Looking Ahead -What’s New in

Prostate Cancer Diagnosis

Mr Matt Simms

Consultant Urologist

Hull and East Yorkshire Hospitals

Incidence of Prostate Cancer at Post

-Mortem

Age at PM % Ca Prostate

<30 5%

30-39 25%

40-49 35%

50-59 45%

60-69 65%

70-79 80%

The Ten Most Common Cancers in 1984, 2007 and projected to 2030

Number of Cases, Persons, UK

Cancer Site 1984Cancer Site 2007 Cancer Site 2030

Lung 43,049Breast 45,758 Prostate 61,090

Colorectum* 29,216Lung 39,490 Colorectum* 58,176

Breast26,600

Colorectum*38,442

Breast57,442

Stomach 13,329Prostate 36,083 Lung 57,201

Prostate 11,714Uterus 15,062 Malignant Melanoma 21,824

Bladder11,629

Non-Hodgkin Lymphoma 10,928

Uterus21,443

Uterus9,112

Malignant Melanoma10,723

Non-Hodgkin Lymphoma 15,386

Pancreas 6,811Bladder 10,151 Kidney 14,815

Ovary 5,500Kidney 8,205 Bladder 14,092

Leukaemia 5,443Oesophagus 7,969 Pancreas 11,927

Diagnosing Prostate Cancer- What are

We Trying to Do?

• An efficient, cost effective diagnostic pathway

• Diagnostic pathway should be acceptable to patients

• Should avoid excess morbidity

• Should be good at detecting clinically significant prostate cancer

Benefits of A Standardised Prostate Cancer

Diagnostic Pathway Across Yorkshire and

Humber

• Opportunity to introduce high quality, safe

and efficient diagnostic pathway across the

region

• Better for patients

• Easy referral between trusts and MDTs

• May ultimately be more cost effective

Traditional Diagnostic Pathway

• Detects 80% of cancers

• Risks overdiagnosing non significant cancer

• Imaging / Staging takes place after diagnosis

• Increasing risk of Sepsis

Sepsis

• Currently up to 6% of patients develop

significant sepsis following TRUS/S Biopsy

• Incidence of Ciprofloxacin resistant coliforms

is increasing

• Associated with repeat biopsies and antibiotic

use in last 6 months

Prostate cancer: diagnosis and treatment

Issued: January 2014

Consider …….

• Multiparametric MRI for assessing T Stage

• At enrolment of Active Surveillance

• If previously negative biopsy and suspicion of

cancer

Pre Biopsy MRI

Advantages• Negates issue of post biopsy haemorrhage

• Allows for rapid disease staging (31/62!)

• Could allow accurate targeting of lesions

• Has the potential to reduce number of biopsies

Potential Disadvantages• Cost

• Wasted Resource

• Logistics

• mpMRI is a new tool

Multiparametric MRIAllows radiologists to

• See how tightly cells are packed (diffusion weighted imaging)

• Assess blood flow (dynamic contrast enhanced MRI)

• Assess chemical make-up (Spectroscopy)

Allows differentiation between benign and malignant issue

• The advantages of MP MRI are lost if it is performed too soon after biopsy

Pi-RADS score

Pi-RADS classification Definition Total score T2,DWI,DCE

1 Most probably benign 3-4

2 Probably benign 5-6

3 Indeterminate 7-9

4 Probably malignant 10-12

5 Highly suspicious of

malignancy

13-15

Roethke M, Blondin D, Schlemmer HP, Franiel T (2013) PI-RADS classification:

structured reporting for MRI of the prostate. Rofo 185:253–261

Pi-RADS

• Pi-RADS 1-2

Negative predictive score 84%

• Pi- RADS 4-5

92% sensitivity for detecting Gleason 4-5

disease

Truss Biopsy

• Sextant biopsy 60% of cancer

• 8 biopsies 75% of cancer

• 10 core specimen 78% of cancer

• 12 core specimens 90% of cancer

Fink, et al Urology 2001;58,735-739

Biopsy Types

• Standard 12 core biopsy

• Cognitive Biopsy

• MRI Fusion Biopsy

• Template transperineal biopsy

Transperineal Biopsy

MRI Fusion Biopsy

Incidence of Carbapenem Resistant Enetrobactriaecae

Worldwide Prevalance of Carbapenem

Resistant Enterobacteriaecae

Countries with High Incidence of Healthcare Associated

Carbapenem Resistant Enterobacteriaceae

• Bangladesh

• Balkans

• China

• Cyprus

• Greece

• India

• Ireland

• Italy

• Pakistan

• SE Asia

• Turkey

Sites of Healthcare

Associated

Carbopenamase

Resistant

Enterobacteriaecae

outbreaks across

UK 2010

Antibiotic Susceptibilities for Carbapenem Resistant

Enterobactriaecae

Lancet Infectious Diseases

2010 ;10:597-602

Avoiding Sepsis

Rectal Swabs – could

potentially Identify those with

resistant organisms

Rectal Cleansing with iodine

might reduce sepsis rates

Tailored Antibiotic

Usage – might prevent development

of resistant strains

Questions

• Do we feel that pre biopsy MRI is useful

(what are the barriers to implementing this)?

• How can we protect patients from

bacteraemia / sepsis from multi resistant

organisms?

• What does the ideal prostate cancer

diagnostic pathway for patients in Yorks and

Humber look like?

• Should be able to reliably detect clinically

significant prostate cancer

• Is likely to see increasing use of pre- biopsy

MRI (PROMIS Study)

• Needs more microbiological input

• Biopsies (and antibiotics) need to be tailored

to individual patients

Prostate Cancer Diagnosis in the

Future

Discussion and Questions