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A Navigational Guide to the Imaging-Led Prostate Cancer Pathway

Consultant Urologist Tim Dudderidge discusses the stages in the imaging-led prostate cancer diagnostic pathway, and outlines what patients need to know.

Press play in the audio player below to hear the interview.

Please find below a written transcript of the interview.

Clare Delmar:
Hello and welcome to On Focus brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood and almost never talked about. Prostate cancer is now the most commonly diagnosed cancer in the UK. And with this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Today I’m speaking with Tim Dudderidge consultant urologist at Southampton University NHS Trust and The Focal Therapy Clinic and a pioneer in non-invasive treatments for prostate cancer. We’re going to discuss how advances in the diagnostic pathway for prostate cancer give patients more opportunity to engage with their care and treatment. Tim, thanks for joining me today.

Tim Dudderidge:
It’s a great pleasure. Yes. I like to talk about this subject. So it’s a pleasure to talk to you every single time.

Clare Delmar:
Excellent. So let’s let’s go right in. I mean, I think we all agree that the diagnostic pathway for prostate cancer has been revolutionised – I know that’s a strong word and I’d like for you to comment on that – over the last 10 years. So how do you communicate this to patients?

Tim Dudderidge:
Well, I think the one thing that hasn’t changed is the PSA test. And so perhaps that’s the next revolution. The revolutions that have occurred really surround the use of imaging. In the past where we used to have a high PSA or an abnormal prostate examination, which might have been found when men had symptoms, the decision was whether to biopsy or not. And everyone recognises, I think now the value of the multi-parametric MRI scan. And basically this MRI scan allows us to have diagnostic imaging and people are familiar that with all sorts of other tumour sites. Breast cancer being a great example. And it’s really from that change that all the other changes with biopsy have followed. The big change with biopsy, I suppose, is and it helps to try and understand some of the terminology here. But traditionally the biopsies were going through the rectal wall. And I think that is a big change to move away from that into transperineal biopsy. And the chief driving force behind that is to reduce infection. But that doesn’t really make the link with imaging. The thing that imaging has allowed is targeted biopsies. In the past, what we used to use was a systematic biopsy, and there are a number of different patterns of biopsy through the transrectal route that people used to follow. And so a lot of the academic focus was about trying to work out which of those patterns of biopsy was the best. Well, we’ve completely moved away from that. And now it’s all about having an image with a lesion and targeted biopsy. And there are different ways of targeting the biopsy and a good clinician will be able to just use their skills to target the needle into the lesion. And they can look at the MRI scan, find the same area using the ultrasound and get a good target. And we call that cognitive fusion. So we’re joining in our mind the image on the MRI with the image on the ultrasound. That works for big lesions, but not for small lesions. And so the other big revolution is the use of software fusion to basically enhance the accuracy of that targeted biopsy. In terms of the changes, those the two big changes, I think.

Clare Delmar:
OK, yeah, they are big indeed. So and there’s a lot of terminology, as you quite rightly pointed out, which is that it’s fair to look at this pathway and it’s sort of sequential elements, almost like a supply chain and one that patients can focus on any one link and begin to understand how that might affect him and what questions he should be asking. So let’s start with the MRI. What does a patient need to know to give him confidence in his care?

Tim Dudderidge:
There are lots of variables in this. First of all, you’ve got the type of scanner and you can do a very good multi parametric MRI scan on a 1.5 tesla scanner. But some centres will have access to 3 tesla scanner and it can give slightly better resolution. And the radiologists might identify some features slightly better with that. So I think in an ideal world, you might go for 3 tesla scan every time, but some people aren’t suitable for that. The magnet strength means that some people can’t go in there and some of the side effects – some people will get nausea in a stronger magnet.

Clare Delmar:
But is one better than the other or are they more?

Tim Dudderidge:
I think you can get adequate images with a good well conducted 1.5 tesla scan, but I think maybe a 3 tesla scan would be preferable if one had access to that.

Clare Delmar:
And how many people, for example, in the UK would have access to that?

Tim Dudderidge:
Within NHS services, I’d say it’s patchy. Most of the big centres would have one. But even in our centre where we have one, not all of the scans are conducted on the 3 tesla scan. The radiologist might sort of pick and choose a little bit which one’s done on the 3 tesla scan. I think most of our initial scans are actually done on a 1.5 tesla scanner just because of the volume. But we get an acceptable quality from the 1.5 tesla. So it’s I don’t think it’s a deal breaker, that issue.

Clare Delmar:
OK, so. There in a one point five, the majority of people, what else should they know?

Tim Dudderidge:
Well, I think that the way that the scan is conducted should follow most of the protocols laid out in, for instance, the ESUR guidelines. This is the European Society of Urogenital Radiologists. And there are several publications I think will put a link of one up just to give an idea of the technical detail that goes into making a really good prostate MRI. And that’s not just how the sequences are put together, which include the T2 weighted sequence, diffusion related sequences, making sure you get the v-value that’s appropriate for prostate and also the use of contrast. I mean, contrast is my preference, but I know there’s a lot of debate about it and it adds some additional diagnostic kind of resolution, if you like, but a lot of…

Clare Delmar:
Diagnostic how? Like the strength of the cancer or the site?

Tim Dudderidge:
It just just helps interpret areas that may look like cancer, but the enhancement characteristics might add to the radiologists ability to differentiate between inflammation or scarring, and particularly after previous treatment it’s really helpful to have contrast. If you if you look at patients, you’ve had previous ablation, for instance. The use of contrast is something which I prefer and many other people prefer. But in terms of the efficiency of an NHS pathway and the supply chain, as you put it, it’s challenging. Sometimes for centres to have contrast because it takes longer in the scanner and therefore one can do fewer scans in a day. And this can be a challenge for the centres. So there’s a lot of work going into looking at the the use of bi-parametric – is the sort of terminology – MRI scans, and I think it’s a pretty close thing where actually the contrast in the initial diagnostic setting is really necessary and I think more research will come out.

Clare Delmar:
OK, so so I’m a patient and I now know that I need to have an MRI and the MRI is going to determine whether or not I need to have a biopsy. OK?

Tim Dudderidge:
Yes.

Clare Delmar:
So you’ve given me a few variables. And again, I’ll point listeners to our website later for more detail on this. But so let’s just say our patient needs to have an MRI. He understands why. He understands that it’s going to be interpreted to determine whether or not he needs a biopsy. So how critical, then, is the reporting? And it sounds like more variables occur here. Does the reporting vary amongst practitioners? And can that lead to bad diagnostic and treatment decisions?

Tim Dudderidge:
Well, I think that the first thing is, in an ideal world, a prostate MRI should be reported by somebody reporting a lot of prostate MRIs and uroradiologists will have this is one of their main chunks of their work, because there’s a high volume pathway. So there’s a lot of these scans to report. And if they’ve been through the sort of training of prostate MRI reporting, then hopefully you will get a kind of standard of report which meets those ESUR guidelines. Now, not all centres against for time pressures are able to produce a report which includes an image representation of the location of any lesions. And that is really the ideal where you get a graphical representation and maybe even some representative images embedded in that report to show you where abnormalities are. But I think at the very least, you do want to be having reporting using the Likert or PIRADS reporting system – these are two different systems. The PIRADS one purely relies on the imaging characteristics, whereas the Likert score does incorporate some of the clinical characteristics. There’s, again, a debate about which of those is best. Well, basically, it’s a one to five scale with one being benign and five being cancer. And you’ve got shades of grey in between. And the bottom line is, if you’ve got a three, which means equivocal, there’s a strong chance you should have a biopsy. And I personally recommend biopsy for all of the Likert or PIRADS three cases. But in patients who have a low PSA density that basically measures the amount of PSA relative to the size of the prostate. In those cases where you score a three, you can consider avoiding a biopsy and maybe reviewing the situation after a year with repeated imaging. And that’s not at all unreasonable. And people use cut points of, say, 0.12, for whether you have a biopsy or not, with high PSA density above that level triggering a biopsy. So I think you can discuss that with the patient and also have a sense of their comfort level with risk. Some people want to avoid a biopsy at all costs. Other people want to make sure we don’t leave a stone unturned and get every bit of information. So you have to just assess the patients view on that.

Clare Delmar:
So you have PIRAD and that’s a piece of information that the radiologist determines through from the image. What about Likert? Can you just describe that briefly?

Tim Dudderidge:
So Likert is effective is a sort of parallel system which incorporates a sort of clinical judgement. And so if with the PSA and the interpretation of the image, the radiologist feels that that they want to sit on the fence, they’ll give it a three, if they think they’re suspicious, they’ll give it a four if they’re absolutely sure it’s cancer they’ll give it a five. And on the other side, if they think it’s probably benign but there are some characteristics which are not entirely normal, they might give it a two. But if it’s plumb normal, they’ll give it a score one. So it’s much more a clinical judgement by the radiologist.

Clare Delmar:
Do radiologists communicate both of those scores are one or the other?

Tim Dudderidge:
Normally they just communicate with the system that they stick to. Otherwise, it gets it gets confusing enough as it is, I think.

Clare Delmar:
OK, so the patient should know that the communication between the radiologist and the urologist based on the image is going to be based on this score.

Tim Dudderidge:
After treatment, it’s probably more appropriate to use the Likert scale because after any ablation and so on, the PIRADS is not really designed for that situation.

Clare Delmar:
OK, all right. So to me, those are the big critical things to understand, at least at a surface level about the imaging. So then then you, the urologist, makes a decision about whether to biopsy or whether or not to biopsy. And that’s based on the information we’ve just discussed. So what does the patient need to know about the different types of biopsies? I know you’ve touched on this a little bit earlier, but maybe you could just sum that up here as we move down the supply chain, so to speak.

Tim Dudderidge:
I’ll just get transrectal out of the way, because I think it’s not completely historic. It’s still done in many centres. It’s a very convenient way of having patients come through the system and get through maybe six or seven patients in a morning quite comfortably. But really, you are limited to sampling the peripheral zone and you can do some targeted biopsies. It’s quite possible to do that with this cognitive fusion. And even some of the systems allow for software fusion during transrectal biopsy, but it’s quite difficult to sample the front of the gland. It’s quite painful to have to insert the needle a couple of centimetres in and then fire it rather than just firing it when it’s been inserted five millimetres of so through the rectal wall. And so I think that there are some limitations with transrectal biopsy. And of course, you’ve got the infective risks associated with it.

Clare Delmar:
How severe is that how how much should. patient be concerned?

Tim Dudderidge:
Well it varies from centre to centre. It depends on the local flora – the bugs basically that are around and also what antibiotic protocols used. Some centres are avoiding infection by giving three different types of antibiotics, others maybe using a pre biopsy test to look for resistant organisms just by culturing the fecal flora. So there’s lots of different ways to reduce it. But I mean, it really is trying to avoid a very avoidable problem if you just don’t put the needle through the rectal wall. And that’s really why everyone, I think, feels that transperineal biopsy would be better. Now the problem historically has been that with a transperineal biopsy and this is a biopsy where the needle travels through the skin just in front of the anus and behind the scrotum, the problem is that that’s quite uncomfortable to do that on the local anaesthetic historically. And so it’s all been done under the general aesthetic. And clearly the resource implications for that are quite significant. And so it’s not just the needles passing but actually we’ve used this thing called a stepper and a template. So a stepper basically holds the ultrasound. And it’s sort of a rigid thing which moves in and out of the rectum. And the trouble is, if you’re awake and that is sitting in the rectum, it’s very uncomfortable, not just the passage of the probe, but the fact is sort of on a fixed jig and the patient is having this thing moved in and out and patients don’t tolerate that so well and they end up moving around, which really then compromises that situation if you’re doing software fusion. There has been an advance along side improvements in the technique of local anaesthetic. There’s been an advance with the use of something called a precision point needle guide. And I think for delivering outpatient ambulatory transperineal biopsy, this allows the ultrasound to be free hand, which means you’re not forcing it against the patient, which it what causes the discomfort. And a combination of the transperineal approach and the avoidance of this kind of fixed stepper means that the procedure is pretty well tolerated and then overcomes the problems of transrectal biopsy, which is you can’t sample the anterior part of the gland. With the precision point biopsy it’s quite straightforward to sample the front of the gland. So I think that we’re going to see in the high turnover situation where resources are important and general anaesthetic is not possible that the precision point biopsy will largely take over. And I think there will still be a place for general anaesthetic, targeted biopsies and systematic biopsies. So I think that the fusion is probably going to be a bit more reliable when you’ve got a static situation and you don’t have the free hand ultrasound probe. And I think when you need to take lots of biopsies in a prostate mapping situation -which doesn’t apply to all – but when you need to take lost of biopsies, I think it’ll be more comfortable for patients to have that under a general aesthetic. So for the time being, I think my preference is to offer a general aesthetic where it’s possible but where that’s a challenge for resource purposes, then the precision point transperineal biopsy is probably the favoured approach.

Clare Delmar:
OK, so that’s a lot for patients to take on. But again…

Tim Dudderidge:
It is, I think, a diagram of this would be useful.

Clare Delmar:
But the key takeaway is that a transperineal over a transrectal is …

Tim Dudderidge:
I would say so, yes.

Clare Delmar:
From both an infection point of view and often from a targeting point of view and often from an anaesthetic point of view.

Tim Dudderidge:
One thing that people ask me a lot about any kind of biopsy is about seeding. And I don’t know where they’re finding information suggesting that seeding is a problem. But I’ve never come across a case… there’s only a couple of reported cases I’ve seen. But it’s not a problem that we encounter. And I think for a tumour to seed through a prostate biopsy, you’re dealing probably with a very aggressive type of cancer anyway, not the sort of standard type of prostate cancer. And I’d imagine that the seeding would be one of many problems in those circumstances. And so I’ve never seen in my practice seeding from a transperineal or transrectal biopsy. So I don’t think men should be worried about that.

Clare Delmar:
OK, so now let’s move on to the sort of not final, but the maybe the last stage before you ultimately have a diagnosis, I guess. And that’s the pathology. I mean, is the provider in the process for pathology or histopathology something a patient should be concerned about?

Tim Dudderidge:
Well, most uropathology will be reported by specialists, but if you’re in a centre where it’s not a specialist centre where maybe prostatectomies are not being undertaken, just the diagnostic side of things, you may have a generalist reporting the biopsies. And in some centres, those biopsies are then re-reported at the the tertiary centre where we have MDTs occurring. But if that’s not the case, particularly if the biopsy grade or the details on the biopsy are critical to your decision making, you may wish to consider getting a second opinion on that. We’ve certainly seen cases where that has changed and where that has led to an alteration in the decision. The other thing is about the nature of the report. Some pathologists who are still not familiar with the use of focal therapy may not give the details of each individual core, which allows you then to plot whereabouts the cancer is and help to plan focal therapy. So I think that making sure that you’ve got in the report enough information to determine the location where the disease is and where it is not, and also which side has what grade. So the right might have a low volume Gleason 3+3 and left, might have a moderate 3+4 and that kind of case would be suitable for focal therapy. But if the summary is just that you’ve got cancer on both sides and it’s 3+4, which is still correct, it’s just too much of a generalisation. It doesn’t give you enough information to know. And so in those cases, we sometimes have to re-report the biopsies as well.

Clare Delmar:
And then finally, I mean, all this so-called supply chain gets pulled together through something called the the multidisciplinary team or the MDT. And I know you’ve been a strong advocate and innovator around MDTs, which I guess in some ways can be considered the most important part of the pathway, because I guess this is where you determine what are the options for the patient and where you really engage him. Can you just explain briefly how these work and how a patient can engage with the process?

Tim Dudderidge:
The first thing that the MDT is not something which engages with the patient, which is its chief problem. It’s basically a business meeting amongst specialists. And we have all the information drawn together and it serves a number of purposes. It’s largely something that belongs with the NHS. But in the private sector, these meetings have also sprung up but they serve slightly different purposes. Within the NHS the first target was to make sure that patients have an opinion about their cancer, which included all of the relevant specialists, including the radiologist, histopathologist and the oncologists and the surgeons. And that way that it meant that all the relevant options were considered. And I think that there’s a bit of a difficulty with recommendations coming out of MDTs because the person who’s missing from that room is the patient. And it’s not possible to have this meeting with patients involved. The net result is that you you are missing a very important bit of information. And it may be that some of that is captured in the clinic letters where the patient has been involved. But very often elements will be missing from that. And so I think at best, the MDT can assimilate the information, although sometimes it fails to do that. It can identify the relevant options. And again, sometimes MDTs fail to do that and then it can allow the clinician who sees the patient to discuss the findings, a bit of a guide as to where the likely best option for the patient is, but the person who sees this MDT report really should start afresh with the patient and use the MDT opinion as a sort of a clue, but not as a sort of a diktat. And I think this is where things can sometimes go wrong, especially where the MDT has misinterpreted something. I’ve seen cases where the MDT has an outcome written down which is completely incorrect. And so human error can come into play. It’s very important clinicians check everything, make sure that the MDT has got it right. Also, sometimes the MDTs might have a biased view. For instance, some MDTs don’t mention focal therapy at all. They have a biased view against it and just say because it’s not in a guideline, it shouldn’t be even talked about. I think that that is unfair because we have sufficient evidence, in my view, to say that men should be presented this is an option where it’s a suitable option. And so I think it may be that the MDT that your case has been discussed that just wouldn’t have considered it at all. And I think that that’s a great shame.

Clare Delmar:
How does a patient respond to the to the MDT report?

Tim Dudderidge:
I think as far as the patient is concerned, I’m not sure they should take a great deal of attention to it because there is a tool in the NHS as much for managing the workflow of cases coming through so that people end up in the correct clinics and so on. But I think in terms of trying to make a decision, I think it’s far more valuable to have a discussion with a clinician to get a feel for how the options are being explored and whether all of the options are being considered. And it may be that the clinician says, well, I just don’t know about that. And then you can say, well, I know a bit from my reading, I would like to know more from an expert. Can I have another opinion? And so I think any clinician who resists that I think is is doing patients a disservice. I think that if a patient has an interest in a type of treatment, answers should be provided in a balanced way. And, you know, sometimes people ask me about types of radiotherapy that I don’t know about. I know that my colleagues might say, oh, like proton beam therapy, we don’t normally recommend that and gives a few reasons. But if a patient really wants to know about it, you shouldn’t dismiss that. You should say, well, if you want to know about it, this is how you pursue that.

Clare Delmar:
You operate that way, I know you’re a big advocate of the so-called Montgomery ruling from a few years ago, which kind of upholds what you talking about.

Tim Dudderidge:
Well, I think that patients don’t just give informed consent about procedures. They need to make an informed choice. And that means being informed about things you might not agree with. I mean, your job is to explain why you don’t think it’s a good idea if you don’t think it’s a good idea. But if the patient doesn’t like your opinion, you know, that’s their prerogative. They should go and find a doctor who can explain in a way that they find agreeable. I have to say, good practitioners of things like proton beam radiotherapy, for instance. I’ve seen letters where they’ve said, I think you should have normal radiotherapy. And if they’re good clinicians, they will state factually what is recommended. So I think that if if you’ve not had that experience out of the MDT or out of your clinical discussion and you feel that you haven’t been provided with that rounded opinion, that’s where a second opinion can be helpful, because what it might do is completely just repeat what they’ve already told you and then it gives you confidence that what you were told the first time was correct. But sometimes, especially when you speak to someone who does get involved with focal therapy, you can find out whether or not you are a suitable candidate. And certainly in my practice, if I wouldn’t normally recommend it, I don’t recommend it. If somebody is really, really keen on focal therapy, but I think they should have surgery. I say you should have surgery or radiotherapy or whatever the options are.

Clare Delmar:
Yes, very important.

Tim Dudderidge:
And I think it’s important that people seeking a focal therapy opinion should be reassured that they’re not just going to get a yes or no about focal therapy, they’re just getting an overall holistic opinion about their case

Clare Delmar:
Excellent. No, I think that’s that’s crucial. Tim, thanks so much for sharing your experience and insights.

Tim Dudderidge:
Pleasure.

Clare Delmar:
It’s been an absolute pleasure talking with you. If you’re interested in contacting Tim or learning more about imaging led diagnostics and treatments. Visit our website at www.thefocaltherapyclinic.co.uk, where you can access additional interviews with patients and clinicians about their experiences with prostate cancer. Thanks for listening and from me, Clare Delmar. See you next time.

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