A specialist prostate MRI scan. Image provided by Professor Mark Emberton.
All men with suspected prostate cancer should be offered a specialist MRI scan when they’re referred to the hospital in England, before a biopsy.
That’s what the National Institute for Health and Care Excellence (NICE) has recommended today in its latest guidelines.
And it’s a decision that prostate cancer expert Professor Mark Emberton is extremely happy about.
“It’s a landmark,” says Emberton, a prostate cancer specialist at University College London. “The UK are the first country in the world to formally recommend MRI scans for prostate cancer.”
This special type of imaging, called multiparametric (mp)MRI, combines three different scans to help build a clearer picture of what’s going on in the prostate. And as we’ve blogged about before, it could help to rule out or guide follow-up biopsies.
“The benefits of doing mpMRI is that fewer men will need to have a biopsy. We think that using MRI will mean a quarter of a million fewer men per year in Europe alone will need a biopsy. And there’s a million biopsies done each year in Europe.”
Emberton says that using mpMRI will mean that fewer prostate cancers will be missed. And it will help to reduce the diagnosis of prostate cancers that would never have caused harm, so called overdiagnosis.
Finally, using mpMRI could be easier on NHS purse strings.
“Our multicentre studies have shown that if you rely on mpMRI you’re going to get the biggest bang for your money in terms of diagnosing clinically significant cancer,” says Emberton.
“There are few things that have as much going for them as these scans.”
But while it’s the most budget-friendly method to help assess if someone has prostate cancer, the latest guidelines could have a big impact on another NHS resource: its staff.
The staff behind the scans
First, some potentially good news for the NHS – specialist MRI scans could help to ease some pressure on pathologists.
That’s because mpMRI scans will reduce the number of men who need to go for a biopsy. And it will help to guide the test for men who do need a follow-up biopsy.
Together this means fewer samples (cores) for pathologists to analyse.
“There’s a world shortage of pathologists and so decreasing the number of cores that need to be looked at is important,” says Emberton.
But while routinely using mpMRI might decrease some of the workload placed on pathologists, it will have the opposite effect on NHS staff involved in taking and interpreting MRI scans – radiographers and radiologists.
Radiographers are responsible for taking MRI scans.
“From a UK perspective, imaging resources are already overburdened and so there’s an access issue,” says Emberton. He believes a piece of work needs to be done to work out how much extra MRI capacity is needed in the NHS to accommodate specialist prostate scans.
Dr Philip Haslam, a consultant radiologist and mpMRI lead at the Royal College of Radiologists, says the College is looking at how mpMRI is provided across the UK. The data hasn’t been published yet, but shows that the number of hospitals providing mpMRI is on the up.
“In 2016 we found that 75% of trusts were able to provide mpMRI and in 2018 that went up to 87% in the UK,” says Haslam.
According to Haslam, the introduction of mpMRI will increase radiologists’ workloads quite a bit over the next few years.
“We’ve only got a finite number of trained radiologists in the UK and a finite number of scanners that everyone is fighting to use, who says prostate cancer gets priority?”
And it’s not just having the staff in place. The Royal College of Radiologists surveyed hospitals and found that 77 out of 140 said they needed an increase in scanner availability. And just over half said they wanted a new or additional scanner. This costs money.
But it’s here that the NICE recommendation could help. Although it doesn’t come with funding attached, Emberton hopes the decision will help hospitals to get more resource allocated to the scans.
“It’s always a battle for resources in most trusts, so it will allow people to prioritise MRI prior to biopsy,” he says.
Emberton also hopes that the recommendation will help to start conversations about improving the quality of mpMRI scanning.
Upping the quality
When asked for his mpMRI wish list, Haslam said good quality scanners and well-trained radiologists and radiographers were top of the list. Together these could help provide top quality scans across the country, which may not be the case at the minute.
“I think there’s lots of evidence at present that the quality of the MRI and the way it’s read is really not good enough around the country. And obviously with poor quality imaging we’re not going to get the results that we could,” says Emberton.
One issue that Emberton points to is getting MRI scanners set up properly. “I’d say around half of hospitals have not got their MRI optimised for this type of scan.”
According to Emberton, a lot of MRI scanners are set up primarily for taking images of bone – they’re not tuned to pick up soft tissue like the prostate. And it’s not something that machines come with already in their settings – each hospital will have to set up and optimise their scanner individually.
“It took us about a year to tune our machine until we were happy with it,” he says. For both Emberton and Haslam, improving the quality of MRI for prostate cancer is a priority. But there isn’t a single way forward to help make that happen. Haslam believes some of the answers may lie in training.
Prostate Cancer UK and the Royal College of Radiologists is setting up an online training programme where radiologists can look at prostate MRI scans and practise analysing the images. They’d then get feedback about what they got right and how they’re scoring compares with other radiologists.
They’re also trying to set up a way to remotely help hospitals to optimise their scanners for mpMRI.
“It would be virtually impossible for a group of people to go around every scanner in the country and try and optimise them,” says Haslam. “But if there’s somewhere people can send images from their scanner and we could help improve them remotely then fantastic.”
What’s next for prostate cancer diagnosis?
There’s a lot of work to be done to make sure the NHS has the right staff and tools in place to make mpMRI the success that it could be in prostate cancer diagnosis. But scientists are also thinking about the future, which could mean linking MRI and molecules or gene faults (biomarkers) inside cells.
“That’s the challenge for the next 10 years, integrating all these data – imaging and maybe molecular or chemical biomarkers – with clinical information,” says Emberton.
Together, these could help doctors to better identify who might need treatment, and who doesn’t.
Researchers are also investigating if the time it takes to capture an MRI scan could be shortened, without losing the benefits.
The recommended mpMRI scan records three different images. And according to Emberton, this type of scan takes around 40 minutes to run and requires an injection beforehand, to help improve the contrast of the image.
Emberton believes future work should look at whether two images would give doctors enough information to diagnose prostate cancer in the future, with a scan time of 10 minutes.
But for now, there’s still some work to do to ensure that all men with suspected prostate cancer have access to high quality, specialist MRI scans. And that requires having the NHS staff and scanners in place to deliver them.