Prostate imaging: the diagnostic revolution continues
A conversation with Oliver Hulson
Oliver Hulson, Consultant Radiologist at Leeds NHS Trust and Clinical Champion for Prostate Cancer UK joins OnFocus today to discuss the critical importance of radiology in the diagnosis and treatment of prostate cancer, and what he’s doing to both advance imaging effectiveness and instill these advances in clinical practice.
Clare Delmar
Hello and welcome to on focus brought to you by the focal therapy clinic, where we engage 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 among men in the UK, and with this somber fact comes a multitude of challenges and opportunities. I’m Clare Delmar. As we move into 2022, I’m going to be diving deeper into some of the more challenging issues faced by both patients and clinicians, including technology, clinical adoption of innovation, inequalities and nonclinical aspects of prostate cancer. Today, I’m joined by Olly Hulson, consultant radiologist at Leeds NHS Trust and clinical champion for Prostate Cancer UK. He’s here to discuss the critical importance of radiology in the diagnosis and treatment of prostate cancer and what he’s doing to both advance imaging effectiveness and instill these advances in clinical practice. Olly, thank you so much for joining me today.
Olly Hulson
Thanks for the invite, Clare. It’s really good to talk to you.
Clare Delmar
Good. Well, I have such an interest in imaging, and I see this as an area that’s probably had some of the greatest advance in the last ten, five, even the last couple of years. And I really want to sort of dig in to hear how you’re leading this field. But before we do that, and or maybe a nice segue into that is maybe you could just share with us a little bit about you and you I know you trained as a radiologist. How did you come to specialise in uroradiology?
Olly Hulson
OK? Well, I think I’ve always had an interest in men’s health as a man who likes to stay healthy. And I was training in radiology at a time when multi parametric prostate MRI was gaining traction in the diagnosis and treatment of men with prostate cancer. I’ve been a consultant for just over five years, and even in this relatively short space of time, there’ve been further significant developments in the area. As you know, pre biopsy MRI is now become firmly embedded in the patient pathway for suspected prostate cancer within NICE guidance and as a significant role in the management of patients on active surveillance. And also we’ve seen transperineal prostate biopsy come to the forefront, too. So I’m excited to see what developments the next five years have in store of my career.
Clare Delmar
OK, well, indeed. And so you mentioned about the changes and particularly in what you’ve called the pathway. So maybe you could talk a little bit more about how you see the development and perhaps even more importantly, the acceptance of multiple parametric MRI impacting the diagnosis and treatment of prostate cancer in this country.
Olly Hulson
I think that’s a really good question. We’ve already seen the effects pre biopsy, multiple parametric prostate MRI has on patients with suspected prostate cancer. We know from good quality research that it’s highly accurate in detecting clinically significant prostate cancer, and around 90% of these cancers can be picked up on MRI and perhaps almost as important, we know that in the case of men with a reassuring PSA level with a reassuring DRE that a physical examination of the prostate and a reassuring MRI scan, we can safely exclude clinically significant prostate cancer in these men, such that these men can safely avoid a biopsy and be followed up with a PSA test or a further MRI if needed. As I said previously, multi parametric prostate MRI is well-established in the management of men on active surveillance and again from good quality research we know that there’s no contraindication to continued surveillance for these men if their PSA is reassuring and the MRI is reassuring also, so we can safely follow these men with serial MRI scans and avoiding either repeat biopsies and also disadvantages of progressing to treatments as well. I think in the future, there’ll be further advances relating to artificial intelligence in the interpretation of prostate MRI. And I know there’s a number of companies making exciting developments in this arena, so it will be fantastic to see these developments come to the market. I think these artificial intelligence software solutions are being utilised in the detection of cancer on MRI, but also to assist us with treatment planning, tumour surveillance in the active surveillance program and also decision making as well.
Clare Delmar
Mm-Hmm. OK. Well, I mean, that kind of introduces a something I wanted to talk about, which might be a little bit controversial, and that’s this sort of so-called shortage of radiologists generally in this country. And then I expect even more so within the specialism that you’re practicing in, uroradiology. And obviously, that would be one driver of some of the artificial intelligence solutions you were just describing. And I’d like to come back to that. But before we do, I’d like to just hit on this point about sort of not just the productivity of a radiologist, but I guess the variability of how radiologists read prostate MRI scans. So why don’t I just throw out a hypothesis that a limiting factor in realising the full impact of multi parametric MRI in diagnosing prostate cancer is that there is this variation in the quality of reporting across hospitals. Do you agree with that? And if so, how do you see this challenge could be addressed?
Olly Hulson
I think it’s a really good point, but I’m not sure that I agree. There’s been a lot of talk. In professional forums the last few years about whether we should be certifying radiologists as being accredited in the interpretation of prostate MRI. And this has been done in other areas of radiology and other areas of medicine as well. And I agree that whilst we need to maintain standards in reporting and this is the best thing for the patient. This approach concerns me for a number of reasons. One, as you’ve alluded to, we don’t have enough radiologists currently to report the imaging that we undertake. And I think taking an approach of accreditation may deter others from taking on this work, and it may also deter trainees from embarking on a career in prostate MRI and uroradiology thinking, actually, if I need to become accredited, this is another hurdle I need to get through an already packed training program. I think probably a better approach would be to develop kind of regional imaging networks and regional imaging collaboratives where colleagues can discuss cases, share cases, look at difficult cases together and learn from one another. And also, I think this will have benefit as well in improving our MRI protocols. So that’s the protocols that we set up on the MRI scanners to get the best imaging as possible out of the machines. And I think arguably this would have a significant improvement on the quality of reporting by osmosis, really, if we’re kind of learning from one another and learning from the best rather than looking at accreditation.
Clare Delmar
And sharing those interpretations?
Olly Hulson
Exactly.
Clare Delmar
Is that what you’re doing with Prostate Cancer UK? So I mentioned in my introduction that you were recently appointed a prostate cancer UK clinical champion. Is this the kind of work you’re doing in that regard?
Olly Hulson
I have been in the past actually, and I’ve been working with them looking at the adoption of MRI across the country. But my clinical champions project is something entirely different. I think in my role as a radiologist in Leeds, I perform a lot of prostate biopsies, and when I’m talking to these men, when they come in for the biopsy as part of my initial patter with them, I ask them how they’ve come to this point. What prompted them to get that PSA checked and that type of thing. I was hearing with kind of relatively alarming frequency, the same thing over and over again from these men that they’d been to their GP or they’d been to the, you know, the nurse at their GP practice to ask for a PSA test, either because they had symptoms or not uncommonly, because, you know, a friend at the golf club had been diagnosed with prostate cancer or someone down the pub had been diagnosed with prostate cancer and they thought, Well, maybe I should get my PSA checked. And then when they go to their GP, the GP says, Oh, well, maybe if you’ve got no symptoms, we shouldn’t be doing this or the risks of a biopsy and the risk of you getting significant infection after a TRUSS biopsy, or there’s a risk of over-diagnosis which… and I hate that term because you can’t over diagnose cancer, you can over treat cancer. You can’t over diagnose cancer. Cancer is cancer. So as part of my program with Prostate Cancer UK for their clinical champions, I’m trying to educate and empower GPs and nurses in primary care about the significant advances and developments we’ve made relating to prostate MRI and also trans perineal biopsy and kind of getting across to them the message that may be the scales have tipped in favour of PSA testing now, and we’re not where we were ten or 15 years ago, where we were picking up more insignificant cancers and we were causing infections from TRUSS biopsy. Now we’ve got pre biopsy MRI so we can safely avoid biopsy in some men and so in Leeds, around 30% of men won’t have a biopsy on their initial kind of journey down the pathway. And also with trans perineal biopsy, as you know, the risk of infection is significantly reduced. So my work with Prostate Cancer UK is more about kind of getting that message across to GPs.
Clare Delmar
And so what are you finding? I mean, can you share some of your observations?
Olly Hulson
Yeah, my wife’s a GP. So we have arguments over the dinner table about this. And although she’s on board with what I’m doing and she’s very supportive, she’s coming at it from a general practice point of view, and they have so much work on their plate, as you’ll see in the press. General practice is getting hammered as as is the whole of the health service currently, but those guys are right at the front and the message often comes back from general practice is well – Why does prostate cancer matter? Why not the other 100 cancers we deal with? Why not blood pressure? Why not heart disease? And we can’t expect them to be experts in every area of this. We can’t expect them to keep up to date with all the advances in all the cancers. But what what I ask of them is not to deter men. So say, for example, a 60 year old man has come to them with a chest infection. And just as an aside, he said, Oh, I’ve read about this PSA test in the newspaper. What about this? What I’m asking GPs to say is, Oh yeah, maybe we can do a PSA. Maybe that’s a good thing to do, rather than saying, you know, this isn’t for you, because that could be that man’s only visit to the GP in ten years. That’s your one chance to pick up the cancer, I guess.
Clare Delmar
So how is that being received?
Olly Hulson
Pretty good, actually. I’ve been doing some kind of online education stuff and just trying to keep it really open, so an open forum for discussion. And I’ve been wanting to hear back from GPs as well about their thoughts rather than me kind of pointing the finger and saying, You’re doing this all wrong. The approach I’ve been taking is well, you know, this is my take on it. But what do you think? So far, they’ve been really supportive, actually, and I’m hoping this will pan out to more men being referred and we pick up more significant cancers.
Clare Delmar
I mean, just the radiology element actually help in your argument and that what you’re saying is that, look, if I can get you to undertake more PSA tests for men now that we have this, this new intervention, we could actually catch more cancers. In other words, it’s all part of a pathway.
Olly Hulson
I think so, yeah. And I think the message that not all men embark on the pathway are going to end up with the biopsy, they’re going to end up with a prostatectomy. The fact that if we do find anything on the MRI scan yet you can say you need a biopsy, but we’ll give you the best biopsy first of all, that’s a transpariniel biopsy. It’s it’s much safer. It’s more accurate. So we can be confident that we’re picking up the cancer that we can see on the MRI scan. And then also, you know, not all men with prostate cancer need treatment. So the fact that we’ve got really robust active surveillance program again utilising MRI. So we’re using the technology we’ve got. And so we’re trying to treat the men who need treating. And clearly at the moment, maybe there’s an argument that we do over-treat, but we’re asking that question more often. So I think that’s just the message I’m trying to get across, really.
Clare Delmar
And, you know, back to the radiology element. I mean, for most of these practices, if they concede to your request and say, Yeah, yeah, you’re doing a great job, yeah, we’re going to try to do more PSA tests. Can they also guarantee that their patients will be able to get an MRI should that be required?
Olly Hulson
Yeah, I think we’re very lucky in Leeds that we’ve got fantastic access to MRI and also, as you said, the radiologists to report it. I know in other parts of the UK that’s not always the case. But again, I think Prostate Cancer UK and NHS England are making headway with that, such that pre biopsy MRI, for the most part, is the standard of care now.
Clare Delmar
And you think back to what you said earlier that some of these some may be diagnostic centres, I don’t think used that term, but would actually help in reducing any kind of variation and give more men access to the pathway?
Olly Hulson
Yeah, yeah, these kind of imaging collaboratives and working together. Yeah.
Clare Delmar
So I just want to pick up on another sort of point about the GP project. I mean, are you also finding I mean, I’m presuming that your work isn’t concentrated in any one particular area. I know you’re based in Leeds, but is this more regionally dispersed?
Olly Hulson
Yeah. So I’ve been focusing on the north of England really.
Clare Delmar
Okay. And I guess my question is in terms of observing other things, what are you observing in terms of different populations? I mean, one of the things we keep hearing about coming out of the pandemic is how these health inequalities across the country, you know, across all kinds of disease areas and all kinds of populations have become even more pronounced. Is that something you’re seeing through your work?
Olly Hulson
That’s really important. And I think before I embarked upon this project, I don’t think that had appreciated the health inequality within prostate cancer, really. I’m sure you’re aware that black men are at increased risk of prostate cancer. So if we consider, you know, the average man walking down the street, his risk of prostate cancer in his lifetime is one in eight, whereas for a black man, that’s one in four. Asian men. interestingly, they’re at reduced risk of prostate cancer compared to the general population. So we see for an Asian man, their risk is one in twelve. But that doesn’t really reflect the true picture because we know that men that move from Asia or the Indian subcontinent, for example, once they move to the UK and adopt the more Western lifestyle, their risk of prostate cancer increases as well. So there’s clearly environmental factors we’re not aware of such that, you know, people saying, well, actually it doesn’t apply to us, and that’s not the case. And also, it’s a double edged sword, particularly with black and ethnic minority groups, because we know that our current health interventions aren’t particularly great at targeting these groups of patients. So these men will present later with more advanced prostate cancer. And I know that in my own practice, I’ve probably done over 200 biopsies in the last twelve months, but I can probably count on two hands the amount of black and minority ethnic patients I’ve biopsied. And that’s not to say, you know, as you’ll be aware, Leeds is a hugely multicultural, diverse city. And so we know that our current health intervention isn’t targeting these individuals. And so that’s something I want to develop further over the next few months really, about how we how we target these groups and how we get the message to the to the men that need it most really.
Clare Delmar
Really important, and my first podcast of this year was with a extremely inspirational man called Errol McKellar, who has set up a foundation to bring mobile PSA screening to minority populations. And I’m going to connect the two of you around this. And I think there there are a number of people who are really trying to implement what you’ve described, so hopefully this can be implemented.
Olly Hulson
Yeah, definitely.
Clare Delmar
Super important. So what you’re doing is absolutely fascinating, and the other thing I’m picking up is, quite impressed with the fact that as a radiologist who isn’t diagnosing clinician per se. Correct?
Olly Hulson
Yep, yep.
Clare Delmar
You know that you have such a level of a) concern and b) engagement with patients. I think that’s that’s really impressive. And so far in our conversation, I think we’ve been talking at a kind of a sort of a higher level, population level. But what I’m really interested in is, you know, since a lot of people listening to this would be prospective patients or current patients, what would you like to say to men who are patients or could be patients or who have friends who are patients that they need to know about the radiology that underpins their diagnosis and ultimately their treatment? How can patients be better informed about the kind of work you’re doing and its importance?
Olly Hulson
Yeah. So what I would say is the message I want to go out there to to all men over 50 is that you’re entitled to a PSA test. So if you go to your GP or the nurse at the practice and you’re over 50, you don’t need to have symptoms. You’re entitled to a PSA test as per the NICE guidance when you’re over 50. If you have a family history of prostate cancer, so be that your dad or your brother or even a family history of breast cancer. So if your mother’s had breast cancer or sisters have breast cancer, then we advise that you have a PSA test over 45. So don’t take no for an answer. And if your GP or the nurse says you know this isn’t for you, then ask why and have that conversation with them. And if you do have a raised PSA, this doesn’t mean you’re going to end up with a biopsy at the end of that , it doesn’t mean you could end up with a prostatectomy and your prostate is going to end up in a bucket. It means that we need to investigate it. Most causes of raised PSA aren’t cancer. There’s lots of causes of rage PSA. It can mean that the prostate inflamed. It can be raised after sexual intercourse or vigorous exercise. So just because you have a raised PSA doesn’t mean you have cancer. But as I’ve said previously, now that we have access to fantastic quality MRI imaging, we have access to the best biopsy and in a trans parieniel biopsy at the first visit. We know that we can provide you with the best possible care and we can pick up the cancers that matter, and we can keep an eye on the cancers that we consider to be lower risk of of causing any harm.
Clare Delmar
Olly, thank you so much for joining me today. This has been really interesting and I think of enormous benefit to to our listeners, so thanks once again.
Olly Hulson
Thanks so much, Clare.
Clare Delmar
A transcript of this interview and links to all of his work for Prostate Cancer UK are available in the program notes on our website, along with further information on diagnostics and treatments for prostate cancer. And additional interviews and stories about living with prostate cancer. Please visit www.thefocaltherapyclini.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic. Thanks for listening and from me, Clare Delmar. See you next time.