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Despite national guidelines, we see considerable variation across the country in key elements of the diagnostic pathway for prostate cancer, exacerbated over the last year by the constraints on diagnostic services incurred by the Covid19 pandemic.
We hear this continually from our patients, who come to us with imaging, biopsies and histology that often need to be undertaken again in order to accurately assess these patients for their suitability for focal therapy. If a patient is suitable, this upgraded quality of diagnostic information is required for focal therapy to be effective in removing targeted cancerous tissue whilst preserving healthy tissue within and around the prostate. Focal Therapy is literally defined and guided by the highest standard of precision and accuracy in determining the location, size and severity of cancerous lesions within the prostate.
Our patients’ stories paint a picture of variability and inconsistency across the health service, so it’s important for prospective patients to know what the standards are in prostate cancer diagnostics that will give them accurate information and optimal choice in their treatment.
Imaging
A pre-pandemic report on availability and variation in prostate mpMRI by the Royal College of Radiologists revealed that about 87% of cancer centres provided the service, but that there was considerable variation in implementation across centres.
A recent study on prostate Cancer diagnostics during the Covid19 pandemic investigated 148 cancer centres in the UK, all of which offered mpMRI pre-pandemic. During the pandemic 14 (13%) centres stopped performing prostate MRI altogether. While, 39 (37%) continued to offer MRI for the same indications as prior to the pandemic and 48 (46%) offered prostate MRI to selected high-risk patient groups only
As evidenced in a recent study led by TFTC uroradiologist Clare Allen, overcoming this variability through standardisation of practice delivers real benefits. Her study explored prostate mpMRI protocols across 14 London hospitals to determine whether standardisation improves diagnostic quality. It concluded that targeted intervention at a regional level can improve the diagnostic quality of prostate mpMRI protocols, leading to improvements in prostate cancer detection rates and targeted biopsies.
We uphold the highest standards for imaging as it drives the consistency and accuracy required to assess suitability and undertake focal therapy on our patients. It underpins both biopsy and treatment planning as it reveals the exact location, size and severity of prostate cancer. More information on what every man should expect from his mpMRI and its reporting is provided here.
Biopsy
According to the most recent National Prostate Cancer Audit, 70% of prostate biopsies in England were TRUS, and only 21% were transperineal (TP) despite national guidelines to adopt the latter approach.
Interestingly, The BMJ study of prostate cancer diagnostics during Covid shows that while the overall level of biopsies dropped across centres, of those that performed prostate biopsies there was a shift away from TRUS .
“Most centres that continued biopsy during the COVID-19 pandemic did so only on selected higher-risk patients. Of all centres that responded to the survey LATP (local anaesthetic transperineal) was offered for higher-risk patients in 43 (41%), GATP(general anaesthetic transperineal) in 23 (22%), and LATRUS (local anaesthetic TRUS) in 22 (21%) centres. However, some centres continued to offer biopsies using the same method as prior to the pandemic; LATP 13 (12%), GATP nine (9%), and LATRUS 12 (11%) centres .”
Our biopsy standard at TFTC is MRI/US fusion transperineal biopsy, undertaken with a detailed report on the patient’s mpMRI and a targeted biopsy plan prepared by an expert uroradiologist.
Histology
The final piece of information in the diagnostic pathway is generated under the pathologist’s microscope when s/he grades and scores the cancerous cells observed from the biopsy samples according to a system known as Gleeson scoring. Studies have shown that there is known “inter-observer variability” in histological detection and grading from biopsy samples, and it’s the one area where machine learning is emerging to aid in accuracy and consistency.
Automated deep learning systems have delivered promising results from histopathological images to accurate grading of prostate cancer, and studies have shown that deep learning strategies can achieve better outcomes than simpler systems that make use of pathology samples.
Men should be aware of the variability that exists in Gleeson scoring and ask about the pathology lab undertaking their biopsy results and its record. They should also ask about the histology report being reviewed and discussed by an MDT.
MDT
This is perhaps one element of the pathway with the greatest variation in availability, constitution and quality.
At TFTC each patient is reviewed by an MDT made up of a uroradiologist, several urological surgeons, an oncologist and medical technicians that have been involved in patient procedures. Since the pandemic these have been undertaken digitally which has in fact improved frequency, attendance, quality of discussion and patient outcomes.
Ultimately the diagnostic pathway comprised of these elements leads to treatment recommendations, which again will vary across hospitals depending on a number of factors in addition to the diagnostic information.
Similarly, support services for non-clinical aspects of prostate cancer and its treatment also vary considerably – this includes counselling for the impact on sexual, urinary and mental health that a prostate cancer diagnosis brings. The variation here is stark - from nothing at all, to the recommendation of a service provider, to active counselling. All men need to know about the side effects of any treatment they are recommended, and to have access to counselling on these.
In summary, it’s a challenging time to manage a prostate cancer diagnosis, and we want to encourage and support men in building awareness of best practices, so that they can discuss diagnostics and treatment recommendations meaningfully with their care teams and feel confident to challenge them when necessary.
Do you have a story to tell about variability or inconsistency in prostate cancer care? We’d love to hear from you.
