Prostate Imaging: Crisis or Opportunity?

Prostate Imaging: Crisis or Opportunity?Recent stories in the media have highlighted growing backlogs in cancer imaging within the NHS.

And there has also been recent announcements from the NHS on a future of “one-stop”diagnostic centres based in local communities where cancer imaging could be made more easily available and accessible.

As voices build on how to restore cancer imaging services to stave off a new crisis in cancer care, and to create an opportunity for better and more accessible imaging, it’s a good time to assess what is needed in prostate imaging and to build a platform for consistent, high-quality delivery – which will ultimately lead to better care.

At its most basic, the prostate MRI scan underpins the decision to biopsy or not to biopsy, and it can eliminate 30% of patients from undergoing biopsy.- a huge step forward from the days when all patients with elevated PSA were biopsied.

TFTC Consulting Urologist Alan Doherty points out that:

“One of the main things I think about an MRI scan is that you can try and avoid doing biopsies. You want a patient to have confidence that the PSA is borderline elevated not because of an aggressive cancer and therefore doesn’t need a biopsy. That is the most important aspects of an MRI scan. If you biopsy everyone who has an MRI scan, then there’s no point doing the MRI scan because you’re going to find out what they got anyway. So it’s really important that this concept, and I don’t like the term pre-biopsy MRI scan because it suggests that the MRI scan is just a sort of adjunct to the biopsy.”

At its most sophisticated, the prostate MRI scan confirms location, size and severity of prostate cancer with high levels of accuracy, underpins targeted biopsies and treatments, and monitors progression through active surveillance.

“The current best practice is to have a report where they look at what’s called the PIRADS scores and something else called the Likert score”, says Alan Doherty. “Relatively recently, and even now, you’ll get some reports which will say something like there’s is a slight abnormality on the left hand side. As clinicians, we were left to say what you mean by slight abnormality? Do you mean small? Do you mean it looks like there is a cancer? How likely is there a cancer? So what sort of evolved was a score where a radiologist will say that they think it’s virtually 100 percent likely that there’s cancer there and they’ll give that a score of five and then there will be a situation where they think it’s likely rather than very likely, and in that situation they’ll give a score four and then you will get the sort of threes which are equivocal and then twos where they think it’s unlikely and one where they think it’s very unlikely. Now, within the prostate, I want to know what the score is and I want to know where they think that cancer is likely to be. And so a good radiology report will map the prostate and in different parts of the prostate, will give it different scores. And then what I like to have is a diagrammatic representation of what they’re talking about so I can actually see it in a cross-sectional basis. What that does is it then allows me to biopsy the area more accurately. So basically a report needs to have accurate PIRAD scoring. It needs to tell me where they think the abnormality is. I want to know more than that. I want to know the size of the prostate. I want to know the shape of the prostate. I want to know if there’s any effect on the possible blockage on the bladder. I want to know that there aren’t any surrounding abnormalities in the lymph nodes or the bones. And ideally I’d like to know what’s going on in the kidneys as well. So there’s a lot there. And if an MRI is done properly, you can really move forward with the whole management of the patient”

In the UK, the NHS performs well on delivering the basic requirement, enabling an informed decision on whether to biopsy. Since 2018 NICE guidelines recommend an MRI before biopsying a patient, and the implementation of this has been good. However, at higher levels of sophistication, there is considerable variability in the quality of imaging and reporting. This can have a significant effect on achieving optimal diagnostic and treatment decisions.

According to Alan Doherty:

“(the quality of reports) varies enormously. And I think the diagrams are just so useful because the diagrams reflect what you see when you do the biopsies. They’re the same sort of cross-sectional pictures. And so it makes the biopsy so much easier and better. But also when you communicate the results to your patient, the visual image is universal, whereas the way the radiologists describe the changes varies enormously and it’s really quite complex language. So it’s like listening to a foreign language.”

Alan’s full interview can be heard here.

At TFTC, all patient cases are brought before a multidisciplinary team (MDT) to agree diagnostic and treatment decisions., and the MRI scan and report is the foundation of this discussion. The Consulting radiologist, Dr Clare Allen, presents each patient’s MRI report, and a team of consulting urologists discuss this in the context of the patient’s lifestyle and personal circumstances, leading to consensus on diagnosis and what treatment to recommend. It is very much a case of high quality information (the MRI scan and report) leading to highly informed discussion (the MDT) which leads to optimal diagnostics and treatment decisions.

If you have any questions about your MRI scan and report, or how and where to access a best-practice prostate MRI, please contact us at the Focal Therapy Clinic.

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