We often talk about focal therapy as the "male lumpectomy", comparing advancements in techniques that have enabled targeted treatment for breast cancer to those for the prostate. The recent publication of an imaging technique called Prostagram extends the comparison further to screening, potentially leading to a world where men undergo prostagram screening for prostate cancer as regularly and routinely as women undergo mammogram screening for breast cancer. According to the investigators at Imperial College London, "The prospect of a male equivalent of the breast mammogram or so-called 'prostagram' has been a long-standing goal in prostate cancer diagnostics. Image-based screening has been adopted for other common cancers including mammography for breast cancer and low dose CT for lung cancer screening. TRUS was touted as the original 'male mammogram' in the 1990s but did not prove to be effective as an independent test. The revolution of MRI has offered a new opportunity to re-explore this area. If the performance characteristics of a standard mpMRI can be replicated in the general population this would address some of the issues with PSA as a screening test." While mpMRI has become the standard of care for prostate cancer diagnostics, it has not been adapted to screening. Often discussed interchangeably, cancer diagnostics and screening are different. Cancer screening is for people without current symptoms, while cancer diagnostics are for people with current symptoms that are suspicious of cancer. Regular screening coupled with quick diagnostic testing helps to ensure that cancer is caught early, giving the patient the best chance of successful treatment and recovery. The Imperial team tested Prostagram in a study of over 400 men across the UK, comparing different ways of scaning the prostate and optimising the technique, which eventually led to finding the best approach to score the prostate. The study participants were aged between 50 and 69 years, and included a significant cohort (32.4% of total participants) of black men who are at increased risk of prostate cancer. All were invited for prostate cancer screening, using both the new scan and other established methods, from October 2018 to May 2019. Results showed that Prostagram picked up twice as many prostate cancers compared to the standard PSA (prostate specific antigen) blood test. The team was especially pleased with the demographic diversity of the trial participants:  'A major achievement for the trial was the recruitment of ethnic minority and lower socio-economic participants broadly equivalent to their proportion within the community, which could be replicated in future general population screening trials.' A more extensive trial involving 20,000 men is in development, and if results from this study are similar or better than those produced in the recent study, there will be a clear pathway to the widespread implementation of Prostagram into the general population. Prostagram's impact for men and their healthcare is potentially huge - reducing under- and over-diagnosis of prostate cancer and allowing for precision-led and more personalised treatment – eg focal therapy. The Focal Therapy Clinic team is enthusiastic about the emergence of Prostagram. Consultant Urologist Tim Dudderidge foresees multiple benefits for both treatment and workflow: "The Prostagram study opens up a new chapter in the screening, diagnostic and treatment pathway for prostate cancer. Precision screening will improve the detection process increasing diagnosis of clinically significant disease and reducing unnecessary detection of insignificant disease. It's likely that focal therapy will emerge as a preferred alternative to surgery and radiotherapy for many men with localised prostate cancer. The other exciting consequence of an image-based screening programme could be the acceleration of AI supported reporting systems for both MRI and pathology. This will provide the framework and free time for radiologists and pathologists to provide image-based reports to help guide treatment planning." Alan Doherty, Director of the Birmingham Prostate Clinic and Consultant Urologist at TFTC, regards the development of Prostagram as a boost for precision treatment which challenges the future of Active Surveillance. The adoption of Prostagram will increasingly reinforce the acceptance of focal therapy and the rejection of Active Surveillance, as target lesions are identified early getting more precisely determined as the diagnostic pathway unfolds, and a non-invasive curative treatment is available. Prostagram raises many questions about acceptance, adoption and treatment adaptation, and it will be exciting to watch how and when this step-change innovation will deliver direct benefit to men’s health. We’ve seen mpMRI revolutionise the prostate cancer diagnostic pathway over the last ten years and with it improve treatment options, particularly for men with early-stage, localised prostate cancer. Integrating its use into screening completes the pathway. We are getting closer to a time when the Prostagram is as convenient and routine as the Mammogram.

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