Mātai To Launch Game-changing Public Pathway For Accuracy And Equity In Prostate Cancer Diagnosis

The Mātai Medical Research Institute will begin a game-changing prostate cancer diagnostic pathway project.

The project has been made possible through the generous support of the Hugh Green Foundation, who donated the biopsy machine, the essential piece of equipment required for this project, and the Prostate Cancer Foundation of NZ, as well as support from Mātai’s establishment fund from Kānoa-Regional Economic Development and Investment Unit, JN & HB Williams Foundation, and Trust Tairāwhiti.

Currently, prostate biopsies in New Zealand’s public system are untargeted: resulting in cases where tumour size is underestimated, non-significant cancers are reached, or the tumour is completely missed. The 3-year New Zealand first project, titled Accuracy and Equity in Prostate Cancer Diagnosis, is aimed at vastly improving this prostate cancer diagnostic pathway, particularly for those who live in under-served and remote communities.

Peter Dickens, Chief Executive of the Prostate Cancer Foundation of NZ, says“TheAccuracy and Equity in Prostate Cancer Diagnosisproject is an enormously exciting and important initiative, with the potential to be significantly influential in bringing Aotearoa New Zealand into line with best diagnostic practice globally. What is particularly exciting is that it is planned to take place in communities we know, through research, have experienced significant inequities in terms of disproportionately poorer rates of accurate diagnosis and sadly poorer outcomes as a result. We commend the Mātai team for this initiative and look forward to working with them as their plans progress.”

The new pathway is designed to decrease the risks associated with prostate cancer screening, achieve parity in the proportion of Māori and rural men who are enrolled in prostate cancer diagnostic and management pathways, and improve outcomes for men diagnosed with prostate cancer. Along with the use of state-of-the-art technologies the pathway is focused on community and physician education; pre-biopsy MRI; and image guided, targeted, prostate biopsies. The project is a collaboration between Mātai, primary care, and community health groups. The project team includes radiologists, urologists, imaging processing PhDs, GE Healthcare scientists and community leaders.

Community and regional partnerships, including those with iwi, will play a key role to engage men in the study. Participants will be selected and counselled through a dedicated prostate cancer outreach and education programme.

The work will be led by Dr Daniel Cornfeld, the Clinical Lead at Mātai Medical Research Institute and honorary senior lecturer at the University of Auckland. Dr Cornfeld, previously Chief of Abdominal MRI at Yale-New Haven Hospital and Associate Professor of Radiology at the Yale University School of Medicine, works adjunctly as Chief Radiologist at Hauora Tairāwhiti, Gisborne’s public hospital, and says the project will chart the efficacy in New Zealand of a model of care approach for patients using the latest evidence-based methods already adopted in prostate cancer diagnostic pathways in the United States, the United Kingdom, and Europe.

Dr Cornfeld says “There are deficiencies in current biopsy techniques that must be addressed. We can do a better job and do it equitably. Typically, men with high prostate-specific antigen (PSA) test results undergo random prostate biopsies. However, this method can lead to over-diagnosis, under-diagnosis, and tumour mis-characterization. It is important to only treat the cancers likely to spread during someone’s lifetime. Pre-biopsy MRI followed by guided biopsy identifies more significant cancers and fewer insignificant cancers. It allows for correlation between the size, location, and grade of detected tumours and opens the door for personalized treatments.”

He adds “Once the pathway is proven, we would like to encourage the use of the MRI guided biopsy method as a general standard for prostate cancer diagnosis in New Zealand.” Performing a targeted biopsy allows for correlation between the biopsy sample and imaging so that the size, grade, and location of prostate cancers can be correlated. Without this correlation it is not possible to determine whether the edge of a large tumour or the centre of a small tumour was sampled (see diagram below). Radiology–pathology correlation allows for increased risk stratification and personalised treatment planning. In addition, MRI performed pre-biopsy identifies approximately 30% of men with an elevated PSA who do not need invasive biopsies.

Multiple large clinical trials have shown that compared to random biopsy, pre-biopsy MRI combined with targeted biopsy results in identification of more significant cancers, fewer insignificant cancers, and fewer required biopsy samples. Current limitations to this pathway in New Zealand include the lack of availability of pre-biopsy MRI, lack of expertise in interpreting prostate MRI, and lack of equipment for performing guided biopsies.

Images: Courtesy of KOELIS

The Mātai state-of-the-art GE Healthcare 3T MRI scanner, located in Tairāwhiti, will be an integral tool to help achieve the accuracy and equity goals of the pathway. The MRI will be used to introduce pre-biopsy MRI to the diagnostic pathway as well as to guide the targeted biopsy technique. Pre-biopsy MRI identifies 30 percent of men with elevated PSA who do not require a biopsy. Knowing this can make it easier for someone to decide to undergo screening.

Mātai and GE healthcare scientists have collaboratively pushed the limits of their advanced MRI scanner to develop a complete MRI prostate scan that will take 15-20 minutes. This will greatly reduce the current standard scan time in New Zealand of approximately 45 minutes. A shorter scan time means more scans can be performed, which could increase access to MRI.

Image: Courtesy of KOELIS. The tumour as delineated on the MR images is fused onto 3D ultrasound images, to provide a real-time target for the biopsy (orange region). The KOELIS Trinity system creates a 3D map of the prostate (blue mesh) onto which the urologist can see, target and record each biopsy core (red and green lines).

Dr Cornfeld says “The goal of our optimised diagnostic pathway is to improve screening in our most vulnerable populations, increase the number of men receiving curative treatment when required, increase the number of men on active surveillance when appropriate, and eventually decrease the number of older men presenting with incurable, metastatic, disease. This project will increase the number of patients evaluated with MRI and use this information to tailor treatment to the patient.

Mātai plans to continue with the pathway in Tairāwhiti beyond the 3-year scope of the project, and based on current capacities, would be able to image all men between 40-70 years old who are at risk for prostate cancer within the next ten years. The ultimate goal is to eliminate the late diagnosis of prostate cancer in our region.

MRI guided biopsy is currently available in New Zealand only in several private practices, and is not available in the public system.

This project is not designed to be a screening programme. However, the guided biopsy reduces the incidents of inaccurate diagnosis, and therefore reduces the risks associated with screening. Through community and physician education, Mātai wants to empower men to have informed conversations with their GPs about prostate cancer detection and make choices regarding screening that are best for them. Accordingly, Mātai anticipates more men will undergo screening.

Reweti Ropiha, Chief Executive at Turanga Health said “Turanga Health will help the Mātai team develop an outreach and education strategy to encourage more Māori men to participate in the new pathway”.

Dr Antoine Leroy, CEO of KOELIS, makers of the MRI guided biopsy machine said“Weare proud to be involved in this project to support a programme of real change through the use of more accurate imaging and diagnosis tools in the battle against prostate cancer.”

Prostate cancer is the most commonly diagnosed cancer in New Zealand, accounting for 1 in 6 of all cancers diagnosed. Approximately 30,000 New Zealand men are living with prostate cancer and require surveillance, and every year around 650 New Zealand men die from prostate cancer.

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