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RM Partners / Imperial
RAPID Programme
Rapid Access Prostate Imaging and Diagnosis
Hashim Ahmed Professor and Chair of Urology
Division of Surgery, Imperial College London
Consultant Urological Surgeon
Department of Urology, Imperial College Healthcare NHS Trust
Prostate cancer is a growing health burden
Time, years
To
tal N
um
be
r o
f
Ca
se
s D
iag
no
se
d
0
50,000
100,000
1984 2007 2030 2009
Clinically indolent cancers are
identified by chance
Important cancers are incorrectly
classified as unimportant
Clinically significant lesions are
missed
The errors that result from the current pathway...
Men undergo whole-gland
treatment which carries harm
A strategy to overcome the errors in the current
pathway…
Not all lesions have the potential to
progress to invasive and metastatic
cancer
Imaging and precision biopsy can
identify those lesions that are likely
to progress
Prostate ‘lumpectomy’ can reduce
treatment related harms
Co-Chief Investigator: Mr Hashim Ahmed
Co-Chief Investigator: Prof Mark Emberton
Sponsored by University College London
Managed by MRC Clinical Trials Unit
Funded by UK NIHR HTA
PROMIS: Prostate MRI Imaging Study
PROMIS is funded by the UK Government Department of Health, National Institute of Health Research – Health Technology Assessment
Programme, (Project number 09/22/67).
UK Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect
those of the health technology assessment program, NIHR, NHS or the Department of Health.
MP-MRI triage compared to Transrectal biopsy
Test
attribute
Transrectal
biopsy
MP-MRI Odds ratio*
[95% CI]
p-value
Sensitivity 48% 93% 0.06
[0.02-0.12]
p<0.0001
Specificity 96% 41% 0.02
[0.003-0.05]
p<0.0001
PPV 90% 51% 8.2
[4.7-14.3]
p<0.0001
NPV 74% 89% 0.34
[0.21-0.55]
p<0.0001
PSA
MRI Prostate
Biopsy
Diagnosis
Low risk MRI
The new pathway
What have we learnt so far when we embed
MRI into the pathway?
Standard TRUS
pathway
Triage mp-MRI
Pathway
p-value
Biopsy 100% 59% ≤ 0.05
UCL/Ahmed definition 1 12% 24% ≤ 0.05 UCL/Ahmed definition 2 25% 33% ≤ 0.05 Any length of Gleason >/=3+4 23% 31% ≤ 0.05 Any length of Gleason >/=4+3 6% 16% ≤ 0.05
Insignificant cancer detection 12% 2% ≤ 0.05
Definition 1: Any length of Gleason >/=4+3 or >/=6mm of Gleason 3+3
Definition 2: Any length of Gleason >/=3+4 or >/=4mm of Gleason 3+3
We will need to set standards for MP-MRI
- Independent accreditation
- Independent scan conduct and report quality control
- Rates and types of cancers detected
- Rates of repeat biopsies
- Rates of unnecessary radical therapy
Hashim Ahmed
RM Partners / Imperial RAPID Programme
NHS England Transformation Funded
Lead: Ahmed HU. £2.8M (2017-2019)
• 3 pilot sites (Imperial, St Georges, Epsom)
• Same day MRI and report, clinical review and IF
NECESSARY, a targeted biopsy
• Transperineal NOT Transrectal biopsy
• Quality reviews at every stage
1
2
Conventional Pathway RAPID Pathway
GP referral under 2WW GP referral under 2WW
Day 1
MRI
Days
2-7
1st appt: Tests organised (repeat
PSA & Urine Culture)
2nd appt : TRUS biopsy
Days
7-14 Analysis of
result
3rd appt : MRI
Days
15-21
Days
22-42
Days
43-62
MDT review Potential DTT and
Tx (hormones)
Further investigations
MDT (DTT)
First definitive treatment (Tx)
If active monitoring
remove from p/w
4-6 weeks
required between
biopsy and MRI
negative
positiv
e
Senior Clinical Triage
1st appt
Mp-MRI
Targeted biopsy
30% of men
discharged to
primary care
Biopsy results /
MDT
If active
monitoring remove
from p/w
Further
investigations
MDT (DTT)
Same day
diagnostics
‘One stop’
MRI not
suspicious
MRI
suspicious
Potential DTT and
Tx (hormones)
First definitive treatment (Tx)
Indicative timeline
1
3
Initial pilot results at Imperial
99 patients
75% biopsied
Time from Referral to Diagnosis 26 22 17 days
Time from Referral to Treatment 37 45 37 days
Conclusions
The standard approach to diagnosing prostate cancer is
blind to location of cancer
The standard approach to diagnosing prostate cancer leads
to unnecessary harms
Prostate MRI can allow at least one-third of men to avoid an
unnecessary biopsy
Prostate MRI can improve the detection of higher risk
cancers
There is a considerable challenge in delivery and
dissemination
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