18th July 2019

Latest guidelines recently released from NICE recommend that all men with suspected prostate cancer should be offered a specialist multiparametric MRI scan when they are referred to hospital before a biopsy. Prostate Cancer UK say that only 51% of men in the UK have access to this vital service. At MEDICA we are on a mission to support the NHS in improving this access.

MEDICA Group has been consulting with experts, collaborating with the NHS and investing in the field of prostate care. Our mission? To improve access to the best practice diagnosis for men in the UK.

To start this mission, we set things in motion with our technical, clinical and operational project teams who were tasked with getting us ready to deliver a prostate service that meets the needs of the NHS.

As part of our delivery plan, in January 2018 MEDICA Group appointed Dr Natasha Jefferson as our expert Clinical Advisory Lead for multiparametric prostate MRI. Dr Jefferson is passionate and highly knowledgeable in the field of prostate cancer diagnosis and has experience of training in prostate MRI both in the UK and abroad.

We recently asked her for her view on prostate diagnosis in the UK.

What exactly is mpMRI?

mpMRI, or multiparametric MRI, is the use of multiple imaging parameters – anatomy, diffusion restriction and contrast enhancement – in the acquisition of a study to increase confidence in the likelihood of malignancy within a lesion. This is distinct from dual parametric MRI which uses only two imaging parameters – anatomy and diffusion restriction – and which has been performed more widely in the past. mpMRI is the technique recommended in recent high profile papers that are currently shaping practice.

What is your view of the current diagnostic landscape for prostate health in the UK?

A Pre-biopsy mpMRI of the prostate gland for patients in whom there is a concern for undiagnosed prostate cancer (based on a raised PSA test and/or a suspicious digital rectal examination) is now considered to be the gold standard for care in this clinical scenario. This is based on the fact that a recent study in the Lancet entitled PROMIS (PROstate MR Imaging Study) found that an unsuspicious mpMRI of the prostate gland may obviate the need for biopsy (in up to 27% of patients who would previously have undergone an untargeted TRUS guided prostate biopsy) with its associated morbidity and mortality, or, will enable Trusts to remove such patients from their 31/62 cancer waiting pathways whilst they await biopsy (NICE draft guidance to be published this year). A suspicious mpMRI of the prostate enables the most appropriate biopsy technique to be used (TRUS biopsy, which is a local anaesthetic procedure, or transperineal template biopsy, which is a longer general anaesthetic procedure) and facilitates better targeting of areas of concern at biopsy. Due to the fact that mpMRI is better at detecting significant prostate cancers that require treatment and may not identify non-significant prostate cancers (that might have been identified on random TRUS biopsy), the use of pre-biopsy MRI means that overtreatment of insignificant prostate cancer (with potential complications of impotence and incontinence) may be prevented. Regular mpMRI of the prostate gland also enables active surveillance of biopsy-detected insignificant prostate cancer. This means that potentially harmful treatments can be delayed until a cancer becomes significant with the intention of cure at that time. There is also the potential to “fuse” the mpMRI dataset with a real-time ultrasound study, enabling an ultrasound biopsy to be guided by MRI images overlaid on the ultrasound images; fusion biopsy has the potential to reduce the demand on pathology imposed by template biopsy.

How does the UK landscape compare to the rest of Europe?

mpMRI was developed in Europe but its utilisation is variable and largely dependent on the structure of healthcare services within individual countries. The practice described above is that recommended by the European Society of Uroradiology.

What is the advantage of mpMRI over more conventional reporting?

The advantage of a well-performed mpMRI of the prostate is that it enables a Radiologist to assign a score from 1 to 5 to any abnormal area within the prostate gland which reflects how likely that abnormality is to reflect a significant cancer, using published guidelines (PI-RADS 2 criteria). A score of 1 suggests that the area is highly unlikely to reflect a significant prostate cancer, a score of 2 suggests that the lesion is unlikely to reflect a significant prostate cancer, a score of 3 suggests that the lesion is equivocal, a score of 4 suggests that a lesion is likely to reflect a significant prostate cancer whilst a score of 5 suggests that a lesion is highly likely to reflect a significant prostate cancer. Assigning such scores to areas within the prostate gland enables a Urologist to make a decision about whether or not a biopsy of any lesion is necessary. mpMRI is better in patients who have implanted pelvic metalwork such as total hip replacements which degrade the quality of the diffusion weighted images, it is helpful in characterising lesions at the front of the gland in some cases and it is essential in patients undergoing follow-up of treated prostate cancer in whom dual parametric studies are unhelpful.

Is there a cost saving for the NHS using this new method?

Although the use of contrast media in an mpMRI study adds to the cost of that study, by reducing unnecessary prostate biopsies and their associated potential complications and avoiding overtreatment of insignificant prostate cancer, the use of mpMRI of the prostate has the potential to save the NHS money.

PCUK say that only 51% of men in the UK have access to mpMRI scan with 13% of UK hospitals offering no access – why does the service vary so much for men across the UK?

Those men unable to access mpMRI at their local hospital are probably undergoing dual parametric MRI of the prostate at those centres instead. All the studies which are being used to direct contemporary practice have used mpMRI imaging rather than dual parametric MRI of the prostate and thus the conclusions made in these studies cannot be directly applied to the results of dual parametric imaging. Some of this lack of access will be due to radiologists lacking experience in reporting mpMRI of the prostate and some will be due to Trusts refusing to fund the contrastenhanced element of an mpMRI study. I suspect that those hospitals offering no access to prostate MRI at all are small centres with no appropriately trained radiologists and/or no MRI scanner.

What are the barriers for the Trusts using it?

In a centre with an MRI scanner capable of acquiring appropriate images, lack of radiologist expertise and the increased cost/scanning time of a mpMRI study compared to a dual parametric study are barriers to those Trusts implementing mpMRI of the prostate.

How is the work that MEDICA are doing helping to improve prostate diagnosis across the UK?

MEDICA have developed a Prostate MRI service through a collaborative and thorough process with support from a dedicated Clinical Advisory Lead and a wider delivery team. In addition MEDICA have created ‘best practice’ prostate imaging protocols and referral information guidance, designed to support PIRADS-2 reporting. Partners of MEDICA have access to a dedicated team of subspecialist radiologists who can provide PIRADS-2 reports to supplement NHS local reporting capacity when required.

Tell us more about your work at MEDICA and your joint aim to bring this service to more men across the UK?

I was appointed as the MEDICA Prostate Imaging Advisor in January 2018 with the aim of developing the mpMRI reporting offering from MEDICA. So far, I have recruited a panel of radiologists fully trained to deliver high quality PI-RADS 2 reports for mpMRI studies performed in NHS Trusts. This has involved scrutinising the experience and training in mpMRI of the prostate of individual radiologists through the use of a carefully designed questionnaire. For Trusts that perform dual parametric MRI of the prostate, a PI-RADS 2 standard report is delivered, as far as is possible given the limitations of those studies. I also offer advice to existing clients whose images are suboptimal or whose images do not conform to the protocol recommended in the PI-RADS 2 guidelines in how to address those limitations to improve the diagnostic quality of the images. New clients wishing to use our mpMRI reporting service are asked to follow our (PI-RADS 2) image acquisition protocol and this is a relative condition of us accepting them as a client. By providing a quality reporting service for mpMRI of the prostate and by advising on image optimisation, MEDICA is raising the standard of mpMRI imaging and reporting in centres that have lagged behind implementing such a quality imaging and reporting practice themselves and maintaining that standard in those centres that run a contemporary practice but are overwhelmed by the numbers of scans being requested in response to the publication of PROMIS and recent recommendations for UK practice published in the British Journal of Urology. By advocating the same imaging protocol to all our clients, MEDICA is trying to standardise imaging practice across multiple centres to an internationally accepted standard.

Click here to find out more about MEDICAs Prostate service or contact us on 033 33 111 222 for a consultation.