of Practice Pathways Event Thursday 8 February 2018 The Wesley - - PowerPoint PPT Presentation

National Cancer Communities

• f 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 Clinical Lead, RM Partners RAPID Programme Chair, NHS England Prostate Clinical Expert Group Chair, NCRI Prostate Clinical Studies Group

Department of Urology, Imperial College Healthcare NHS Trust Division of Surgery, Imperial College London

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) Hashim U. Ahmed, Imperial College London Reference

Gleason >/=7 on TRUS-biopsy (in non-suspicious MRI)

% Gleason 7 on TRUS biopsy (in non-suspicious MRI) Itatani 2014

20/193

10% Pokorny 2014

9/81

11% Wysock 2016

0/29

0% Wang 2017

4/39

10% Lu 2017

1/38

3% Washino 2017

21/131

16% Sokhi (ECR 2018)

1/26

4% An JY 2017

0/20

0% Porpiglia 2017

1/16

4% PROMIS (Ahmed – comm)

8/158

5% Dutch (Barentsz – comm)

11/306

4%

Most studies report approx. 5% (0-16%)

Can we justify transperineal in all?

Hashim U. Ahmed, Imperial College London

Biopsy related sepsis – an avoidable harm

N=198,361 ~2% sepsis

Anastasiades et al, 2015 Hashim U. Ahmed, Imperial College London

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

• 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

Hashim Ahmed

‘Biopsy all’ versus ‘MRI pre-biopsy’

Standard TRUS pathway Triage mp-MRI Pathway p-value

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…

Reflections on today Topics for next time