National Cancer Communities of Practice Pathways Event Thursday 8 February 2018 The Wesley Hotel, London
The RAPID Pathway... ...and national roll out Hashim Ahmed Professor and Chair of Urology Consultant Urological Surgeon Division of Surgery, Imperial College London Department of Urology, Imperial College Healthcare NHS Trust Clinical Lead, RM Partners RAPID Programme Chair, NHS England Prostate Clinical Expert Group Chair, NCRI Prostate Clinical Studies Group
RM Partners / Imperial RAPID Programme NHS England Transformation Funded • £2.8M • 3 pilot sites (Imperial, St Georges, Epsom) • Same day MRI and report, clinical review and targeted/systematic biopsy if suspicous • Transperineal NOT Transrectal biopsy (Transrectal biopsies stopped at UCH 3 years; stopped at Imperial in April 2017; stopped at Guys in September 2017) • Image-fusion in all 3 centres • Quality reviews at every stage Hashim U. Ahmed, Imperial College London
Current RAPID model Initial pilot results 99 patients 75% biopsied Average time from Referral to Diagnosis 22 days Average time from Referral to Treatment 40 days Hashim U. Ahmed, Imperial College London
Can we justify no biopsy in non- suspicious mpMRI? Hashim U. Ahmed, Imperial College London
Detection of Gleason 7 cancer on TRUS Biopsy when MP-MRI is Negative (adapted from Anwar Padhani table) Reference Gleason >/=7 on TRUS-biopsy % Gleason 7 on TRUS (in non-suspicious MRI) biopsy (in non-suspicious MRI) Itatani 2014 20/193 10% 9/81 Pokorny 2014 11% Most studies report approx. 5% (0-16%) Wysock 2016 0/29 0% Wang 2017 4/39 10% Lu 2017 1/38 3% Washino 2017 21/131 16% 1/26 Sokhi (ECR 2018) 4% An JY 2017 0/20 0% Porpiglia 2017 1/16 4% PROMIS (Ahmed – comm) 8/158 5% Dutch (Barentsz – comm) 11/306 4% Hashim U. Ahmed, Imperial College London
Can we justify transperineal in all? Hashim U. Ahmed, Imperial College London
Biopsy related sepsis – an avoidable harm N=198,361 ~2% sepsis Hashim U. Ahmed, Imperial College London Anastasiades et al, 2015
Transperineal biopsies under LA or sedation 1 in 500 sepsis Hashim U. Ahmed, Imperial College London
Do we need image-fusion? Hashim U. Ahmed, Imperial College London
Hashim Ahmed - Pre-biopsy mpMRI - Non-suspicious mpMRI - Biopsies in non-suspicious mpMRI - Low-risk cancers diagnosed - Low-risk cancers treated (unnecessarily) - Significant cancers diagnosed when mpMRI suspicious - Rates of repeat biopsies and re-referrals
‘Biopsy all’ versus ‘MRI pre - biopsy’ Standard TRUS Triage mp-MRI p-value pathway Pathway Biopsy 100% 59% ≤ 0.05 UCL/Ahmed definition 1 12% 24% ≤ 0.05 UCL/Ahmed definition 2 25% 33% ≤ 0.05 Any Gleason >/=3+4 23% 31% ≤ 0.05 Any Gleason >/=4+3 6% 16% ≤ 0.05 Gleason 6 insignificant detection 12% 2% ≤ 0.05 Definition 1: Any length of Gleason >/=4+3 or >/=6mm of Gleason 3+3 Definition 2: Any length of Gleason >/=3+4 or >/=4mm of Gleason 3+3 Hashim U. Ahmed, Imperial College London
Conclusions The RAPID pathway will test the combination of key innovative elements across a region RAPID has the potential to place UK prostate cancer diagnosis at the international leading edge Key metrics of quality will need to be agreed, shared and standards for improvement set (regionally and nationally)
Forward look for the National Cancer Communities of Practice • Communities of Practice Group – focus on shared learning and support across Cancer Alliances • Complementary to National Cancer Team programme of meetings • Quarterly meetings – next meeting in early June 2018 • Kahootz platform for sharing
Forward look for the National Cancer Communities of Practice • What would be helpful to Cancer Alliances? • For example…. – Shared learning from other CAs on challenges in establishing projects / sharing documentation / challenges around performance targets? – Focussed discussion on key clinical issues? • Tell us what you think… Topics for next time Reflections on today
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