This machine can defer prostate surgery for years. Yet worryingly few British men have access to one
01:06 GMT, 1 May 2012
Many men will have been left shaken by the news this week that operations to treat prostate cancer are little more effective in saving lives than ‘watchful waiting’.
This will have be particularly difficult news because the surgery leads to impotence in half of all men and incontinence in one in ten.
Cancer specialists are still coming to terms with the implications of these early findings from the Prostate Intervention Versus Observation Trust (PIVOT) trial.
A biopsy without an Magnetic Resonance Imaging (MRI) is like digging around in the dark in men's nether regions
One specialist, who would not be named, has voiced what many must feel: ‘The only rational response to these results, when presented with a patient with prostate cancer, is to do nothing.’
In fact, the practice of watchful waiting, or active surveillance, as it is known, doesn’t mean just doing nothing.
Increasingly, cancer teams monitor the growth and activity of tumours through sophisticated scanning.
This development is ‘one of the greatest, least recognised developments of modern cancer treatment,’ according to Dr Gina Brown, co-chair of the Royal College of Radiologists Working Group for Cancer Imaging.
Better survival rates for serious conditions such as stroke and cancer are generally thought to be thanks to breakthrough drugs or novel surgical techniques.
But, in fact, a growing number of cancer patients owe their greatest debt to Magnetic Resonance Imaging (MRI).
MRI works by firing radiowaves through the body. These force the body’s atoms to send out radiowaves of their own, which are picked up by the scanner and turned into images by a computer.
And because there’s no radiation, MRI is safer than an X-ray.
Furthermore, the crystal-clear images of the inside of the body have changed cancer treatment for ever.
The resulting ability of cancer teams to ‘stage’ the tumour — to closely monitor its activity — means that, for instance, the patient can avoid unnecessary treatment (and potentially debilitating side-effects).
The latest developments in prostate cancer offer perhaps the clearest evidence of the benefits.
The crystal-clear images of the inside of the body have changed cancer treatment for ever
At University College Hospital London, urologists have been carrying out MRI scans on men before they have had a biopsy for possible prostate cancer for the past eight years.
The fact is that a biopsy without an MRI is like digging around in the dark in men’s nether regions.
The results are used to decide
whether to do a biopsy, where and how to take the biopsy, as well as
planning treatment and monitoring treatment response.
review of 13 studies showing that MRI-guided biopsy is superior to
ordinary biopsies is due to be published shortly in the journal European
miss one in two tumours while a high-quality MRI scan can rule out
important cancer — tumours that require urgent treatment in 95 per cent
of men with prostate cancer,’ says lead researcher, Professor Mark
Emberton, a urologist at University College Hospital.
is set to play a crucial role in what is being hailed as a safer
treatment for prostate cancer, using a sound wave known as
high-intensity focused ultrasound (HIFU) instead of surgery.
MRI is needed to pinpoint the exact location of the tumour, often the size of a grain of rice.
This technique produced dramatically positive findings in a small trial reported in the journal Lancet Oncology last month, and a larger study is planned.
Engineering manager Alan Johnson is cancer-free after HIFU treatment rid him of the cancerous cells that had felt like a ‘ticking time-bomb’.
But instead of surgery with all the risks that involves, Alan had nothing more than two MRI scans before and after the HIFU treatment.
The findings will need to be replicated in a larger trial before HIFU becomes routine.
‘Traditional treatments treat the whole prostate, regardless of how much cancer there is in the gland, and damage to normal tissues can lead to significant side-effects, including impotence and incontinence,’ says Professor Emberton, who has led the research.
‘HIFU with MRI should help make these a thing of the past.’
An MRI scan 12 months ago was ‘a lucky break’ for retired Leicester greengrocer Hugh Gunn, 66.
Diagnosed with prostate cancer in 2007, he was not surprised after five years of treatment to be told it had spread to his bones.
But he says he’s for ever grateful that rather than giving up on him, doctors gave him an MRI scan.
‘It gave me my life back,’ he says.
The scan showed clearly that the cancer had not spread to other organs, putting his life at risk.
He was given six months of chemotherapy and then started on a new drug, Abiraterone.
‘I’m feeling as good as new, without any side-effects at all,’ says Hugh.
The quality of life MRI provides has helped another patient, David Fryer.
Fourteen years ago, he was diagnosed with a brain tumour.
Now 48, he has just had his third operation, with a second session of radiotherapy due to start this week.
David has been able to avoid treatment until necessary and so has enjoyed years of better-quality life.
‘Because my medical team could see the tumour so clearly, they could make a confident decision to leave it alone, thereby avoiding the risks involved in carrying out brain surgery,’ he says.
During that time, life continued with surprisingly little disruption, apart from regular imaging.
It was the best result for him, his wife Carolyn and their daughters.
David, a businessman from Buckingham, has not been left unscathed by his treatment — he has short-term memory problems and tires easily.
But he says: ‘Regular scanning enables the consultants to monitor the tumour’s growth.
'Without it, treatment would rely on guesswork and life would be uncertain.’
A further key role for imaging should be to monitor the growing number of people living with cancer, to detect the earliest possible signs of a return or spread of the disease.
‘Patients should be aware that regular surveillance scans can detect any spread of cancer cells so they can be treated, and even fully removed,’ says Dr Brown, who is also a radiologist at the Royal Marsden Hospital.
Scanning technology is also indispensable in diagnosing musculo-skeletal disorders and spinal cord injuries, as well as stroke, heart defects and brain tumours.
However, despite its crucial role, the equipment is in scarce supply compared with other countries.
There are only six MRI scanners per million of the UK population, compared with 19 in Greece, 11 in the Netherlands and 43 in Japan.
Cancer tsar Professor Sir Mike Richards acknowledges there isn’t enough imaging capacity.
‘We are still doing fewer scans per million of the population than other countries,’ he said last year.
Scarcity is not the only problem. A standard machine costs around 900,000 and those already in hospitals may need replacing.
‘Half of this high-value medical equipment is due to be replaced within the next two years,’ says Amyas Morse, head of the National Audit Office.
The machines, bought on average six years ago, become outdated, as well as slow-running, after seven to ten years.
‘This is a huge challenge requiring planning by trusts — especially at a time when the Government wants the NHS to deliver up to 20 billion of savings.’
The PROMIS (Prostate MRI Imaging Study) study, led by Professor Emberton, is recruiting men referred for a biopsy for prostate cancer.
Contact the Medical Research Council on 020 7670 4848 if you would like to take part.