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A Letter from the President of BAUS to the Daily Telegraph

19th June 2013

Sir,

Laura Donnelly’s article (Daily Telegraph Sat 15th June) contains some factual inaccuracies. She estimates that if all men referred with suspected prostate cancer received an MRI scan prior to a prostate biopsy, a quarter of them could be reassured without the need for a biopsy. This is fundamentally misleading because as yet there is insufficient evidence to support this assertion.

The article further claims that an initial MRI could halve the number of men who would be diagnosed with significant cancer incorrectly by biopsy and subsequently receive unnecessary treatment.

Similarly, this has not yet been confirmed by rigorous clinical research. Validation, via the PROMIS trial – https://www.controlled-trials.com/ISRCTN16082556 is currently being undertaken at UCLH by Professor Mark Emberton’s team. Should evidence emerge of the usefulness of MRI in identifying men with prostate cancer the process would need to be standardised by protocols endorsed by The Royal College of Radiologists and significant training would need to be undertaken by radiologists nationally.

MRI scans are expensive, as each scan costs £400, thus there are significant resource implications. This diagnostic pathway would need to be funded by Primary Care Commissioners for both an initial scan plus any repeat scans that may be required if biopsy is not deemed necessary. Regretfully currently such funding is not confirmed.

BAUS fully supports all endeavours to improve the diagnosis and treatment of prostate cancer for men in the UK but evidence of effectiveness needs to be in place before new modalities can be introduced nationally.

 

Adrian D Joyce MS FRCS(Urol)

Consultant Urological Surgeon & Hon Senior Lecturer

St James’ University Hospital

Leeds LS9 7TF

 

President, British Association of Urological Surgeons

[email protected]

[email protected] or [email protected]

https://www.baus.org.uk

 

 

Comments on this blog are now closed.

 

 

 

 

21 replies
  1. Declan Murphy
    Declan Murphy says:

    Very sensible comments from BAUS President. This daft headline and misleading comments in a major paper (https://www.telegraph.co.uk/health/healthnews/10121870/Half-of-prostate-cancer-cases-may-be-missed.html) caused reaction not only in the UK but also around the world, including Australia where I dealt with enquiries from patients and health correspondents alike. The tone of the comments contained would lead patients to believe that outside a “handful of hospitals”, that patients are being managed inappropriately by not having an MRI before a decision is taken regarding a biopsy (or to guide a biopsy).
    This remains a very interesting research area and the group at UCL are leading here. However, it is certainly appropriate for the BAUS President to remind people of the current status and to reassure clinicians and the general public that the current standard is not MRI for all with a raised PSA. I am equally impressed and disappointed on a weekly basis by the results I see using 3T mpMRI – we have a way to go yet before this expensive modality finds its place in routine practice.

    • Nathan Lawrentschuk
      Nathan Lawrentschuk says:

      Unfortunately another case of ‘placing the horse before the cart’. The response of the BAUS president to the Telegraph article is correct. MRI has specific indications at present such as unearthing ‘PEATS’ or Prostatic Evasive Anterior Tumour Syndrome where anterior tumours may be identified and biopsied. MRI is by no means a part of routine practice based on current data. Medical reporting all too often suffers from sensationalism and bias- which only serves to confuse a public already weary and fearful of prostate cancer and any tests surrounding it. Let’s stick to data not dogma going forward.

    • Ben Challacombe
      Ben Challacombe says:

      Excellent points from the President.
      This article has worried many and undermined the current diagnostic pathway in the UK.
      However many urologists including myself now believe MRI has an important diagnostic as well as staging role. All the problems come from uncoupling the MRI from the biopsy in the diagnostic pathway before the case has been proven.
      We certainly need to move on from 12 needle random sampling of the prostate through the rectum. MRI is excellent at picking up anterior lesions which may be missed at standard TRUS and Trans-perineal biopsies will become increasingly used due to their low sepsis rates and good anterior/apical sampling.
      It is however surprising how often there is significant disease at biopsy not seen on MRI and this fact alone means MRI cannot be used diagnostically on its own.

  2. King
    King says:

    MRI has become the sexy new tool of urologists not only in the UK but also in the US. If we are to believe reports from NYC – every sentient being has a endorectal coil placed in the waiting room. Why? I haven’t a clue. I have spent years reading the sparse data and i have re-read the MRI AS data that is slowing coming to the fore. The conclusion is a massive question mark. The future of MRI can not be for screening. Just saying it makes me laugh. It’s such a pathologically myopic view of healthcare economics that I am both laughing and crying

  3. Roger Kirby
    Roger Kirby says:

    Laura Donnelly’s article in Saturday’s Telegraph is most unhelpful.
    Sadly, it is only likely to spread further alarm and despondency among patient’s and clinicians about the diagnosis of prostate cancer. While we support the view that MRI can be useful in targeting lesions in the gland that may require biopsy, we are certainly not yet in a position to implement the practice across the UK, nor is there evidence yet that we should do so. In an recently published comment for the BJUI (https://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11779.x/full) we discussed the changing paradigm for the evaluation of a raised PSA and discuss the implications of the more widespread use of multiparametric MRI, in terms of cost, availability of 3 Tesla scanners and critically expertise in the interpretation of these complex images. Simplistic and alarmist articles in national newspapers are not the best way to achieve changes that result in an eventual benefit to patient care.

  4. Prokar Dasgupta
    Prokar Dasgupta says:

    USANZ have published guidelines on MRI Prostate, similar to articles from other countries. See video on the BJUI Facebook page here
    While the evidence in favour is mounting, many radiologists are not savvy with the PIRADS system yet. That being said would I have a 3T MRI myself before a prostate biopsy? Absolutely.

  5. Mark Speakman
    Mark Speakman says:

    Whilst agreeing with comments above I would remind everyone that in typical ‘good’ journalistic style the article was placed at the top of the front page of the Telegraph and has sparked all this comment. The final paragraph of the article was positioned away on page 2 and included the more balanced and conciliatory paragraph below. ‘She said: “This early data suggests that giving men an MRI scan before a biopsy may put clinicians in a better position to tailor investigations and treatments further down the line. However further research is necessary before we will know the true value of this method.”’

  6. David Neal
    David Neal says:

    We will for sure see massive improvement in the future in how prostate cancer is diagnosed and improved imaging will form an important component. The article is correct in part. We know that we miss many cancers at present in men with high PSA levels who undergo regular trans-rectal biopsy. There is in my view an important role for MRI in men who have a negative biopsy whose PSA is raised.

    It may prove to be correct that an MRI will be useful before a biopsy is done men with a high PSA, and that this biopsy will be done using image registration using template approaches so that biopsies can be targeted to abnormal areas. We do not yet know if MRI misses important cancers in men with an abnormal area, but we do know biologically that many prostate cancers are multifocal; and we know from men undergoing radical prostatectomy that MRI misses many of these cancers.

    However, where the article is really very misleading is to suggest that a man with a negative MRI should not undergo biopsy – we simply do not know if this is correct.

    Whilst I might personally want an MRI if I had a high PSA before a biopsy was done; I would still want a biopsy if the MRI was normal – the jury is still out on this question. Importantly I think that a urologist reassuring someone and not doing a biopsy simply because the MRI was normal in a man presenting for the first time might find themselves in a tricky legal situation if the man subsequently presented with significant prostate cancer within a few years.

  7. Caroline Moore
    Caroline Moore says:

    There are a number of questions that need to be answered about prostate MRI, and challenges for the development of an approach to prostate cancer diagnosis that will detect those cancers that need treating, and leave undiagnosed that which don’t pose a threat to health or life expectancy.

    1. What is the positive predictive value of MRI? On current data, either before first or subsequent biopsy and taking’ all comers’ it is around 66%. If you use a scoring system like PIRADS and subdivide it into those with an equivocal score (3) and those with a higher risk score (4/5) and look at all cancer then you have about 50% and 80%+ PPVs respectively. If you try to apply some sort of threshold for clinical significance then those figures change.

    2. What is the negative predictive value? A high NPV would mean we could use MRI to allow some men to avoid biopsy. I think this is easier in the older man with a large BPH prostate where the higher grade lesions show up as discrete lesions, and the PSA density is low, than the younger man whose MRI is more difficult to interpret, and diffuse change in the PZ can hide tumour.

    As well as the performance characteristics of the test there are other factors to consider – would adding in MRI to the diagnostic pathway actually reduce the numbers of men biopsied, or would it just be an additional test to add to the expense of a diagnosis of PCa? What proportion of men ‘should ‘ test positive on MRI? In cervical screening the screeners are checked for ‘compliance’ with expected rates of positive tests and if they are far away form the average their work is checked to see whether it reflects different disease prevalence, or a tendency to ‘overcall’ or ‘undercall’.

    There is a suggestion that in some practices a radiologist is unwilling to score a 1-2 if they think a man will not get a biopsy as a result. If that means that many are scored equivocal ‘just in case’ then adding MRI would not result in any greater efficiency but would only add to burden and cost.

    MRI will not detect all cancer, and will not detect all of the clinically significant cancer – no test is perfect. The question, to my mind, is – is it better than what we have now (standard TRUS)? Who would it be most useful in – men with a borderline biopsy indication? Those at high risk (eg family history)? Those with a negative biopsy and a persistent indication eg rising PSA?

    What is the best way to target a lesion on MRI? Software assistance, cognitive registration , in bore targeting? Is a transperineal & GA necessary or can most lesions be targeted using TRUS, once the area of a higher probability of cancer is known?

    Ultimately, as evidence to answer these questions accumulates, we will need to consider how to control the use of MRI. Already a number of hospitals in the UK have MRI before biopsy for selected patients – if we can collect data on this, and assess how/if it changes biopsy practice then we will be in a position to assess its usefulness in UK practice. And, if it is useful outside of few highly specialist centres then we would need to address issues of capacity, training and access at that point.

  8. Hashim Ahmed, UCL
    Hashim Ahmed, UCL says:

    There have been many articles on prostate cancer in the press, some in which a number of us have engaged with, about new and existing tests, new and existing therapeutics, doing more PSA testing, and doing less PSA testing. I am sure many of these articles in the press have veered into sensationalism – journalism is a different skill and none of us can account for what they write. This particular article was picked up by Laura Donnelly, the journalist, from a poster presented at the National Cancer Intelligence Network conference last week at which she was actually present.
    https://www.ncin.org.uk/news_and_events/conferences/. The poster was based on developing a health economic model within the Wellcome/DoH funded SmartTarget project that UCL is conducting with the LSHTM. We were surprised it was picked up at all let alone hit the front page.

    However, despite the sensationalism, I don’t think we should forget the facts of the current pathway in prostate cancer diagnosis and treatment. It is considerably flawed. I think men should know about and understand these. Not through headlines, but we should all be very clear to men who come to us with an elevated PSA what the performance characteristic are of the tests we are subjecting them to. Many think, and I agree, that the TRUS biopsy is the one test that makes generalised screening or informal screening practices tremendously difficult to recommend.

    First, not only is TRUS biopsy harmful in terms of toxicity, but it is harmful by leading to over-diagnosis/over-detection with consequent over-treatment and its harms. Although the UK clearly has lower rates of over-diagnosis and over-treatment, I am not sure we can be complacent about how many low and low-volume intermediate risk men are diagnosed and treated with no significant benefit from having that treatment but considerable risk of toxicity.
    With a consistent negative predictive value across a number of expert centres shown in the literature of 85-95% for disease that meets criteria for Gl7 and/or 0.5ml in volume, I am not sure I agree that the technology itself does not work. One of the major advantages of multi-parametric MRI is its inherent inability to detect low-grade, low-volume disease. From some of the comments above, some recent press articles and from the statement below in a recent BJUI editorial it is clear that many of us have lost individual equipoise on this subject.

    “An alternative approach, and one that we have recently adopted, is to respond to the raised PSA level, or one that is rising progressively over time, by requesting a 3T MRI scan with diffusion-weighted sequences and gadolinium enhancement (Fig. 1) for post-PSA test and pre-biopsy risk stratification” https://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11779.x/full

    Second, the other error of TRUS biopsy is under-detection and under-treatment. The extent of this is hard to estimate as the negatives were previously not fully evaluated with a gold reference test. Only now with Template Prostate Mapping biopsies are we starting to appreciate how much disease TRUS biopsies actually miss. The negative predictive value of TRUS biopsy is certainly considerably lower than a multi-parametric MRI performed at an expert centre with optimised sequences and an expert reporter. What are the medico-legal aspects of not offering a man with a negative TRUS biopsy a Template Prostate Mapping procedure or a multi-parametric MRI in the knowledge that one-third of these men harbour clinically significant disease? https://onlinelibrary.wiley.com/doi/10.1111/bju.12134/abstract
    Isn’t that the disturbing fact in all of this?

    The questions about capacity, infrastructure, quality, training, dissemination of reporting and targeting skills, costs and cost-effectiveness are all legitimate and all very important. Huge investments needed to be made for breast cancer screening despite questionable therapeutic ratios in that disease. However, these questions about health service delivery seem not to be questioning the performance characteristics of the technology. Cost is an issue, but with an MRI equivalent in cost to a TRUS biopsy in the UK (approx. £400-500) and IF biopsy can be avoided in one-quarter to one-third of men with an elevated PSA, and therefore avoid TRUS biopsy’s consequent harms of toxicity, over-diagnosis and over-treatment, one can start to appreciate that even on a ‘back-of-the-envelope’ cost analysis there could be substantial savings. Overall cost-effectiveness analyses are built into the NIHR-HTA PROMIS and Wellcome/DOH SmartTarget projects. In France, an MRI is approximately 300Euros. I am sorry to our US colleagues that their MRI costs vary between $1000 to $3000 USD. The cost-effectiveness in the USA may not be as clear-cut, especially if their radiology colleagues are less likely to call a scan ‘negative’, but there are certainly respected academic urology advocates for this in the USA as well.

    As urologists, we should be anticipating these needs and pushing and lobbying for high level discussions to start on how these needs can be met if, in 2 years’ time, the NIHR-HTA PROMIS trial, reports back with favourable results on the reproducibility of pre-biopsy MRI across a number of UK centres and a number of trained and quality-control reporters. We should do everything we can to support the PROMIS trial with recruitment so that it completes and reports in a timely fashion before practice changes because men start demanding the test just like they have demanded access to other technological innovations within the UK.

  9. Simon Brewster
    Simon Brewster says:

    I saw a draft of the BAUS Presidents letter and fully support everything it says. And as Mark Speakman points out, the only third-party comment the DT reporter obtained was from Kate Holmes of Proster Cancer UK, who added a cautionary tone about further research being required, which was unfortunately hidden at the bottom of the article on page 2 of the broadsheet. I believe a very few urologists are reassuring men with normal MRI that they don’t need a biopsy, but hopefully within a research clinic and perhaps repeating MRI as well as PSA on them at intervals. I agree with the UCLH team and others that this is coming, pending the PROMIS trial. I hope the radiological community is preparing for this influx of new work. But for now a realistic position must be stated: the UK in general terms is not ready yet.. not trained & not funded. The big issue I have with this DT article is that it undermines what the health service can currently offer. This will cause frustration and friction between patients and their doctors.

  10. Declan Murphy
    Declan Murphy says:

    Great to have the UCL imaging experts adding comments here. Thank you Caroline and Hashim. The work you are doing is very valuable and is advancing this field continuously. It is a shame that sometimes it gets sensationalised in the press before it all gets digested properly. Keep up the good work

  11. John Davis
    John Davis says:

    The construct of this debate is illustrative of the challenges of bringing novel ideas to routine practice. Early in cycle of a novel test, its use is clearly experimental and outside of clinical practice. After rigorous study showing a benefit of a novel test and its inclusion in clinical guidelines, then not using it along such guidelines may be sub-standard care. The challenge is this “grey zone” period where we have some data and experience, but not definitive. Its hard to determine if its sub-standard to use it versus wait for more data, and who decides when the evidence is officially “definitive.” As Prof. Dasgupta says–he would consider using and MRI before biopsy, but at this point I can neither fault him for doing that or not doing that.

  12. Uday Patel
    Uday Patel says:

    The reality on the ground is that few centres in the UK have access to the best kit for prostate MRI. Pre-biopsy MRI, as distinct from standard staging MRI, demands the highest spec kit. Of the 5 or so MRI machines I regularly see scans from, only 2 could be considered high spec, and I consider myself very fortunate. But one should not underestimate the interpretative difficulties with prostate MRI. Few prostate glands are unequivocally ‘MRI normal’. Subtle abnormalities are almost the rule and reflected in the widely variable data on performance – the PPV was only 0.38 and accuracy 80% in what I consider the most thorough recent paper (Eur Urol 2012;62:986-96). And these are the performance figures from one of the best units. In spite of all this, I am a Prostate MRI enthusiast as properly done it could avoid needless biopsies.

  13. Mark Emberton
    Mark Emberton says:

    I have just used this blog – to great effect I think – to introduce a panel discussion with the title, ‘Which men should be getting an MRI before biopsy?’ at a meeting in New York organised by Herb Lepor. The audience was particularly taken by the comments made on New York practice. I think it is fair to say that most of the well known units (MSKCC, NYU, Cornell) are offering high quality pre-biopsy MRI (or more correctly post-biopsy) as most consultations are the second, third or sixth opinion in many. Adoption in the USA is happening, largely led by academic centres, but this of course should not influence us.

    There are, I believe, three dimensions to the discussion: a moral one; one based on evidence and one that relates to issue of access. I shall leave the moral issue until later but it may prove to be the one that drives change.

    Much of the evidence has been summarised and commented upon by earlier bloggers. There are two errors that we can make in relation to adoption – to be too early or too late. Much of the concern has focused on the first of these errors. This is quite a reasonable position. However, when we adopt this position we should recognise that we become vulnerable to the second error. The second error should not be taken lightly given that one million prostate biopsies are performed each year in the EU alone, many more in the USA. Lets assume that about half of these are probably unnecessary, and therefore better avoided – in that these men will either have no disease or harbour truly low risk disease with nothing more than micro-focal Gleason 3 plus 3. Lets assume for a moment that the NPV of MRI is a 95% for clinically significant disease – a figure that has been arrived at in a large number of studies. Lets assume that the MRI is reported as ‘normal’ in about 30% of patients. It follows that if this is the case about one third of a million men per year might reasonably avoid a procedure that is uncomfortable, increasingly dangerous (Meropenem resistant plasmids were identified in India 6 months ago) and may confer a diagnosis that is associated with limited utility and possible harm (low risk prostate cancer). MRI would also increase the proportion of men with clinically significant disease that are correctly identified and risk-stratified. For this we have a systematic review as evidence and another 1000 patients reported in the literature since that review was published in January 2013. This space is not a static one.

    When people have looked back on the rate of adoption of thrombolysis in the management of CVA the general consensus is that it was adopted too late, given that several RCTs (diagnostic studies do not require RCTs to generate level 1 evidence) had shown time and time again that disability and death were reduced by offering victims of stroke early intervention. Instead of adoption, the response was always ‘one more trial’. Indeed, as a result of this observation several commentators have calculated the number of lives lost and the years of life compromised by not adopting the technology earlier. It makes difficult reading. Indeed, it is humbling to note that full adoption in the UK required government intervention.

    In relation to the issue of access I believe that urologists have an important role. All things in medicine have to be done well. The driver for improvement usually comes from someone asking for something better. If an MRI has movement artefact at UCLH we get another one. If the MRI quality is compromised by biopsy artefact (something that can last 6 months), we get a repeat scan in 6 months. This is no different to the quality control standards that we apply in other areas of urology. The important thing is that we, as urologists, are probably the group best placed to drive this process. The passive stance of ‘we have no resource’ is going to be hard for many outside observers to accept given how successful many groups have been in finding resources (often from charitable sources) for an equally expensive capital investment (Da Vinci robot) at a time when most of the literature was pointing to no more than equivalence.

    The moral or ethical dimension is proving more and more interesting. Some of the bloggers have indicated that they themselves would probably insist on an MRI prior to a biopsy. Of note Roger and Damien in their excellent and brave newspaper piece on their own diagnoses both stated quite emphatically that they chose imaging prior to the biopsy. Indeed most urologists now hold this position. Who would not, as there is little obvious downside? This does create the dilemma that professionals may have views on their own care that is discordant with the care or advice that they offer their own patients. This is a position that is clearly not sustainable.

  14. Shwan Ahmed
    Shwan Ahmed says:

    In this day and age, I think the main issue will still be cost and capacity. Assuming that the majority of men diagnosed with prostate cancer in UK (40 000 / yr ) get MRI at some stage during their pathway, and the positive yield rate for prostate biopsy is 30-40% as reported in literature, then you will be looking at an additional 60 000 MRI scans/ year. We all love to have the best scanners, but like the Da Vinci robots, 3T MRI scanners availability will be limited to few centres in UK in my view.

    I can compare this to transperineal (TP) prostate biopsy. We all know the benefits of TP biopsy in terms of better yield and less risk of sepsis compared toTRUS biopsy, yet the majority of biopsies in UK are still done trans-rectally. Even in centres that provides TP biopsy, TRUS biopsy is still carried out. This is mainly due to limited capacity with theatre time.

    There is a little disagreement amongst us that per-biopsy MRI scan is a great idea, but the main question is can we afford to adopt it for 100 000 per year in UK?

    • Amrith Rao
      Amrith Rao says:

      Dear Shwan,

      You have underestimated the number of MRI scans performed. The emphasis is on pre-biopsy MRI scan. This is not equivalent to the number of prostate cancers diagnosed but multiplied by a factor of 4 if not more. If and when pre-Bx MRI does hit the main stream, we will be faced with as you rightly pointed out, more template biopsies. However, there is emerging evidence that targeted biopsy using the fusion technology is the way forward! Given the cost implications, there may be a move to centralise Targeted template biopsy to bigger centres who can afford it!

      Secondly, there will be soon papers coming out in support of MRI as a means for Active Surveillance rather than repeat TRUS/TPBx. Therefore, there will be a huge increase in the number of MRIs being requested, performed and reported!

  15. UABUroOnc
    UABUroOnc says:

    I agree that the sensationalism of a technology that is not perfect is hurtful to the science of improving prostate cancer treatment. However there are some arguments such as that using MRI as far as a myopic view of healthcare is sad and makes some laugh…..is itself a very narrow view of this issue. I agree there needs to be prospective studies looking at MRI versus other urine based biomarkers (PHI, ERG fusion proteins, etc) is the next step, but there are many issues to consider. There are centers of excellence where this technology is performing with great benefit such as NCI (where I have gained experience with this approach). What if an MRI can prevent a patient from ever getting a prostate biopsy? What if by preventing some patients from getting biopsies it can decrease the overall sepsis rate by even a small amount? What if we can use MRI to change active surveillance regimens to decrease the amount of biopsies? What if we can use MRI alone or in combination with other markers to better stage prostate cancer and decrease over-treatment and the cost of treatment and resulting complications? There are multiple issues such as these to consider before automatically assuming that MRI will only drive up the cost of prostate cancer treatment.

  16. Alan McNeill
    Alan McNeill says:

    Isn’t part of the problem the weakness of PSA as an indicator of prostate cancer? We should be looking for other measurables that are cheap and better predict whether a man with a PSA above his age specific reference range has prostate cancer. The existing risk calculators may then get better and be used more widely allowing us to target our efforts better. MRI machines are always likely to be an expensive resource which is likely to limit the application of pre-biopsy MRI for all – morally tricky if urologists have a ‘do as I say, not as I do’ approach.

  17. Frank Chinegwundoh MBE
    Frank Chinegwundoh MBE says:

    Another reason why we have moved to pre biopsy MRI is the ‘clock ticking’ as regards treatment target times. If prostate cancer is diagnosed by biopsy, commonly there is a 6 week wait before a staging MRI as before that post biopsy haemorrhage may cause artefact. This has led to breaches of the somewhat arbitrary 62 day cancer treatment target time. This greatly exercises management.
    If however, a ‘staging’ MRI is done pre biopsy and the man turns out to have prostate cancer on biopsy, we know from the MRI whether it is T2 or T3 and an appropriate treatment plan can be instituted, avoiding a 6 week delay.
    The point of the MRI is for staging rather than diagnostic, although there has been ‘mission creep’ so to speak.
    It does mean that men without cancer on their (usually TRUS biopsy) have had an unnecessary MRI. The issues of cost and time come to mind. How to deal with a suggestive pre biopsy MRI but negative TRUS? Previously these men would have been on psa surveillance.
    Having said the above, I believe the future will be diagnostic MRI and largely transperineal biopsy, should the evidence support this approach. Normograms may help further define who to biopsy.

  18. Andrew Hamm, Patient
    Andrew Hamm, Patient says:

    Hope my contribution to this blog isn’t too late, but I’ve only recently become involved in this topic.

    I’d like to present my observations from a PATIENT’S point of view.

    Firstly, I’m very thankful that my GP and myself decided to monitor, in addition to my cholesterol, my PSA, starting about 6 years ago.

    A steady increase (to a present figure of about 6) made both of us decide a visit to a urologist would be a good idea. I’m nearly 61 years old (no secret – at least 3 of those on this blog already know that!).

    So, I start thinking: “What if I’ve got prostate cancer?”

    The only experience I’ve had is: one friend who died of it, and one who had it significantly bad that he himself knew something was wrong.

    With me? NO symptoms whatsoever.

    Start worrying about the little I’ve heard friends/family talk about: Chemo, Radio/hormone therapy or radical surgery.

    Deciding to select a urologist close to my city office, I found Emberton’s private practice on google.

    I now realise that was certainly God’s guiding!

    Since then, I reckon I’ve become a reasonable expert on the topic (Emberton, Ahmed: gissa job!)

    I soon found on youtube the excellent Nuada Medical videos, particularly the one on focal HIFU.

    Most impressive was the sequence Emberton instigated: MRI then TPM biopsy.

    The results of that revealed I was the proud owner of a 1cc anterior tumour containing 12mm of Gleason 3+4, with the added bonus of 5mm of Gleason 3 in the right lateral aspect (buy one, get one free!)

    My insurance not fully covering Princess Grace Hospital, I’ve now transferred for treatment to UCLH.

    Now “looking forward” (!) to focal HIFU in April, to be done by…..(Schhh…. She-knows-who!)

    I do feel concerned for chaps I know (funny, the women don’t seem to be interested…), who are NOT being even TOLD about the limitations of the standard TRUS biopsy.

    A relative of mine in Bedfordshire, with a concerning PSA figure, was told he’d have to find somewhere ELSE to have his investigation, because “we don’t do prostate MRI in Bedford hospital”. They were only offering him TRUS. Had I not already gone down this route in MY case, I wouldn’t have been ABLE to tell him about these better options.

    Where are the campaigning posters for men 45 and over to have regular PSA tests? The women had their equivalent re. breast cancer, some decades ago. Even included trailers in car parks where they could have a scan. (I’ll keep my eyes open for trailers with prostate MRI scanners in Tesco’s car park next week!) Ok, to be fair, I’m aware of the earlier Bob Monkhouse campaign.

    It’s now become an “additional good news” subject for me to broadcast: “If you’re over 50, have regular PSA tests”.

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