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