies guided by prior MRI.
With MRI targeting, fewer patients need repeat biopsies because of negative biopsies.
While UHNM are 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 men have scans that show there is nothing suspicious in the prostate and there are no other clinical factors suggesting prostate cancer.
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In Profile: Dorset County Hospital NHS Foundation Trust
Dorset County Hospital NHS Foundation Trust is the main provider of acute hospital services to a population of around 250,000 living within Weymouth and Portland, West Dorset, North Dorset and Purbeck. It provides a full range of district general services and links with satellite units in five community hospitals. 296 men were diagnosed with prostate cancer in this Trust’s area in 2017.(1)
Dorset recently set out to transform their prostate cancer diagnostic pathway using multi-parametric MRI (mpMRI) before biopsy, overcoming challenges.
Their route to implementation
“It took us a while to convince others of the benefits of pre-biopsy MRI, but we did so by demonstrating the visibility of tumours in pre-biopsy patients. We could also show anterior tumours that had been missed by a trans-rectal ultrasound (TRUS) biopsy.
“We began by optimising MRI sequences and used another centre’s knowledge to help. There are other radiology departments in the UK who have optimised their scanning sequences – and if enough of them have done so, this should cover every type of MRI scanner. If any centre that is new to mpMRI before biopsy is struggling to get imaging optimised, it should be easy to share sequences between units.
“To build the confidence needed to report 'normal' (non-suspicious areas in the prostate) scans that enable some patients to avoid an immediate biopsy will require radiologists to see and report many scans.
“For those men who are biopsied, it is imperative that reporting radiologists attend multi-disciplinary team (MDT) meetings to make sure that TRUS and/or template biopsy results correlate with their interpretation of mpMRI scans. For departments with low MRI reporting confidence, there are several MRI prostate reporting courses now in place. They should also use mentoring / visits to exemplar sites.”
What they’ve achieved
Dorset offers a fast-track service to patients with suspected prostate cancer. This consists of an MRI within 2 weeks, which is then discussed at the following MDT. The decision is then made as to whether to biopsy or not and, if so, whether to perform trans-rectal or template biopsies. Their MRI uses T1, T2, diffusion and apparent diffusion coefficient (ADC) imaging.
Patient and service outcomes
- Benefits to patients: A significant number of men now avoid biopsy as a result of a normal MRI, if there are no other red flag criteria. If in the future patients are re-referred, an up-to-date scan is performed that allows comparison and the assessment of interval change.
- Effect on the 62 day wait: Patients' progression through the diagnostic pathway is quicker and it reduces the referral to decision to treat times, as the wait between biopsy and post-biopsy MRI has been eradicated.
- Clinicians can have increasingly candid discussions with the patient in the knowledge that they have the best grading and staging information available.
- Although it is important to improve the speed at which men progress through this diagnostic pathway, it is imperative that they have sufficient time to agree on their best treatment option.
Dorset do not routinely use dynamic contrast enhanced (DCE) imaging. Level one evidence supports the use of DCE – see the PROMIS trial – and we promote its use as an important safety net for ruling some men out of a biopsy.
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References
1. National Prostate Cancer Audit ‘Annual Report 2017’ available at: https://www.npca.org.uk/content/uploads/2017/11/NPCA-2017-Annual-Report_final_211117.pdf [accessed 2nd February 2018].