National Cancer Communities of Practice Pathways Event. Thursday 8 February 2018 The Wesley Hotel, London

Transcription

1 National Cancer Communities of Practice Pathways Event Thursday 8 February 2018 The Wesley Hotel, London

2 Using MRI in the prostate cancer pathway a decade of experience Caroline Moore MD FRCS(Urol) Reader in Urology, UCL Honorary Consultant Urological Surgeon, UCLH

3 T2 weighted images 3

4 Dynamic Contrast Enhancement 4

5 Diffusion Weighted Images 5

6 A long journey! MRI for focal therapy study MRI before biopsy much better than after Introduced slowly in clinic practice Caused significant delay in timed pathway! MRI clinic v MRI, MDT and CNS appointment on same day Biopsy then booked afterwards Transrectal biopsies by uro-radiologists MRI clinic v 2 November 2015 LA transperineal biopsy offered on same day as MRI and clinic appointment Urologists doing TP biopsies 6

7 Results of first MRI clinic cohort

8 UCLH direct access MR clinic 2 week rule referrals: Booked directly into MRI clinic Morning MRI slot MRI reviewed with referral details at lunchtime prostate MDT meeting (radiology/urology) Likelihood of significant disease reported Afternoon clinic appointment with nurse specialist (Jane Coe/Victor Abu) Decision to biopsy or not, biopsy booked for another day

9 What proportion of men had a suspicious MRI? 13% 16% Low suspicion Equivocal 36% 35% High suspicion for significant disease (organ confined) High suspicion for advanced disease

10 What proportion of men had a biopsy after MRI? 12% 3% Advised no biopsy 31% Declined biopsy Limited TRUS (advanced disease) Standard TRUS 36% 11% 7% Targeted TRUS Template biopsy

11 What were the biopsy findings according to MRI category? Minimum 6mm any cancer or primary pattern or 5mm any cancer or secondary pattern 4 40 Max 3mm Gleason Negative biopsy 0 Low suspicion Equivocal High suspicion (organ confined) High suspicion (advanced) No biopsy

12 What were the findings according to biopsy strategy? Red disease Amber disease Green disease 20 Negative 10 No result 0 Advised no biopsy Declined biopsy Limited TRUS (advanced disease) Standard TRUS Targeted TRUS

13 Average time from referral (days) 100 men before and after MRI clinic v Group A Group B First Investigation MRI Biopsy Decision to Treat Pathway time point

14 MRI clinic v2 (post PROMIS) Clinical triage of referrals Admin team phone patient to check MRI compatibility MRI first then CNS appointment Same day LA transperineal biopsy offered or transperineal biopsy on a later day (after pre-assessment) All biopsies done by urologists Need MRI drawing with formal report from radiologist 17

15 UCLH Prostate One Stop pathway

16 Acceptability of LA TP biopsy Patient survey of 65 men having first biopsy August Local anaesthetic Procedure time (mins) Time to discharge from hospital (mins) Procedural pain mild to none % 80% Uncomfortable or worse 68% 3% Preference if repeat biopsy needed Sedation 72% LA again 97% sedation again

17 Key elements MRI to inform the biopsy decision Can reduce standard biopsies if: Equivocal or negative MRI AND low PSA density Patient preference MRI to inform biopsy route Can target transrectally or transperineally in most cases May influence anaesthetic type & biopsy operator (urologist or radiologist) 20

18 London Cancer Prostate MRI group 2014 onwards Urologists and radiologists from each of the Trusts Formal guidelines 2014 Pictorial report of MRI PACS snapshot or PACS diagram or hand drawn diagram Sharing of best practice Work to optimise MRI at each site Ongoing discussions re Shared reporting formats Shared reporting capacity Training and development across sites for radiology/urology/radiographers 21

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