Network meeting Taunton Rugby club January 20th Nick Burns-Cox Consultant Urologist Musgrove Hospital, Taunton

PROMIS To determine the accuracy of MPMRI in the diagnosis of clinically significant prostate cancer (CSPC) . Any man with clinical suspicion of cap mainly PSA < 15 and volume <100 No previous biopsy Clinically significant disease defined as- Gleason score ≥4 + 3 or a maximum cancer core length 6 mm or longer

All men to have an MPMRI (1 All men to have an MPMRI (1.5 Tesla) and a combined 20 Zone Template mapping biopsy (60- 120 biopsies) and TRUS and biopsy (10) under GA Blinded to MPMRI at time of biopsy All MPMRI -specific training, protocol (scoring with Likart) and all reviewed by 2 radiologists

Results N= 740 complete data etc. on 576 On TPM 70% cap On TPM 40% CSPC

Accuracy of MPMRI TRUS and biopsy MPMRI Sensitivity 48 93 Specificity 96 41 PPV 90 51 NPV 74

93% of CSPC will be diagnosed with MPMRI score 3 or greater (High sensitivity) But 50 false positive (low specificity) 90% of negative MPMRI do not have CSPC. 17 (7%) of men with a MPMRI of 2 or less will have CSPC TRUS will only diagnose about 50% of CSPC but if positive very highly likelihood of CSPC.

MPMRI ?good at ruling out disease Of 576 men 158 had a negative scan of which 17 (7%) had CSPC Possible reduction in Prostate biopsy of 27% (stated in the paper)= 40,000 TRUS and biopsy per year.

Pre biopsy MPMRI Other benefits Potential for decreased diagnosis of Clinically insignificant disease = 5% and increased diagnosis of CSPC 18% increased detection of significant disease if targetted biopsy based on MP MRI

PROMIS strengths Multi-institutional including DGH 1.5 Tesla Results of MPMRI blinded to all involved Prospective TPN accepted as currently the most accurate investigation to diagnose presence, grade and volume of Cap.

Weakness of PROMIS Due to blinding they were unable to assess the targeting on the MRI suspicious lesions. Do the areas of cancer correspond to the areas of suspicion on the MRI reports? Patients on finasteride and prostates larger than 100ml were excluded Further work on inter-observer variability. TRUS and biopsy may have been affected by the TP biopsy

Gains of the Proposed pathway using MPMRI as a triage test MPMRI and then targeted Truss if positive Reduced truss and biopsy by 27% (40,000 men) 18% increase in the detection of CSPC 5% Reduced diagnosis of clinically insignificant cancer 18% increased diagnosis of clinically significant cancer Better local staging of T3a/b etc. B Better planning of surgery i.e. site of tumour (avoid positive margin) and safer nerve spare. Better anatomical planning eg. large median lobe etc.? Reduced complications

Pre-biopsy MRI Loss- 7% of men will be missed with CSPC Very significant potential challenges for MRI capacity Very significant challenge for a pressured pathway (breach risk) ? Increased biopsies and change of technique to TPN instead of Trus

Thoughts PROMIS included a thorough in depth financial appraisal this will be assessed by the HTA NICE are planning to relook at their guidance and clearly will be steered by the HTA . Assumption that targeted and TPM equivalent (our own data showed using just targetted TRUS misses some CSPC) ? Targeted will miss tumours picked up by TPM MRI clearly better at detecting CSPC than TRUS and biopsy Safe followup for those with negative MRI if no biopsy