IP2 – ATLANTA is launched! ATLANTA is a phase II randomised controlled trial that will explore sequential multi-modal treatment using systemic therapy, local physical cytoreduction and metastasis directed therapy in men with newly diagnosed metastatic prostate cancer against a comparator of standard of care alone.
All men with new histologically diagnosed hormone sensitive metastatic prostate cancer, within three months of commencing androgen deprivation therapy (ADT), and of performance status 0 to 2 are eligible. No upper limit on metastatic burden will apply, although men must be fit to undergo all trial interventions at point of randomisation.
Men will be randomised to: Control (Standard of Care) OR Intervention 1 (Minimally Invasive Ablative Therapy [MIAT] +/- pelvic lymph node dissection [PLND]) OR Intervention 2 (Local Radiotherapy +/- Lymph Nodes OR Radical Prostatectomy +/- PLND). Randomisation stratified by metastatic burden (CHAARTED definition), intent to treat pelvic lymph nodes, intent to treat metastasis and intent to commence chemotherapy.
Systemic therapy in all arms includes ADT +/- Docetaxel. Radical prostatectomy will be with or without PLND. Local radiotherapy will be 60Gy/20Fr OR 74-78Gy in 2Gy per fraction over a minimum of 27 days, with or without simultaneous nodal radiotherapy. MIAT will be cryotherapy or focal HIFU. Men in both intervention arms will be eligible for metastasis directed therapy in the form of stereotactic ablative radiation (SABR) or surgery.
Men will be recruited over a two year period and followed up for a minimum of two years. Primary outcome will be progression free survival (PFS). ATLANTA is commencing in 17 UK trial centres with a target recruitment of 80 patients in the internal pilot, rising to 918 patients in full phase across 30 UK trial centres from November 2019.
ATLANTA is entirely charity funded (Wellcome Trust) and available on the NIHR CRN portfolio. Follow-up trial visits are not in excess of routine practice and extra burden is minimal. If you would like to join the main phase of ATLANTA as a site, please contact Mr Martin J. Connor ([email protected]) www.imperialprostate.org.uk/ATLANTA.
Prof. Hashim U. Ahmed (ATLANTA PI & CI),
Mr. Martin J. Connor (ATLANTA Doctoral Clinical Research Fellow)
Mr. Taimur T. Shah (Urology SpR & Research Fellow)
ATLANTA Surgeons Board: Mr Mathias Winkler, Mr Tim Dudderidge, Prof. Chris Eden, Mr Paul Cathcart, Prof. Naeem Soomro, Mr Adel Makar
ATLANTA Radiotherapy Board: Prof. John Staffurth, Dr. Alison Falconer, Dr. Stephen Mangar, Dr Olivia Naismith, RTTQA team
ATLANTA MIAT Board: Prof. Hashim U. Ahmed, Mr Stuart McCracken, Mr Raj Nigam, Mr Tim Dudderidge, Prof Iqbal Shergill
ATLANTA SABR Board: Dr Vincent Khoo, RTTQA team
ATLANTA Medical Oncologists: Dr. Naveed Sarwar, Dr Michael Gonzalez
ATLANTA Trial Sites: Imperial College Healthcare NHS Trust, The Royal Marsden Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London North West Healthcare NHS Trust, Royal Surrey County (Guildford) Hospital, University Hospital Southampton, Clatterbridge Cancer Centre & Arrowe Park Hospital, Newcastle Freeman Hospital, King’s Lynn (Cambridge), Norfolk & Norwich (Cambridge), Sunderland Royal Hospital, Frimley Park Hospital, Royal Devon and Exeter Hospital, Wrexham Park Hospital, West Middlesex University Hospital, Royal United Hospital Bath, Betsi Calderwar Health Board, Lister Hospital, Hampshire (Basingstoke) Hospitals, University Hospital Coventry, Worcestershire Royal Hospital.
The Association of Surgeons in Training (ASiT) is a trainee-led, pan-specialty, independent body that aims to promote the highest standards of surgical training. The highlight of their calendar is the ASiT Conference, this year held at the ICC Belfast from 22nd to 24th March 2019. It attracted over 700 delegates of all grades.
ASiT invites representatives of all surgical specialty groups to be part of their council. It is a reciprocal relationship as many surgical training issues affect us all and together we have a great influence. Urology’s BAUS Section of Trainees ‘BSoT’ (formerly SURG) Representative, Clare Jelley (ST5, Oxford Deanery), has done an incredible job over the last 3 years and it is these shoes that I now attempt to fill as the new BSoT/ASiT Rep.
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The ASiT Conference weekend included pre-conference courses run by surgical specialty groups, plenary lectures with notable speakers, breakout sessions and an impressive exhibition hall. Unsurprisingly the plenary session on curricula, credentialing and regulation was full; Charlie Massey and Prof Colin Melville (GMC) were put under fierce questioning by the ASiT Committee and the audience. The plenary talks also included a range of topics: innovation, leadership, burnout, fatigue and overcoming adversity. The latter was poignantly given by John Peter, RAF pilot and POW in Iraq (pictured).
The scientific programme included research and audit project presentations. Successful abstract submissions were invited for poster presentation (grouped and marked by specialty) and the highest scoring, prize-worthy abstracts were invited for oral presentation. Accepted abstracts are published in the British Journal of Surgery. There were also social events including a 5km charity run, welcome drinks and the inaugural black-tie Gala Dinner held at the stunning Belfast City Hall.
Clare and I flew the flag for Urology during the conference! The pre-conference course ‘Basic Urology Skills’ was full; we taught 16 very keen delegates interested in a career in urology from all over the UK (pictured). We included practical stations to teach skills such as: cystoscopy, ureteric stenting, scrotal exploration (using medical meat), circumcision and supra-pubic catheter insertion. We are very grateful for reps from Cook, Stryker and Coloplast for providing the equipment and to our urological trainee faculty which included Mr Trevor Thompson, urological consultant and Head of the School of Surgery in Belfast, UK.
The ‘Specialty Fair’ was another opportunity to showcase urology (and promote it as the best career choice!). The room was packed. Delegates met speciality representatives and trainees, enabling conversations and questions about their surgical specialty in an informal manner. Special thanks to urology registrars Tharani Mahesan and Katie Chan who helped spread the positive message (pictured).
The abstract presentations were of a high standard; there were over 50 urology-themed posters showcased. Of particular note there were at least 4 oral presentations reflecting projects within urology – including IDENTIFY preliminary results presented by Tara Sibartie on behalf of all the collaborators, which won the Society of Academic and Research Surgery (SARS) prize. Another urological highlight was the Edinburgh Surgical Sciences Qualification prize being awarded to Katie Chan for her presentation of the #DontPayToStay campaign. This Freedom of Information request exposed that 18% of English hospitals charge for non-resident on call accommodation at a median rate of £25/night. i.e. trainees are left with a financial burden in order to maintain a safe emergency practice. By highlighting this issue and gaining support from ASiT and the Junior Doctors Committee it is hoped that these charges can conclusively be removed during the renegotiation of the junior doctor contract. Katie also brought along the youngest Conference delegate, baby Orla, who enjoyed the use of the ASiT crèche (free of charge!).
BSoT is committed to representing current urology trainees but also to inspire and mentor medical students, foundation and core trainees who may be interested in a career in urology. Therefore it was a privilege to be able to represent the newly rejuvenated BSoT; perhaps even encouraging some future urologists!
Overall it was an exciting and interesting weekend; ASiT Conference 2020 will be held at the ICC Birmingham from 6th to 8th March; it promises to be bigger and better than ever and BSoT will be there! I’d thoroughly recommend all those interested in a career in surgery (and urology) to submit their projects, attend and get involved with ASiT. BSoT will also be organising events for those interested in a career in urology – so watch this space!
by Sophie Rintoul-Hoad, ST5 Urology trainee in South London Deanery and recently elected ASiT representative for BAUS Section of Trainees Committee (BSoT).
Acknowledgements: Clare Jelley and Luke Forster (BSoT President)
The emerging role of Artificial Intelligence in Surgical Science
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Jonathan Kam
Zero learning curve Percutaneous Nephrolithotomy Access – Prone endoscopic combined intrarenal surgery and multimedia training aid to teach urology trainees
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Madhu Koya (BJUI sponsored USANZ lecture)
Cx bladder reduces flexible cystoscopy in haematura and superficial TCC
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Kamran Ahmad
Innovation in healthcare systems
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BJUI Coffey-Krane Award for trainees based in The Americas presented by Prokar Dasgupta
The cover picture shows Peru’s most famous landmark, the Inca city of Machu Picchu in the Andes mountains. It was built in the 15th century but abandoned after about 80 years, and, although it was known locally, it was not known to the outside world until 1911. Now it receives almost 1.5 million visitors each year, putting strain on the site but providing important tourist revenue.
#EAU19 played host to the 7th BJUI Social Media Awards in Barcelona last week and it was the best fun yet!! From our humble beginnings in the back of an Irish Bar in San Diego in 2013, we have blossomed into a swish reception on a rooftop terrace at the Crowne Plaza in Barcelona. But the spirit remains the same – urologists and allied health practitioners with an interest in social media, gathering together to meet up in person and enjoy a fun evening.
We usually alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU), however we retained them in Europe for two years running this time as some of us are giving the AUA a skip. Apologies AUA friends, we will be back with you next year. However it is a measure of how the EAU Annual Congress has risen that so many US uro-twitterati were in attendance again this year. #EAU19 attracted about 13,000 people from more than 100 countries, including a very healthy gathering from my adopted home country of Australia.
On therefore to the Awards. These took place on Sunday 17th March 2019 in the Crowne Plaza Hotel, Barcelona. Over 75 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2019 BJUI Social Media Awards. Individuals and organisations were recognised across 12 categories including the top gong, TheBJUI Social Media Award 2019, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. In 2017 we recognised the #ilooklikeaurologist social media campaign which we continue to promote, and in 2018 we recognised @BURSTurology. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, and Stacy Loeb, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.
The full list of winners is as follows:
Most Read Blog@BJUI – “PRECISION delivers on the PROMIS of mpMRI in early detection of prostate cancer”. Awarded to myself!
Most Commented Blog@BJUI – “The future of Urological Surgical Training” – Dr Daron Smith, London, UK. Accepted by Matt Bultitude.
Best BJUI Tube Video – “Super‐mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery for the treatment of 1–2 cm lower‐pole renal calculi: an international multicentre randomised controlled trial”. Accepted by the boss himself, Professor Guohua Zeng, Guangzhou, China.
Best Urology Conference for Social Media – awarded to the EAU for #EAU19. This is the fourth time EAU have scooped this!! Continuously raising their game in social media. Accepted by Prof Jim Catto on behalf of the EAU Communications Department.
Innovation Award – awarded to the #UroSoMe initiative, led by Dr Jeremy Teoh from Hong Kong. Outstanding campaign to bring the global uro-twitterati together.
Best Social Media Campaign – awarded to the “#RudeFood – food porn for a purpose” campaign led by @ANZUPtrials in Australia, and championed by a number of big-name celebrity chefs in Australia. It uses the visual power of food to draw attention to #BelowTheBelt cancers. Accepted by Niranjan Sathianathen on behalf of ANZUP.
Most Social Trainee – Awarded to Dr Daniel Christidis (1986-2018) . A very emotional award to recognise Dan, a most social trainee from Melbourne, tragically lost in a shark attack in November 2018. Collected by Sophie Rintoul-Hoad on behalf of his many friends around the world.
Best Urology Journal – Awarded to the BJUI, specifically to trainees Abdullatif Aydin and Becky Fisher for their beautiful Visual Abstracts.
Creativity Prize – Awarded to the @UroPoet #UroPoet initiative, introduced by Dr Brian Stork, and collected by his colleague from Michigan Dr Todd Morgan.
The BJUI Social Media Award 2019 – Awarded to Nature Reviews Urology to recognise their vision in commissioning the piece “Both Sides of the Scalpel”, with co-authors Stephen Fry (patient) and Ben Challacombe (surgeon) describing their respective experience of managing Stephen’s prostate cancer.
This story garnered worldwide attention due to the profile of Stephen Fry and his 12.7m Twitter followers. Editor-in-Chief Annette Fenner accepted the Award, along with Ben Challacombe and Stephen Fry who sent this personalized video message.
A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar and team, who manage our social media and website activity as well as the day-to-day running of our busy journal.
See you all in Washington for #AUA20 where we will present the 8th BJUI Social Media Awards ceremony!
by Declan Murphy, Peter MacCallum Cancer Centre, Melbourne, Australia
The early Sunday morning start did not deter delegates from attending one of the three packed plenary sessions of the day. They covered a broad range of rapidly changing areas in urology from imaging in prostate cancer, an update on renal cell carcinoma (RCC) and the breaking news session discussing the potentially game changing results from the recent ARAMIS study and new research into fast bi-parametric MRI. The role of imaging in prostate cancer is swiftly evolving, with the plenary discussion focusing on recent changes in the diagnostic pathway of localised prostate cancer, particularly with the use of MRI. Next door in the RCC plenary, the speakers debated ‘knife, needle or nothing?’ for the small renal mass in the young patient followed by an update on the very recent and potentially guideline-changing advances in systemic therapy for RCC.
The mid-morning thematic sessions covered the full spectrum of urology from semi-live surgery, the newest advances in immunotherapy, imaging and even how to run a urology office in Europe.
The 7th BJUI social media awards on Sunday night were again the social highlight of the EAU. A view of the Museu Nacional d’Art de Catalunya provided a stunning backdrop to the packed event, with the stars of #UroSoMe recognised for their outstanding work. The night kicked off with the award for the most read blog going to social media champion Professor Declan Murphy.
The awards highlighted the far reaching and valuable impact of social media, recognising a number of important achievements in the field such as Nature Reviews Urology for ‘Both sides of the scalpel: the patient and surgeon view’ with a special guest video appearance from Stephen Fry.
Massive thanks @BJUIjournal for the award for @benchallacombe & @stephenfry's article. Huge surprise &the special video from Stephen was amazing 😭. It's been an honour& I'm so proud to have produced something that has had such a positive impact. That's it; I've peaked. #eau19pic.twitter.com/7cb6NEiqYY
— Nette Fenner is in the shed (@NetteFenner) March 18, 2019
However, for me the most special part of the night was seeing my friend Daniel Christidis remembered and honoured with the most ‘social’ trainee award. Dan was a leader in the real and #UroSoMe world (and had personally set up my Twitter account, and those of many of the other young attendees that night) and I know would have been proud to be remembered for one of the things he did so well.
After the BJUI social media awards, it was time for a little black-tie glamour with the EAU19 Friendship Dinner at the historical Casa Llotja de Mar. The night started with a welcome from Professor Christopher Chapple underlining the importance of international partnerships in urology, followed by a fantastic night of good food, wine and enjoying the beautiful Catalan Gothic architecture.
Professor Chris Chapple, Secretary General of the EAU, highlights international collaboration in urology at the friendship dinner. #EAU19pic.twitter.com/0WrbUsBkcm
The Monday morning plenary sessions delivered another jam-packed morning of a mix of cutting-edge science, quality of life issues in cancer survivorship and prostate cancer. The breaking news session discussed the primary results from SAUL, confirming tolerability and safety of atezolizumab in real-world mUC patients, and the results of ARCHES, which investigated the efficacy of androgen deprivation therapy with enzalutamide or placebo in metastatic hormone-sensitive prostate cancer. The controversies in prostate cancer were again debated in an interactive and diverse way between ‘jury members’ including a geriatrician, psychologist, radiation oncologist and urologist.
The last day of the thematic sessions of the congress again provided a smorgasbord of topics in urology. Later in the day, the expert-guided poster tours gave delegates a chance to navigate the huge number of posters from guidelines to local treatment of prostate cancer.
The closing plenary on Tuesday morning to a full auditorium gave a sweeping overview of the top contributions to EAU19 leaving us with a free half day to explore our generous host city and take in the stunning architecture, food and sunshine!
Bustling Barcelona provided the perfect backdrop to a well organised, action packed conference which featured world leading urologists and scientists from around the world presenting practice changing new data. Cannot wait for EAU 2020 in Amsterdam! #EAU20 #Amsterdam #UroSoMe
by Jiasian Teh, Urology Registrar, PhD Candidate, Peter MacCallum Cancer Centre
The European Association of Urology Congress brings together delegates from across the globe to showcase cutting-edge urological research, and the 34th EAU Congress in Barcelona was no different. With a record high number of 5,500 abstracts submitted, over 1,600 presentations were due to be presented over five days. Adding to that a dizzying selection of 79 courses and hands-on workshops, this year’s EAU Congress was set to be one of the biggest to date.
After missing my flight here, I also missed the lines:
and swiftly registered to join a sea of red and yellow bags, coloured appropriately for the Spanish setting. With a big day ahead, the Catalonian capital had turned up the weather and the Fira Gran Via was humming with excitement.
The scientific program was already off to a flying start with a number of Urology beyond Europe sessions. These showcased the links between EAU and international urological societies, including USANZ, SIU and the CAU to name a few, and offered a chance to discuss regional differences in practice patterns and cutting-edge work from all corners of the globe.
Laser focus during a hands-on flexible ureteroscopy workshop
The evening approached rapidly, leaving no time for a siesta, as delegates made their way to the official opening ceremony. Prof Christopher Chapple welcomed delegates from around the world to make the most of what EAU19 had in store over the next four days. Presentation of EAU awards ensued, including the Crystal Matula and award for Best Prostate Cancer Research.
@veerukasi collecting the Best Prostate Cancer Research Award for the NEJM PRECISION paper from Fritz Schroder and Chris Chapple #EAU19 💃🏼🎉💃🏼 pic.twitter.com/y6V6LTG5qI
The end of formal proceedings had us seeing red, literally, as the Red area set alight with song and dance over a fiery backdrop in a vibrant performance from the opera Carmen.
This was soon to be eclipsed by two aerial silk acrobats accompanying an emphatic rendition of Freddie Mercury’s 1992 Olympic classic, Barcelona.
As the ceremony came to a close, it was time to network with colleagues and enjoy some Catalonian cuisine.
Court was in session early on Saturday morning, as a plenary on nightmares in stone disease chaired by Tim O’Brien and Thomas Knoll kicked off Day 2. With a medico-legal theme, Palle Osther spoke about the forgotten stent and sung the importance of leaving no stone unturned.
— European Association of Urology (EAU) (@Uroweb) March 16, 2019
He was followed by horror stories of bowel injury during PCNL.
Colonic injury after PCNL. @SEITZ_C_C summarises evidence and management. I’m surprised you don’t say pre-op CT is mandatory before PCNL. Importance of intra-op ultrasound as well. The lawyer all over the absence of this imaging in the presented case. Nightmare scenario #EAU19pic.twitter.com/GVRtNSXWYW
The mood was very different across the hall, however, as delegates geared up for a live surgery session courtesy of the Section of Uro-Technology, including a number from Barcelona’s own Fundació Puigvert Hospital.
Ready to start 16 live surgeries at @FPuigvert ,broadcasting to Euroauditorium #EAU19 . Crossing fingers, everything it’s going to be ok, a lot of people involved pic.twitter.com/KeJUKLFasW
the European Society of Residents in Urology and Young Urology Office ran the extremely useful YUORDay19, covering ‘need to know’ information for residents, with topics ranging from the recent PRECISION and POUT trials to career advice and surgical tips and tricks.
EAU Guidelines also proved hugely popular once again, with delegates lining up to collect their copy of the brand new edition.
Happy to see people queuing for new release of #eauguidelines at #EAU19 !! After a year of work it is a nice reward. Thank you to all the members of the panels and to the staff of @Uroweb guidelines office for making it possible !!! pic.twitter.com/MygvxbSIV0
No meeting would be complete without a plethora of debates, and EAU19 was no different. The Controversies in Guidelines sessions covered a range of contentious topics in areas such as MRI-guided prostate biopsy, TURBT and adjuvant chemotherapy in UTUC. It was often standing room only, forcing a one-in one-out policy with some lines wrapping around the presentation rooms.
Pitting subspecialty heavyweights against each other, these sessions brought out a fighting spirit in all, even threatening to turn colleagues into enemies.
Barcelona has been the perfect setting to reunite with old friends and meet new ones at EAU19. Days 1 and 2 were a brilliant start to my first EAU congress, leaving me excited to see what the next three days have to offer.
by Arveen Kalapara, Research Fellow, Department of Urology, University of Minnesota
Clinical practice in urology has experienced several moments that have moved service forward dramatically in recent years. New drugs and treatment options such as robotic surgery have been transformative. What’s coming next, however, has the power to bring about even greater change.
Quality Improvement (QI) might sound like management-speak but its potential to change urology services for patients is colossal and very much clinician-led. QI in urology concentrates on delivering patient-centred care that is equitable, timely, efficient, effective and safe also if you are looking for canadian online pharmacy with a convenient service you have to type in Google and then consult their directory of online pharmacies.
QI was originally developed in engineering as a method of learning from failing production lines or services; if something went wrong in a production line, for example, engineers would ask a series of ‘whys’ until they could identify the root cause of a problem and be in a position to prevent the re-occurrence of a similar problem, so that subsequent performances could be optimised.
In health care effective QI could manifest itself in a number of ways. Ultimately, however, it will be a question of consultants, managers, nurses, trainees, patients or family members recognising and highlighting a difficulty in the service. Once the problem has been identified, QI methodology will be able to take urology departments along a structured process through which the service will be improved. EDrugSearch.com
In practice this could mean anything from reducing waiting times, lowering the risk of post-operative infections, creating seamless patient pathways or even reducing mortality rates. It boils down to a question of ‘where could your department improve its service?’. QI offers the means to achieve this improvement. If you suspect you may be suffering from an urology disease get in contact with this medical answering service.
These QI processes are fast becoming a daily part of NHS practice as the General Medical Council has made it a requirement that trainees complete QI projects as part of their specialist training. Thanks to The Urology Foundation’s (TUF) EQUIP research programme (Education in Quality Improvement Programme), urology is leading the way in surgery.
Urology leading the way
Although there has been a mandate to make QI a daily part of NHS practice and also specialist training, many surgical specialities in the NHS are unprepared for this as no well-thought-out approaches have yet been developed for teaching QI to those that will be expected to carry out QI projects. Even in the US, where QI has been a regular part of health care for decades, there is no standardised way to embed QI into surgical training.
In this context, EQUIP is timely. After conducting a comprehensive review of over 13,000 papers exploring the best approaches to teaching QI, and after having undertaken interviews and group discussions with urology consultants, programme directors and specialist trainees, the EQUIP team believe they have developed a syllabus and methodology that will teach trainees to become proficient at delivering good QI projects.
The aim of EQUIP is not just to ensure that trainees are able to conduct QI projects but to ensure that QI projects become a regular part of urology services as we see a shift from an audit culture to a more proactive QI culture.
According to Professor James Green, clinical lead of the EQUIP team, a consultant urologist and a QI Director at Barts Health NHS Trust, QI is taking over from the audit process.
“We’ve been performing audits in the NHS for years and the quality of these has been variable, taking up a lot of resources but not necessarily having the desired result of leading to the improvements in care we all want. Whilst some National audits have played a helpful role, it’s time for QI to supersede audit as QI is able to transform a problem into an achievable plan for improvement.
“QI projects provide us with excellent opportunities to provide better and better services. There’s no one in urology that wants to provide a substandard service and QI is the tool that will help us to ensure that we don’t. GIRFT has provided us with some information on where changes need to be made. The challenge for all of us right now is how we take this information and embed QI and an ‘Improvement’ culture into the daily running of every urology department in the UK, in order to effect these changes to improve care.”
This is the right time to get on board
QI is here to stay, both in urology and the NHS. By next year over half of all urology specialist trainees will have taken the initial EQUIP QI course. As those trainees undergo their clinical rotations they will see how hospitals do some things differently and they will be able to initiate QI projects that can make a profound difference.
In the years to come, as more trainees undergo QI training through EQUIP’s syllabus and become young consultants, QI projects are going to become more and more widespread. Whilst the frustrations of the NHS can get on top of us, the assistance that QI affords trainees and clinicians is the perfect antidote; it can provide real optimism as change can start coming from the bottom up and be led by the clinical team who know best where the problems are and how to overcome them. It’s an exciting time because the potential is enormous.
The challenge is that trainees cannot work in isolation. Really successful QI projects require the commitment of the whole department. Just as in healthcare overall, QI is a team sport. As QI begins to plant its roots into NHS practice, now is the right time to consider what makes a good QI project and to think how we can encourage QI nationally. Ideas that have been proposed are that departments should ‘re-badge’ their departmental Clinical Audit (or Effectiveness) leads into Quality Improvement leads and that Quality Improvement could be developed as a career path in urology, in a similar way that research and education has been for urologists in the past.
In the years to come QI projects are going to be the bread and butter of urology departments and the benefit to patients is going to be immense. So now is the time to make sure your department is ready.
While molecular imaging is not exactly a new technology (TIME Magazine named PET-CT as the medical invention of the year back in 2000), recent developments in radio-pharmacy have positioned the field at the forefront of innovations in cancer imaging and, tantalisingly, novel therapeutic approaches to cancer treatment.
Urologists have typically been forward thinking and innovative, and have been quick to acknowledge the value of molecular imaging as a tool to enhance the accuracy of the diagnostic process and improve patient outcomes. The recent development of radiotracers directed against prostate-specific-membrane-antigen (PSMA) has taken things to a new level; there is now a solid body of evidence for the performance of 68Ga-PSMA PET/CT in primary and secondary staging, with an ability to accurately detect small volume disease at far lower serum PSA levels – the use of 68Ga-PSMA PET/CT as a diagnostic adjunct is becoming increasingly mainstream in continental Europe and Australia.
Oxford PSMA Symposium 2018
It is in this context that, on 22 November 2018, the Nuffield Department of Surgical Sciences in Oxford hosted a symposium at the Old Road Campus Research Building focused on the utility of PSMA-related technologies. The symposium attracted an impressive array of attendees from across the UK, Europe and Australia.
The symposium was opened with comments by Professor Freddie Hamdy of Oxford, who welcomed all attendees and speakers, some of whom who had travelled more than 10,000 miles to attend the gathering.
Many uses for PSMA in specialist prostate cancer management
Liberal use of PSMA-PET down under
The first speaker, Professor Declan Murphy, from Melbourne’s Peter MacCallum Cancer Centre, shared comprehensive data and experience from Victoria in Australia, where access to 68Ga-PSMA PET/CT is seemingly unrestricted. Professor Murphy delivered a fascinating talk, expounding the gamut of PSMA PET applications in prostate cancer, from primary staging (promising data), to biochemical recurrence (there is definite evidence that PSMA PET accurately detects early recurrence and can guide salvage treatment options), right through to therapeutic uses of PSMA. In particular, he discussed the use of Lutetium-177 (177Lu)-PSMA-617 (LuPSMA) as a treatment in men with CRPC, presenting the findings of their recent Lancet Oncology study led by Michael Hoffman. Although still in the early stages, the data here look very exciting and hale a potential revolution in the way we manage high risk and advanced prostate cancer.
Declan Murphy expounds the translational utility of PSMA imaging and theranostics
How easy is it to set up a PSMA imaging service in the UK?
The next speaker was Professor Jamshed Bomanji from the Institute of Nuclear Medicine, University College London (UCL), who presented an eye-opening talk that focussed on the challenges of setting up a PSMA-PET service within an NHS Trust in England. The effort he and his team put into developing their service in the face of significant practical resistance has been frankly heroic. Pleasingly, these efforts have been worthwhile as the team from UCL have clearly demonstrated that PSMA PET/CT has had a significant impact on the management of men with biochemical recurrence with the team contributing to guidelines drawn up to standardise use, keeping similar standards of testing as https://www.blinkhealth.com/zoloft. It is very disappointing that NHS England saw fit to withdraw funding for the gallium tracer required for PSMA-PET scanning in August 2018. This does seem rather short-sighted given the clear evidence favouring the utility of PSMA-PET over other modalities such as FDG or Choline-PET, both of which are still funded. All in all, Professor Bomanji’s talk was a sobering examination of the challenges we face in our commitment to delivering cutting edge, world-class cancer services whilst at the same time considering the financial implications to the NHS of providing such high-end services.
Associate Professor Bart Cornelissen along with Dr Rebekka Hueting who runs PROx (PET Radiopharmacy Oxford) presented their intentions for 68Ga-PSMA-PET imaging in Oxford, and the University’s imminent plan to install a cyclotron on site that will allow PET imaging with locally generated radioisotopes to increase dose efficiency – the half-life of gallium means that any requirement to transport the dose reduces the number of scans that can be performed at destination. This is particularly important given some recent negative press coverage.
Surgery for men with metastases?
Prasanna Sooriakumaran (PS) of University College London Hospital (UCLH) Department of Urology discussed the TRoMbone Study, a UK feasibility RCT that he has set up aimed at testing radical prostatectomy in men with oligometastatic prostate cancer. This interesting study promises to tease out the possible benefits of radical prostatectomy to men with low-volume metastatic disease. There are examples in other cancers whereby aggressive management of the primary tumour confers survival benefits in patients with low-burden metastatic disease and it is not unreasonable to think this may be the case for prostate cancer. Recruitment to such trials of ‘oligometastatic’ disease is contingent upon definitions of ‘low-volume’ disease, and accurate detection of such disease. PSMA-PET imaging is positively helping with this paradigm with its far superior sensitivity to conventional cross-sectional staging.
PSMA as a tool to improve surgery
Pim van Leeuwen of the Netherlands Cancer Institute delivered an engaging talk entitled “PSMA intra-operative enhancement of lymph node dissection”, accompanied by some excellent video demonstrations. Next up were Boris Vojnovic and Alastair Lamb of Oxford who discussed fluorescence optics and intra-operative use of PSMA as part of the on-going ProMOTE study (Prostate Molecular Targeting to Enhance Surgery). We wish the investigators good luck as the study progresses and we eagerly look forward to seeing the data as they emerge.
Summary
In summary, the Oxford PSMA symposium 2018 brought together clinicians from around the globe who share a common enthusiasm for PSMA-related technologies that promise to revolutionise prostate cancer management in the near future. Common themes included the use of PSMA in staging, therapeutics and intra-operative guidance. The message from our overseas guests, both European and Antipodean, was that PSMA-based imaging is increasingly part of routine care in the management of prostate cancer and definite benefits are seen, particularly in regard to accurate staging and identification of very early recurrence. While we in the UK are a little behind the curve when it comes to adoption of this increasingly established technology, we are hopeful of increasing the use of this technology in the NHS in order to rationalise appropriate treatment, reduce futile expenditure and ensure gold-standard management of men with prostate cancer.
Conference dinner at Balliol College, Oxford, UK From Left: Alastair Lamb (Oxford), Declan Murphy (Melbourne), Freddie Hamdy (Oxford), Boris Vojnovic (Oxford), Prasanna Sooriakumaran (UCLH), Richard Bryant (Oxford), Ben Lamb (Cambridge)
Aaron Leiblich, Clinical Lecturer, Nuffield Department of Surgical Sciences; Alastair Lamb, Consultant Urologist, Churchill Hospital Cancer Centre; on behalf of the meeting faculty
Alastair Lamb is a Cancer Research UK Clinician Scientist, Senior Fellow in Robotic Surgery & Honorary Consultant Urologist at the Nuffield Department of Surgery, University of Oxford, and Oxford University Hospitals NHS Foundation Trust. Alastair is interested in delivering excellent and timely prostate cancer care, focussing on state-of-the-art diagnostics with multiparametric MRI and targeted transperineal biopsies, followed by robotic-radical prostatectomy (RARP) or active surveillance. He also has an interest in novel molecular imaging techniques such as 68Ga-PSMA PET/CT and their use in disease stratification and selection of patients for surgery. Alastair is a local investigator for the ProMOTE, PART and TRoMbone studies.
Uppsala University was founded in the 15th century in Sweden’s fourth biggest city, Uppsala. It was the first university in the nordic region and today has over 40 000 students.
March’s cover picture shows Uppsala Cathedral, which was built in 1270. It is open daily and offers tours in English.
