The ever-changing horizon of prostate cancer assessment: charting a personalised course.

By Alan Doherty, consultant urologist, BPC

In prostate cancer, the biggest step changes in recent years have been in the way we assess disease. At the Birmingham Prostate Clinic, we were early adopters of what is now widely accepted as best practice: MRI before biopsy to decide whether a biopsy is required and as a key tool in risk stratification.

The development of medical technology has been rapid: we have a proliferation of options in MRI and different ways to undertake a biopsy. How do we navigate these different options? We can start with the key principles: what we are trying to achieve in prostate cancer assessment is to be thorough, have a low rate of false negatives, but also to minimise harm (different biopsies carry different risks of infection and urinary retention).

The challenge is, if we follow these key principles for each clinical scenario, they don’t take us to the same diagnostic pathway. For example, in a recent video consultation with a patient about next assessment step, he told me, ‘I don’t want to miss the boat’. I asked him what he would define as missing the boat, and he described this as postponing treatment for his prostate cancer to a stage when effective nerve-sparing surgery would not be possible. In this scenario, a template biopsy would be recommended, which is sometimes described as a saturation biopsy because of the way the whole prostate is mapped on the template, with samples taken from every area. It is carried out under general anesthetic.

By contrast, if a patient has presented with a legion that is palpable (can be felt) on examination, is graded 4 or 5 (high risk) in MRI assessment, it is difficult to justify a template biopsy approach. This is because in this scenario, prostate cancer will not be difficult to locate using a trans-rectal ultrasound (TRUS) or transperineal (TP) approach under local anesthetic. A template biopsy, using a general anesthetic, carries a ten per cent risk of causing urinary retention, so if it is not critical to the assessment process, should we be selective in its use?

I recently attended an interesting session to see the new PrecisionPoint™ system which supports a transperineal approach under local anaesthetic. This is important because traditionally, a transperineal biopsy required a general anaesthetic, with attendant risks, together with the requirement for operating theatre time. If we can safely and accurately perform prostate biopsies via a transperineal route using local anaesthetic, this will be another major step-change: it is widely accepted that TRUS biopsies have an infection rate of five per cent and are poor at sampling the anterior part of the prostate (the section which is closest to the urethra).

If this seems confusing for patients and their families as they try to navigate the different options and opinions around prostate cancer assessment, I would reflect that even as a urologist specialising in the field, it presents difficult challenges and dilemmas. Going back to those first principles: be thorough, minimise false negatives, minimise harm, we are often weighing up quite different advantages and risks. It is an evolving picture. In one aspect, I do feel certain: one size does not fit all. At the Birmingham Prostate Clinic, as well as having the largest private sector Multi-Disciplinary Team (MDT) evaluating every patient management plan, we have just developed our own MRI results database, which will map each patients’ original assessment information against future treatment or assessments, so we can very precisely map how accurate we are. This is another principle I frequently return to: keep measuring, testing and evaluating everything we do. In this way, as assessments evolve, we have the evidence to chart the best pathways and outcomes for each of our patients.