Radiologists in Scotland have adopted a rigorous approach to quality management to improve the scheduling and reporting of prebiopsy prostate MRI exams. They narrowly failed to meet their 2019 target of reporting 90% of all requested exams within 28 days, but feel they're heading the right way.
Multiparametric MRI prostate exams have become a pivotal and standard tool in detecting, localizing, and staging of prostate cancer, Dr. Abdelaziz Marzoug and Dr. Senthil Ragupathy, both from Aberdeen Royal Infirmary, reported at RCR Digital 2020, the U.K. Royal College of Radiologists' (RCR) online learning program that ran from 21 September to 9 October.
"Recent Scottish government initiatives recommend that all patients with suspected prostate malignancy who are eligible for MRI should have this examination prior to any biopsies performed," they noted. "This exerts a significant strain on the current resources in order to stay within cancer waiting time targets."
Previously, MRI examinations were performed three months after biopsies, therefore allowing more flexibility in booking MRI prostates at the teaching hospital, which has around 900 inpatient beds and offers tertiary care for over 600,000 people across the north of Scotland.
28-day target
Following a meeting with all the stakeholders involved, a local objective was set of 90% of all requested prebiopsy MRI prostates to be reported within 28 days -- i.e., 14 days for booking/performing an exam, plus 14 days for reporting the exam.
Prebiopsy MRI prostate exams in Aberdeen commenced on 14 January 2019, and Marzoug and Ragupathy extracted data from the radiology information system booking system for the requests received until 31 December 2019. They also collected the request date, booking date, report date, and any additional comments about delayed bookings.
Hospital managers at the Aberdeen Royal Infirmary created a pathway for referral of prebiopsy MRI prostates, and it was circulated to the relevant clinical teams.
DRE = digital rectal exam; GA = general anesthesia; mpMRI = multiparametric MRI; PSA = prostate-specific antigen; PIRADS = prostate imaging reporting and data system; THR = total hip replacement; TRUS = transrectal ultrasound.
After radiology administrative staff received a period of training and supervision, they vetted all requests for MRI prostate exams. To allow streamlined vetting by admin staff, it was mandatory to include specific clinical details in MRI requests.
Two consultant radiologists provided comprehensive urological MRI reporting services, and none of the exams were outsourced. To cope with the increasing demand, mechanisms were implemented to report prostate MRIs over and above regular working hours (insourcing model). Liaising effectively with the MRI lead consultant and superintendent radiographer were vital to make these arrangements work.
The total number of patients who were seen in 2019 was 301. There were 39 exclusions due to patient availability, delay in estimated glomerular filtration rate (eGFR), claustrophobia, and a patient refusing to have an MRI or feeling too unwell.
| Time taken to book and report MRI prostates | |||||
| Range (days) | Mean (days) | Median (days) | Interquartile range (days) | No. of patients within target timeframe | |
| Booking time | 1-27 | 13.5 | 14 | 11-15 | 166 (63.4%) (within 14 days) |
| Reporting time | 0-20 | 8 | 8 | 6-10 | 242 (92.4%) (within 14 days) |
| Total time | 6-38 | 21.5 | 21 | 17-25 | 232 (88.5%) (within 28 days) |
"This is our first year of results in scheduling and reporting pre-biopsy prostate MRIs," the authors stated. "Although we did not attain the target of reporting 90% of these examinations within four weeks, we are not far from our target."
However, the data show that there are still difficulties in booking these examinations within the two-week timeframe. With increasing population and awareness of prebiopsy MRIs, this will still prove to be a significant bottleneck and underscores the importance of more MRI resources, they emphasized.
What the guidelines say
In December 2018, the National Institute for Health and Care Excellence (NICE) issued a statement supporting the use of multiparametric MRI as a frontline tool in English hospitals to scan for prostate cancer. NICE guidance is only officially for England, but some advice is provided to Wales, Scotland, and Northern Ireland too.
NICE recommends that multiparametric MRI should be offered as a first-line investigation for people with suspected clinically localized prostate cancer, but it stresses that this will not replace standard first-line tests such as the prostate-specific antigen test and that patients who are not going to have radical treatment should not be routinely offered the scan.
"Multiparametric MRI is clinically cost-effective as it will reduce the number of biopsies performed. Additionally, cancers are more likely to be detected and identified earlier, therefore, reducing the need for further treatment," the regulator noted in a statement.
Editor's note: The image on the homepage used to introduce this topic is a T2-weighted multiparametric MRI scan performed in a 59-year-old patient presenting with dysuria and a family history of prostate cancer. Image courtesy of Dr. Olivier Rouvière, PhD.
