Traditionally prostate cancers have been diagnosed using biopsies of the tumour masses. New research from researchers at University College London (UCL) has shown that a more accurate diagnostic means for prostate cancers is MRI scans and targeted biopsies. Following this research, the UK’s medical guidelines - National Institute for Health and Care Excellence (NICE), have been updated to include this new and more effective way of diagnosing prostate cancers.
There are 130 cases of prostate cancer being diagnosed every day in the UK. The disease killed 11,631 men in 2016 say reports. Early and more effective screening and diagnosis can help save lives say experts.
The NICE guidelines include multiparametric MRI (mpMRI) as the first and most important means of diagnosing clinically localized prostate cancers in men. The UCL researchers conducted two clinical trials called PROMIS and PRECISION in collaboration with University College London Hospitals (UCLH). The new guidelines were released last month.
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According to researchers, this new method of diagnosing prostate cancers provides a clearer image of the tumour and this can help doctors decide the exact location from which the biopsy could be taken to be sure about the cancer. The team says that some men are at low risk of the malignant cancers. In these men, earlier unnecessary biopsies were performed to assess if they have the cancer. This new technique can eliminate the need for unnecessary biopsies in these men. Biopsies come with the risk of pain, bleeding, infections and injury. Eliminating unnecessary biopsies would be thus, welcome news.
For the breakthrough, the PRECISION trial also won the UK Research Paper of the Year at the 2019 BMJ awards held in May. Study leader Professor Caroline Moore from UCL Division of Surgery and Interventional Science said in a statement, “This is fantastic news and means all men at risk of prostate cancer will now have an MRI scan before any biopsy. By having access to high quality MRI at the outset, doctors will be able to safely reassure men at lowest risk, and identify men most likely to benefit from treatment.” She added, “UCL has led the evidence gathering for MRI in men at risk of prostate cancer and it is great to see the UK being the first country to make a formal recommendation that it should be used in all men prior to a biopsy. The challenge now is to ensure the availability of high quality MRI across the NHS.”
UCL’s Dean of Medical Sciences, Professor Mark Emberton, oversaw both the ladmark trials. He said in a statement, “We have been using MRI for men at risk of prostate cancer at UCL and UCLH for a decade, and it is heartening to see our research has come to full fruition with this unequivocal guidance, meaning all men will now get access to this cost-effective and transformative technology. Our PROMIS and PRECISION studies have shown MRI scans will result in fewer unnecessary invasive biopsies for men, and fewer important cancers missed.” He explained, “MRI for all men prior to biopsy of the prostate is the most important development in the management of men with early prostate cancer that we have had in the last 100 years.”
The researchers explain that use of this technique of Multiparametric MRI would be more cost effective compared to traditional prostate biopsy because it takes less time and is more effective in diagnosing clinically significant cancers. The trial proved that a 10 minute scan could help become powerful screening tool for prostate cancers. Prof Emberton said, “I think that could revolutionise the way that we diagnose disease and hopefully identify men who would be better treated than not treated.”
The researchers add that prostate cancer is a slow growing cancer and men with the mpMRI scan saying they have no cancer at the age of 55 or 60 years, could be rest assured that they would be cancer-free for many years and even for life. Emberton said, “If your prostate comes back looking very clean … you’re probably very unlikely to develop prostate cancer. It may be once we learn a bit more about it that you need to refresh it every 10 years or something like that.”
At present raised levels of the protein PSA in the blood are linked with growing prostate cancer while around 75 percent of the men with high levels of PSA do not need treatment for cancers and 15 percent with true aggressive cancers may present with normal PSA levels. This makes PSA an unreliable marker of the cancer, explain the researchers. Emberton said, “You end up with a lot of men being diagnosed with cancer that isn’t destined to kill them. What’s beautiful about MRI is it overlooks the many, many cancers which don’t need to be diagnosed.”
An upcoming trial REIMAGINE this August costing £6 million would be funded by the Medical Research Council and Cancer Research UK and would include 1,000 men aged 55 to 75 for scans through two London GP surgeries. Emberton said that till date most men shied away from screening because of the uncomfortable per rectal examination (probing at the prostate with a gloved finger via the anus) and a painful biopsy. This new method is a 10 minute scan costing about £150 and can help make screening easier he said.
Expert speak
Karen Stalbow, the head of policy, knowledge and impact at Prostate Cancer UK hailed this new trial saying in a statement, “If the results are positive, then MRI scanning could offer a non-invasive first stage of prostate cancer diagnosis in the future.”
Professor Hashim Ahmed, chairman of urology at Imperial College London, said, “In the future we might be able to justify screening all healthy older men for prostate cancer just as we do for women with breast cancer. This would be so useful as the number of men dying from prostate cancer has barely changed in the last two decades despite advances in treatment.”
Prof Ros Eeles, professor of prostate cancer genetics at the Institute of Cancer Research in London, on the other hand was not so convinced. He said, “The use of MRI of the prostate will be important in general management of prostate cancer assessment. However, currently it is not at all clear that MRI will be reliable to detect all cancers. In men at higher genetic risk, there are studies being undertaken at the Institute of Cancer Research to assess if men who have a genetic predisposition to aggressive prostate cancer have changes on their MRI when they get prostate cancer. At present, it is not at all certain that it will be reliable to rely on MRI alone for this assessment.”
A spokesman for NHS England said, “NHS England is already rolling out some of the latest developments in MRI scanning for prostate cancer diagnosis and care as part of the NHS Long Term Plan's ambitions to catch more cancers earlier and save lives. This new test is potentially an exciting development that the NHS will look at as more evidence becomes available.”
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