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Prostate Cancer Diagnosis. Precision enables better choices

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Marc Laniado, consultant urologist at The Focal Therapy Clinic and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer, joins OnFocus to discuss the concept of precision in the diagnosis and treatment of prostate cancer, why it’s important and how it’s achieved.

Marc has been a dedicated pracititoner and vocal advocate for the precision diagnostics that support focal therapy from his base at Frimley Health, where he is prostate cancer lead at Wexham Park Hospital and has contributed to several pivotal clinical studies and trials on prostate imaging, diagnostics and focal therapy.


Marc Laniado explains why precision diagnostics are important and how they are achieved

Please find below a written transcript of the interview, and call The Focal Therapy Clinic today to discuss your prostate cancer treatment options: 020-7036-8870.

Clare Delmar

Hello and welcome to OnFocus, 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, often avoided, or even ignored. Prostate cancer is the most commonly diagnosed cancer amongst men in the UK, and with this number fact comes a multitude of challenges and opportunities. I’m Clare Delmar.

Joining me today is Marc Laniado, consultant urologist at The Focal Therapy Clinic, and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer.

Marc has been a dedicated practitioner and vocal advocate for the precision diagnostics that support focal therapy. From his base at Frimley Health, where he is a prostate cancer lead at Wexham Park Hospital and has contributed to several pivotal clinical studies and trials on prostate imaging, diagnostics and focal therapy.

He’s here today to discuss the concept of precision in the diagnosis and treatment of prostate cancer, why it’s important, and how it’s achieved. Marc, we haven’t talked in a while. I’m so glad to have you back. And this is such an interesting topic to discuss. So thanks for joining me.

Marc Laniado

Thank you very much, Clare, for inviting me. It’s a real pleasure to be back and talking about things that I have a passionate about. So thank you.

Clare Delmar

Yeah, okay. Well, let’s jump right in. This word precision, is one of these words that is used a lot. We hear about precision medicine. We hear about precision in treatment, and I think it means a lot of things to a lot of people. So I think one of the reasons I wanted to chat to you today was to try to put something straight in a more simplistic and honest way. So, let me start by suggesting that we all agree that the more precise the diagnosis, the more options for treatment that men have. And this would include less invasive ones, obviously. So could you define what precision means in a diagnosis?

Marc Laniado

Sure. Well, as you say, we’re all moving towards more personalised and individualised care. So I guess it’s easy to start with what is not precision. What is not precision is really just saying you have a diagnosis of prostate cancer. We know that a biopsy has been taken, it shows some cancer to be present. And then you’re being told that you’re suitable for treatment, which involves perhaps the whole prostate or doesn’t involve any treatment at all. And often there’s enough information to make a decision about that aspect to think. But then if you try to draw down and look at more focal treatments or treatments which are more bespoke to the individual, that’s not enough. 

And what we mean by precision diagnosis, is that we know where cancer is located, exactly. So it’s not just that cancer somewhere in the prostate, but we know it’s at the front of the prostate or the back of the prostate. We also know how many places are involved by cancer. So it’s not just any area in the prostate, but maybe one or two areas or three. And then furthermore, what exactly the type of cancer that is present? So the grade of the cancer in the various locations within the prostate. 

When we know where the cancer is located, exactly, what type of cancer you have, we can then dissect out the various types of treatment that might be suitable for that man. Treatments that might enable him to preserve those structures important for erections and to be able to stay continent, et cetera. So precision diagnosis means knowing exactly the location, the volume, the length and the type of cancer you have in minute detail.

Clare Delmar

That’s really helpful. And let’s just kind of backtrack a little bit. So tell us how the MRI scan underpins this precision. And I guess what I’m really interested in is, are all MRI scans the same?

Marc Laniado

Yes. Well, I mean, like, if you’re about to go out fishing, we could cast our nets or cast our hook to try and find fish somewhere in the lake. And maybe we’ll catch one, maybe we won’t. And in the old days, we did that when we were trying to find prostate cancer, we’d shoot our needle somewhere into the prostate. And by hook or crook or luck, we might find that there’s cancer present somewhere. But again, we wouldn’t really know exactly where. And it really was a fishing trip.It was luck. And we’d miss significant cancer sometimes and sometimes hit incidental cancer and misrepresent it.

Clare Delmar

Okay.

Marc Laniado

What the MRI scan does, it gives you a map. It’s like a sat nav system. If you want to go from A to B, it’s always a good idea to have planned it. And the MRI gives you that map, it gives you that, if you like geo positioning of where your targets are, and tells you exactly the nature of the prostate so that you can plan treatment. So, for example, you might do an MRI scan that shows that there’s a cancer in the back of the prostate, on the right hand side towards the base of the prostate, so that you know, when you’re going to do your biopsy, you’re going to target your needle into that area there specifically. 

Now the MRI gives you that information. But not only does it give you that information, it tells you whether you’re suitable for one type of focal therapy or another. So it gives you very useful information like that, too. And then it also tells us about whether cancer is just confined to the prostate or if the cancer has gone outside the prostate. There might be times when people examine the prostate and think, prostate feels really suspicious or feels really abnormal. And there’s cancer going through the prostate wall. And so you really need aggressive treatment. 

But then you might have a high quality MRI scan that shows actually the borders of the prostate are pristine. They’re clean. There’s no cancer there. So the MRI scan is much more reliable than the finger for example. It gives this idea about where the cancer is located. It tells us whether you’re suitable for treatment, amongst many, many things, and there are other useful aspects of MRI that should be used to.

Clare Delmar

Okay, so I get that. And you used a wonderful metaphor of the roadmap or the Satnav. But isn’t that really what’s kind of put together by the radiologist? So I guess maybe when I asked my original question, I should have separated the scan from the actual scan report or the radiology report. Is that a fair distinction? And do you think that there’s more variation in those, which could affect the precision that we’re talking about?

Marc Laniado

So not all things are equal. So there’s the MRI scan itself and the MRI scan quality varies significantly. So if you have a very high quality MRI scan, that’s great. You can use that reliably. But not all MRI scans are very reliable. We also need an MRI report, and that MRI report by the radiologist ideally would be done by a radiologist, who has a special interest in identifying and evaluating men who might be suitable for focal therapy

So that radiologist would give you a diagram of where the cancer is located in the prostate. It’ll give you a scoring system to say whether cancer is likely or not. Tell you the size of the prostate. Tell you many other things also, that can be useful when planning treatment. So there are two elements to that. The MRI scan has to be decent quality, but also you need to have a very good radiologist reporting it. And the better your MRI scan, the better your radiologist, the more likely you are to be able to choose a focal therapy treatment with reliability. 

That is, you’ll be able to choose a treatment that you know is likely to be successful. Or, on the other hand, you’ll be able to say, well, look, the focal therapy clinic necessarily going to be the right treatment for you and that you might need to have another treatment. So apart from having a really high quality MRI scan with all the bangs and whistles, it helps to have good reporting. And the radiologists can use software tools to help him or her give you a better report. These can be built in to the MRI scans, that very urologist can do the report accurately and well at that time, or it can be done afterwards. But the software used to fuse the MRI scans together, to give you that bill that enables the radiologist to give his or her fantastic report. It’s also critical to the process.

Clare Delmar

Okay, that’s important for patients to know. So it’s really several elements that they should be aware of, and rather than hang about on that, because that’s important. But now moving on down the pathway, so to speak, how does the biopsy add to a precision?

Marc Laniado

The biopsy at the end of the day is what gives you the proof that cancer is present or not. And without the biopsy, the MRI scan tells you that cancer is likely or not likely, but it’s not enough to make a firm decision on treatment. So the biopsy is essential, and the biopsy itself can be done in many different ways.

Ideally, biopsies be done in a way that target the abnormality present in the prostate reliably, but also hit other areas of the prostate to make sure the cancer is either present or not present there. So in recent times, there’s been a new technique of doing biopsies where you put a little tube through the skin to put your needles through, and then you can direct the needle through the little tube into various areas of the prostate that needs to be sampled.

However, that technique doesn’t lend itself to easy fusion with the MRI scan. So what we like to do when we’re doing our biopsies, if you want to get them as accurate as possible, is to take our live ultrasound image and then fuse it with the MRI scan that we’ve had taken before. So we literally overlay the MRI scan onto the live ultrasound. And when you do that, it means that you can then direct your needles into the appropriate part of the prostate and be sure that cancer is present.

Now, that may seem easy to do, but actually it requires some technical and very sophisticated software to do that, and they’re not all equal. Some give you some degree of fusion, but they’re not so precise. Others are much more precise. But unless you actually physically fuse the software together, you can’t be 100% certain. Furthermore, the other problem is that some techniques from doing biopsies results in quite a lot of manipulation of the prostate during the biopsy itself. And if you do that, then it means that the fusion isn’t quite so accurate, so you get less accurate biopsies.

Yeah, well, it’s very difficult to do that reliably. There are software tweaks you can try and make it work better, but actually, it’s pretty hard. If you want the best quality standard of biopsy, in my opinion, is that you have the biopsies under a short general anaesthetic so that you don’t feel the thing, so you’re completely still. And then you very accurately fuse the MRI scan with the ultrasound and then direct the needles through to the prostate gland without moving the prostate during the process. So you don’t suffer with artefacts induced by shifting the positions. So that is the most precise way to do it.

Clare Delmar

Again, there’s several elements, and I’m interested that some of it’s very much technology led, i.e. the imaging and the fusing, but some of it’s about the anaesthetic. I mean, do you want to say a few more words about the difference between those five or six techniques that use a general anaesthetic versus those that use a local and how they impact precision?

Marc Laniado

The anaesthetic can have an impact on the biopsies, absolutely. Although you can take the biopsies on the local anaesthetic, there’s no doubt you can definitely do that. It doesn’t lend itself to precise diagnostics because of the constraints of having to do the biopsies, often through a single channel on each side of the prostate. So it’s difficult to direct the needle into exactly the correct part of the prostate, because the geometry doesn’t match up. So when you’re doing these precision biopsies this way, then you think the needle goes one way, but in fact, it’s going another, and the MRI doesn’t fuse as well with the prostate, so you can’t be 100% certain of where you’ve put your needle, despite what anyone says.

Clare Delmar

So that’s a lot of information about a lot of elements that ultimately need to a precision diagnosis. And I think what you’ve described or began to describe is what you would probably agree is the gold standard. Starting with the imaging all the way through to the biopsy. And I guess my final question is, how accessible are these to men in the UK?

Marc Laniado

They’re becoming more accessible, let’s put it like that. They were very inaccessible a few years ago. Certainly most of it was only available privately or within some clinical trials. Now the technology has dispersed more widely. But where the improvements have been have been largely in the delivery of transperineal biopsies rather than transrectal biopsies. So most places in the country are doing transperineal; well, not most, but many places are doing transperineal biopsies, but they’re still not quite the highest standard in terms of MRI fusion.

So there’s still usually a large degree of a urologist or some other person trying to mentally fuse the MRI images with the live ultrasound. This is actually very difficult to do. And then often, not only is that difficult to do, but then if you’re also trying to take the biopsies through a single channel, put through the skin between the anus and the scrotum, through the perineum, that single channel means that you have to alter the angle of the needle going in so many times, that it’s very hard again for people to triangulate in their head the complex geometry of the prostate and the MRI scan.

So again, that’s difficult. Although that’s to some extent available and is getting more available, it’s still about the best you can get in most parts of the country. So when we come back to where we started, that really high precise or precision diagnostics is not widely available in the country at the moment, but it is growing, but it’s still not typically what we see. So in our clinic we see many patients who’ve come from other parts of the country who’ve had MRI scans and biopsies done, which largely, I’d say, are inadequate really, for deciding on whether someone is necessary suitable.

And so it’s always best if you have a diagnosis or have a suspicion you have prostate cancer, you seek out the best MRI scan that’s possible and seek out the best diagnostic technique. If you can choose those two things, it puts you in a very powerful position to make decisions about your treatment. Because with that high level knowledge, you can then reliably or much more reliably decide if you need to have a whole gland treatment, that is treating the whole prostate or whether you might be suitable for partial abulation or focal therapy. So, armed with that precision, you can then make a better decision.

Clare Delmar

Marc, that’s really helpful. I think we’ll end there. Thanks so much for speaking with me about this, and I will direct people in the programme notes as to how to get in touch with you if they want to discuss it further.

Marc Laniado

Sure and it’s been a real pleasure for me. Thanks so much.

Clare Delmar

Yeah, thanks again. A transcript of this interview is available on our website, along with further information on diagnostics and treatment for prostate cancer and additional interviews and stories about living with prostate cancer.

Please visit www.thefocaltherapyclinic.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic.

Thanks for listening and for me, Clare Delmar, see you next time.

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