Primum Non Nocere: time to revamp the prostate cancer diagnostic pathway
BAUS ePoster online library. Moss B. Jun 25, 2019; 265262; CU-9
Dr. Basil Moss
Dr. Basil Moss
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The PROMIS and PRECISION trials have shown that multi parametric MRI (mpMRI) can be used to risk assess men presenting with raised PSA, reducing the need for biopsy. We are introducing a new pathway whereby a clinical nurse specialist (CNS) will do a telephone assessment and arrange mpMRI: biopsy is avoided if low risk (Prostate Imaging Reporting And Data System (PIRADS) score <3, PSA density <0.1). We tested this pathway using retrospective data.
Four hundred and ten patients referred to one UK Cancer Centre with suspected prostate cancer (CaP) October 2017 to September 2018 had mpMRI. Results of imaging, PSA density, and biopsy were collated and the new diagnostic pathway applied to this data set.
Ninety-four patients were excluded from analysis as no PIRADS score was given. Of the remaining 316, 197 underwent biopsy, 13 complications were recorded and 97 significant (Gleason score 7+ or tumour length >6mm) cancers detected. The cutoff of PIRADS 3+/PSAd >0.1 has 100% sensitivity and 9% specificity for biopsy detected clinically significant cancer. Under the new diagnostic protocol (under 75, performance score <2), 263 patients would proceed directly to mpMRI after CNS telephone assessment, of whom 40 (15%) would avoid biopsy. As we have been doing mpMRI without formal criteria we biopsied nine of these 40, with no significant CaP detected.
We have demonstrated that the new pathway using pre-biopsy mpMRI applied retrospectively is safe and avoids unnecessary biopsy and its attendant complications. Significant cancers are unlikely to be missed. This increases the confidence in implementing the new pathway.

Historically, most men with suspected CaP underwent transrectal biopsy for histological diagnosis, with risks of pain, bleeding and infection. Sepsis occurs in 0.6% - 3.6% (Bruyere et al., 2015; Loeb et al., 2013) usually due to E. coli (Lange et al., 2009), hospital admission in 1 to 4% (Nam et al., 2013; Loeb et al., 2011) and the r
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