RE: National implementation of multi-parametric MRI for prostate cancer detection – recommendations from a UK consensus meeting
Letter to the Editor
National implementation of multi-parametric magnetic resonance imaging for prostate cancer detection – recommendations from a UK consensus meeting [1]
Dear Sir,
Appaya et al report on an expert consensus meeting regarding the implementation of multi-parametric magnetic resonance imaging (mpMRI) for prostate cancer detection [1]. A key item related to ‘who can request an mpMRI’ for patients with suspicion of prostate cancer. The panel unanimously agreed that GPs should not be able to. This is perhaps unsurprising, given the panel was composed entirely of specialists. The authors did consider inviting a GP: however, their assumption was that other than for this question a GP would have little to add. We believe this was a critical omission, as improving access to diagnostic testing in primary care could improve prostate cancer diagnosis, urology outpatient workloads, patient experiences, and outcomes.
The vast majority of cancer diagnoses, including prostate, occur in symptomatic patients presenting to primary care [2]. GPs already have direct access to diagnostic testing for several other cancer types in the NHS – all endorsed by NICE guidance – including gastroscopy, colonoscopy, flexible sigmoidoscopy, MRI head, ultrasound, and CT abdomen. Each can be requested in primary care, with GPs retaining clinical responsibility for the investigation findings [3].
An oft-raised concern with GP direct access to diagnostic tests is that it will lead to inappropriate referrals. However, a recent systematic review of direct access cancer testing in primary care found no significant difference in pooled cancer conversion rate between GP and specialist requests (except for gastroscopy) and no significant difference in the appropriateness of referrals. Time from referral to testing was shorter with GP direct access testing and patient satisfaction was high [4].
If implementation of pre-biopsy mpMRI truly does reduce the need for biopsy in 27% of men, as suggested from the PROMIS [5] and PRECISION [6] trials, then direct access testing in primary care could significantly reduce referrals for suspected prostate cancer. At a time of limited NHS resources and more ambitious targets for cancer diagnosis and treatment times, this could ease the pressure on Urology departments across the UK.
There are several unanswered questions with regard to the optimal use of pre-biopsy mpMRI: for example, which men to test, how to safely follow-up mpMRI-negative patients, and MRI capacity. Including GPs in these discussions would not just be courteous: it may find better answers.
Dr Samuel Merriel1, Dr Fiona Walter2, Prof Willie Hamilton3
1 Clinical Research Fellow, University of Exeter
2 Principle Researcher in Primary Care Cancer Research, University of Cambridge
3 Professor of Primary Care Diagnostics, University of Exeter
References
- Appayya MB, Adshead J, Ahmed HU, Allen C, Bainbridge A, Barrett T, et al. National implementation of multi-parametric magnetic resonance imaging for prostate cancer detection – recommendations from a UK consensus meeting. BJU Int. 2018;122(1):13–25.
- Emery JD, Shaw K, Williams B. The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol. 2014;11:38–48.
- National Collaborating Centre for Cancer. Suspected cancer [Internet]. NICE. London; 2015.
- Smith CF, Tompson AC, Jones N, Brewin J, Spencer EA, Bankhead CR, et al. Direct access cancer testing in primary care: a systematic review of use and clinical outcomes. Br J Gen Pract. 2018;(August):1–10.
- Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet [Internet]. 2017;389(10071):815–22.
- Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med [Internet]. 2018.
Reply by the authors
I thank Dr Samuel Merriel and Dr Fiona Walter for writing in about the role of the GP in requesting prostate MRI studies. Indeed, we reported that our consensus panel unanimously agreed that GPs should not be requesting prostate MRI studies [1]. Their letter in follow-up of this offers an opportunity to explain further this recommendation.
We adopted a UCL-RAND based methodology to conduct the consensus meeting. Whilst we would have liked to have broader representation on the panel, one of the key metrics necessitates that a minimum proportion of participants be able to answer a particular question for that question to be valid. Further broadening of the panel risked delivery of this.
Nonetheless, we agree that GP representation in designing and implementing healthcare is invaluable and should not be ignored and could have all of the benefits for prostate cancer diagnostics that are pointed out by Dr Merriel and Dr Walter.
To clarify the consensus panels discussion on this topic; the panel felt that within the current climate there remained many areas that needed standardisation and improvement if we are to realise the benefits highlighted in PROMIS [2] and PRECISION [3] e.g. diagnostic quality of scans, training of radiologists to report scans all the way through to a consensus from urologists of how to manage patients with a specific scan result. The panel did not believe that GPs were incapable of managing direct referral services for prostate MRI, only that this needed to be introduced in a controlled fashion if we were to be successful in implementing multi-parametric MRI whilst maintaining its performance and value. The panel felt that direct GP referral should therefore be re-discussed once mechanisms to maintain scan quality and standards of reporting were realised across the UK.
Indeed, GPs should be included in the discussion of which men to test, how to follow-up mp-MRI negative patients and those related to MRI capacity – all of these assume that one is looking at a test that is correctly set-up and reported to a specific standard. Perhaps a consensus on management of patients amongst urologists and primary care physicians is a warranted next step.
Shonit Punwani1
1Centre for Medical Imaging, University College London, UK.
References
- Appayya MB, Adshead J, Ahmed HU et al. National implementation of multi-parametric magnetic resonance imaging for prostate cancer detection – recommendations from a UK consensus meeting. BJU Int 2018; 122:13-25.
- Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet [Internet]. 2017;389(10071):815–22.
- Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med [Internet]. 2018.
I take issue with Dr Punwani’s rational for his group’s opposition, at least in the short term, to GP requested multi-parametric magnetic resonance imaging for prostate cancer. One of his arguments, viz. that we should wait until “mechanisms to maintain scan quality and standards of reporting were realised across the UK”, avoids confronting the question of what is happening right now. What is happening right now is that many men are having multi-parametric magnetic resonance imaging for suspected prostate cancer, and most men are having biopsies for suspected prostate cancer.
In our hospital in Auckland NZ, all men who have a referral to the specialist urology service because they have a persistantly elevated PSA end up having an MRI scan, but when they have the scan is dependent on the decision of individual urologists, and the service does not have an algorithm. Current practice here is on a case by case basis after referral and after an assessment of the patient within the clinic ( PSA history , rectal assessment and co morbidities). Some men get a scan after the biopsy and some before. I suspect the situation is similar in many units in the U.K.
If GPs were to request MRIs, the reporting standards of those MRIs would not decline from the current standard, unless Dr Punwani is postulating that radiologists have different reporting standards based on the specialty of the referrer. It may be that there is room for improvement and standardisation of MRI reporting but “room for improvement and standardisation” is and always will be a perennial and pervasive issue in every field of medicine and is not a reason to delay an initiative than has the potential to markedly reduce patient harm and to improve patient outcomes.
I do agree that a couple of actions need to be taken to ensure that MRI requests comply with a set of “acceptance criteria”, and would suggest that these acceptance criteria be the same for GP referrers and urologist referrers. (there are no agreed criteria by urologists in NZ yet)
The first action would be to define a “raised PSA” for the purposes of qualifying for a MRI for “suspected prostate cancer”.
The second action would be write a set of acceptance criteria (there are no agreed criteria by urologists / radiologists / GPs in NZ yet)
The PROMIS trial enrolled patients with PSAs up to 15 ng/ml + no previous biopsy.
As a starter for ten in Auckland, “acceptance criteria” (for community MRI), NZ, could include things like:
1) No previous biopsy
2) PSA between 4 and 15 on at least two occasions at least “x” months apart. Test is invalid if testing is done during an episode of prostatitis or urinary tract infection.
3) If patient has a first degree relative with biopsy positive prostate cancer then PSA between “p” and “q” on at least two occasions at least “r” months apart (assuming there would be agreement that the criteria should be altered for this group)
4) GP has followed the Auckland Regional Health Pathway called Prostate Cancer Testing
And exclusion criteria could include things like:
1) Asymptomatic patients with co-morbidities (need to define these) whose life expectancy is less than “y” years
2) Patient was not asked screening questions about cycling, heavy exercise, intercourse, and ejaculation prior to testing
3) GP has not followed the Auckland Regional Health Pathway called Prostate Cancer Testing
Given that in Auckland all patients who are accepted by the urology service get an MRI at some point in their work up, the cost of the MRIs to the health service would remain the same. Benefits to patients from the proposed change look like they would be very positive on a number of fronts.