London Bridge Hospital has introduced a ‘precision prostate diagnostics’ assessment, with the aim of improving the pathway for diagnosing prostate cancer by determining individual risk and specifically identifying who most needs a biopsy or who can be safely reassured.
For the last 25 years the typical pathway for prostate cancer diagnosis has been unchanged. It is based around an elevated PSA (Prostate Specific Antigen) blood test, a rectal examination and an uncomfortable Trans-Rectal Ultrasound (TRUS) guided biopsy. Unfortunately, although these tests are prostate specific, they are inaccurate, the PSA blood test is not a prostate cancer specific test, elevated levels of PSA may simply indicate in 30% an enlarged prostate but not prostate cancer. Additionally, although trans-rectal biopsies are the most commonly used method to determine whether an individual has prostate cancer, there is a false negative rate of over 30%. Mr Rick Popert, consultant urological surgeon at London Bridge Hospital considers an inbuilt error of 30% is unacceptable for a modern diagnostic pathway: “The standard pathway risks both under diagnosis and misdiagnosis leading to both overtreatment (unnecessary radical surgery) or under treatment (from false reassurance),” he commented. The precision prostate diagnostics assessment takes a new approach to diagnosis by resolving the uncertainty. Patients are referred, as before, with an elevated PSA following a routine medical but they undergo a comprehensive prostate assessment, completing a prostate health questionnaire, an evaluation of their urinary system and a diagnostic 3 Tesla MRI scan to assess the prostate more accurately before any decision is made about the need for a biopsy. Following the initial consultation and MRI scan result, which can be combined in one visit, the surgeon and the patient are in a much better position to decide on the need for a prostate biopsy and also the best method to carry out a precision targeted biopsy. The problem is the MRI may identify a small lesion within the prostate that cannot be seen on the ultrasound (the imaging modality used to take the biopsy). With modern computer software the static images of the MRI with the lesion identified can be ‘fused’ with the live ultrasound to provide precision-targeted biopsies of the prostate. This has improved cancer pick up rates from around 40% of cases to 65% of cases. The information can be used to select patients for active surveillance safely, targeted focused treatments such as brachytherapy, or nerve sparing robotic surgery in the more aggressive cases.
