PRECISION Diagnosis of Prostate Cancer – At Last!

Finally. The high-level evidence we’ve all been waiting for that supports how a number of us already practise: MRI detects more harmful prostate cancers and less harmless tumours than a “standard” prostate biopsy. This is the result of the PRECISION study, led by the extraordinary Dr Caroline Moore, which was published in the prestigious New England Journal of Medicine yesterday.

This evidence will single-handedly revolutionise the way we diagnose prostate cancer. Why?

Because the current standard of care is to offer a 12-core transrectal biopsy of the prostate if a man’s PSA (prostate-specific antigen) blood test is high. As I wrote in my LinkedIn post just last month, this current standard is, dare I use the word, deplorable. It’s deplorable because this invasive procedure is notoriously inaccurate, missing up to 30% of harmful cancers, and because it is also dangerous. Passing biopsy needles through the rectal wall results in an increasingly higher risk of septicaemia. Risking a life-threatening condition for a minor diagnostic procedure is unacceptable by itself, let alone for a procedure that has an almost 1 in 3 chance of missing cancer anyway.

MRI on the other hand is non-invasive and, as the PRECISION study has shown, far more diagnostically accurate. But there is one critically important caveat. All MRIs in the PRECISION study were reported by highly experienced radiologists with an average of 5 years’ experience and 300 cases per year. We’ll come back to this in just a minute.

So what will the results of this study mean in real life clinical practice? It will mean that if a man aged typically between 50 and 70 has an elevated PSA, instead of proceeding to a biopsy, the next step will be to order an MRI. (Based on our own data, our practice has been doing this for years, but with the publication of the PRECISION study, this practice is highly likely to enter official Clinical Guidelines soon.)

If the MRI shows a suspicious lesion, the patient will then go on to have a targeted prostate biopsy. If the MRI shows no lesion, depending on other factors like family history and prostate size, the patient may require no biopsy at all. The PRECISION study showed that this could happen in up to 28% of men – a massive reduction in unnecessary biopsies.

But here’s where we have a problem. A major global problem.

Prostate cancer is an extremely common disease. This means that the number of prostate MRI scans performed will skyrocket. But prostate MRIs are complex scans to read. Even now we know there is vast variation and substandard reporting accuracy of prostate MRIs. (A component of the PRECISION study showed this too.) With the explosion of prostate MRI reporting that will occur, this variation will continue, but on a much grander scale.

This in turn will lead to a lack of confidence in the MRI report. This is especially important when the prostate has been reported as negative, i.e. no lesion was seen. If the urologist who receives the report isn’t confident that the negative MRI is correct, she or he will go ahead and book the patient for a biopsy anyway, which could have been avoided if the radiologist reporting the MRI was a known expert. This will defeat much of the purpose of getting an MRI in the first place. Also, importantly, it will cause a massive increase in healthcare expense.

This major global problem is crying out for a major global solution. At present there are numerous courses and workshops available around the world for both radiologists and urologists to learn how to read prostate MRIs. Attendees gain a basic knowledge of the standard of reporting required (a system called PIRADS v.2), practise on a few cases and leave with a certificate. These courses are a vital part of the training process, but once completed, neither the attendee nor anyone else has any real measure of how good that person is at reporting prostate MRIs.

It is for all of the above reasons that my colleague Dr Rowan Miller and I have created an online training program for prostate MRI, called MRI Pro. Our sole aim is to reduce the variation and increase the accuracy of prostate MRI reporting globally. If we can reach 10,000 radiologists and urologists who report and review 1,000 scans per year, that’s 10 million men around the world who stand to benefit every year.

What’s so special about MRI Pro? It is unique for several reasons. First, it is a program of 300 highest-quality real cases, where users can access all the required images to make a diagnosis and are presented with structured questions for each case. Second, users receive immediate feedback on whether they reported the MRI correctly or not, resulting in instant learning. (Unfortunately, this simply does not happen in real life.) Third, all correct answers shown to users include tissue verification of the MRI by either a thorough transperineal prostate biopsy (18 – 36 tissue samples, compared to the “standard” 12 samples taken by transrectal biopsy) or whole gland pathology review when prostatectomy has been performed. And finally, users will be able to track their progress as they advance through the cases, watching their improvement as they go. This feature could also be useful if accreditation to read prostate MRI demands a certain level of measurable accuracy.

We are extremely excited about the potential impact this program could have at a public health level, and can’t wait to get it out there. We plan to go live in the next few weeks, so watch this space!