mpMRI before biopsy: Improving diagnosis for men with prostate cancer
About the project
Here at Prostate Cancer UK, we believe mpMRI before biopsy is a step-change in prostate cancer diagnosis. In January 2017, the results of the Prostate MRI Imaging Study (PROMIS) were published in The Lancet and showed that giving a man a multi-parametric MRI (mpMRI) scan before a biopsy radically improves the accuracy of the diagnostic process for prostate cancer.
We have been working since January 2017 to make sure that, by March 2020, every man with suspected prostate cancer can get access to an MRI scan before a biopsy.
To be able to measure our progress, we undertook a first UK-wide Freedom of Information Act Request (FOI) in 2017 so that we could understand the availability of mpMRI before biopsy at that time. We also used this research to understand the implementation challenges that Trusts and Health Boards might face, so that we could develop tools and resources to help them address these. These have been developed in collaboration with clinicians, professional bodies and NHS Transformation teams and include a new diagnostic pathway, case studies showing different NHS implementation strategies and protocols to ensure MRI scanners are producing high-quality mpMRI images. Critically, we secured a commitment from NHS England for widespread mpMRI before biopsy adoption by March 2020.
We undertook a second FOI in 2018 to understand to what extent its availability had increased and to pinpoint where more work was needed. The results showed that there was some improvement in the uptake, but overall only 57% of areas were offering mpMRI scans in the UK.
To drive availability even further, we engaged with NICE to make sure that the improvements in prostate cancer diagnosis were included in their latest prostate cancer diagnosis and treatment guidelines. In 2019, NICE issued an update to their guidelines which now includes mpMRI before biopsy as standard diagnostic technique. This inspired the Welsh Government to commit to widespread implementation of mpMRI before biopsy by April 2020.
In addition to this, we have established training programmes for radiologists, developed resources that help to ensure mpMRI is high-quality and engaged with areas across the UK newly implementing mpMRI to tailor our support to their needs.
Our latest FOI shows the impact of our activity and NHS transformation capability. Undertaken in the autumn of 2019, it shows that health services across the UK have made substantial progress in ensuring this diagnostic technique is available to men. 72% of areas are now making mpMRI before biopsy available – an increase of 15% in just 18 months.
Learn how mpMRI can improve prostate cancer diagnosis
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.
The Dynamic Contrast Enhancement (DCE) Debate
The mpMRI technique used in the PROMIS trial included 4 scanning sequences, one of which involved an injected contrast agent called Gadolinium. This agent has become a subject of clinical debate. Its use requires additional resources – potentially lengthening scan type and adding cost. Its added value is also often questioned, and several trials have taken place to test whether it’s necessary.
See our review of the evidence comparing prostate MRI with and without DCE.
Our 2019 FOI shows that 24% of areas across the NHS do not use DCE. For this reason, they are considered to offer bi-parametric MRI (bpMRI), rather than mpMRI. When these areas are added to the mpMRI availability data from our most recent FOI, they increase the provision of a prostate MRI scan before a biopsy to 96%.
In the UK:
- 72% of areas offering mpMRI to PROMIS standards.
- 24% of areas are offering MRI without DCE.
- 4% of areas are not offering MRI.
*Disclaimer: This is based on responses through our Freedom of Information Request (2019).
What UK-wide activity have we undertaken?
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.
Published in 2018, it built 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.
Its aim was to ensure that the technique can be applied consistently across the UK and it has achieved this by helping to inform the mpMRI before biopsy recommendations that NICE made in its recently updated Guidelines for Prostate Cancer NG 131.
Addressing capacity issues
We know that Trusts and Health Boards are struggling with enough radiologists and scanners to keep pace with demand.
To support Trusts and Health Boards to estimate future prostate cancer diagnostic demand, Prostate Cancer UK has developed a ‘Diagnostic Demand Model’ which enables users to estimate future diagnostic radiology services need for prostate cancer over the next 10 years and use this to produce a business case for additional MRI scanning capacity, including additional MRI scanners.
The model allows users to project the numbers of patients who will enter the prostate cancer diagnostic pathway up to 2030 to enable estimates of future diagnostic resource demand. Users can change parameters to reflect local practice including PSA referral values, MRI quality and MRI scan time.
Use our diagnostic demand model.
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 UCLHAn audit of mpMRI scans was undertaken across the South West of England. Read the results here.
Radiologist training
In 2018, 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 several one-day workshops in 2018 and 2019, which were over-subscribed. We have funded training via the British Society for Urogenital Radiology and also funded a one-day mpMRI before biopsy training workshop at the National Imaging Academy in Wales.
Local Expert Centre Training
In 2018, we started to pilot a new approach to training radiologists in reading and interpreting mpMRI scans.
We identified five centres with expertise in mpMRI across the East of England Cancer Alliance and invited them to deliver training to radiologists across the same patch who were relatively new to the technique. They became our expert centres and the radiologists being trained, our participants.
Each participant had 3 training sessions lasting 4 hours. These took place across two different expert centres. As part of the training, the radiologists also completed our e-learning module and before and after tests of their knowledge and skills. Several participants requested additional sessions. They have also been able to establish a mentorship relationship with the expert radiologists, which enables them to get support for challenging cases and to continue to build their confidence in reporting mpMRI scans.
The pilot is currently under evaluation and results from it will be published in Autumn. In the meantime, we have requests from other areas keen to emulate this approach.
Quality assurance
We are investing in the creation of a digital platform that will enable radiologists to compare their reporting results with more experienced radiologists. This means that 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.
This system is currently under development and is being built and designed by RAIQC.
Radiologist accreditation
In November 2019, we held a consensus meeting to establish whether an accreditation programme for radiologists reporting mpMRI was a good idea and, if agreed to, how it could work. A paper outlining the results of this meeting will publish later in 2020.
Providing peer to peer support
Case studies
We asked Trusts in England who were early adopters of mpMRI before biopsy to share their experiences. Five Trusts from across England outlined some of the challenges they faced and the ways they overcame them.
Read about these five Trusts' experiences of implementing mpMRI before biopsy.
Learning curve
We have also asked a leading Trust in the East of England to share details of their mpMRI before biopsy implementation ‘learning curve’. This shows the pathway changes and resources that were put in place, over time to enable their diagnostic pathway transformation to achieve the 62-day wait.
Read the Cambridge University Hospitals NHS Trust mpMRI before biopsy learning.
Events
We have held two events, one in the East of England Cancer Alliance and another in the West Midlands Cancer Alliance that have brought together all clinical staff responsible for prostate cancer diagnostic pathway transformation so that they can share learning.
Attendees at each event were asked in advance to share details of any challenges and barriers they faced when implementing mpMRI before biopsy. They were then grouped by the issues they raised and linked with representatives from Trusts that have successfully transformed their prostate cancer diagnostic pathway. These opportunities to share ideas and learning have facilitated a step-change in mpMRI before biopsy implementation. They have also provided clinical teams with the chance to form networks for further support.
Specific activity in the nations
England
We have supported the piloting of a one-stop-shop prostate cancer diagnostic pathway, which was introduced across 3 Trusts at the Imperial College Healthcare NHS Trust
The approach, called RAPID involves a new scanning and diagnosis method which means men have an MRI scan and can get their results on the same day. For men with a suspicious MRI, a biopsy is done the same day, using new FUSION technology, rather than multiple outpatient visits over four to six weeks.
Its success means that it’s now being rolled out more widely, with pilots in the East Midlands and Northern Cancer Alliances.
Wales
Back in 2018, we supported men who had been unable to access a mpMRI scan before a biopsy in North Wales to petition the Welsh Government. Their action, alongside our continued engagement with the Welsh Government has helped to prompt the substantial progress Welsh Health Boards have made in implementing mpMRI before biopsy since May 2019.
We are currently a member of the Prostate Cancer Diagnostic Pathway Sub-group and are supporting clinicians and the Welsh Government to develop standards that enable mpMRI before biopsy to be delivered to a consistent, high-quality across the nation.
Scotland
Clinical transformation in Scotland requires agreement among relevant clinicians (urologists and radiologists) that the evidence for change is strong enough. We brought these clinicians together to get their backing for the widespread implementation of mpMRI before biopsy. We also worked hard to make sure that the use of mpMRI before biopsy is included in the mechanism Scotland uses to drive quality improvements. This is called the Quality Performance Indicators, which is run by the Scottish Information Services Division.
We have also helped to shape Scotland-wide standards for mpMRI before biopsy, which will ensure that no matter where in Scotland a man receives a mpMRI scan, it will be to the same quality.
Northern Ireland
Since 2018, all health boards across Northern Ireland are now providing MRI scans before biopsy which means men in Northern Ireland are no longer left behind compared to men in England. Only one is using DCE, so most men with suspected prostate cancer in this nation are receiving bpMRI.
