Prostate cancer is the most common cancer in men in the UK. The prostate biopsy is a fundamental stage in the accurate diagnosis of cancer, and traditionally, transrectal ultrasound (TRUS) biopsies have been the de-facto standard practice. However, this method has a high risk of severe infection, such as sepsis, and may under sample the anterior part of the prostate or provide inaccurate identification of potential cancer cells.
Transperineal biopsy developments
To address these limitations, an alternative and much safer method is the transperineal (TP) biopsy, which rather than passing the biopsy needle through the rectum, accesses the prostate through the perineum. However, there have historically been limitations for this method as it requires general anesthetic, due to the need for multiple separate punctures of the perineal skin. This can also cause swelling to the prostate and lead to difficulty passing water, as well as requiring complex equipment. Also, in the past, TP biopsies have typically only been available to men at greater risk of infection from certain medical conditions. But now the picture has changed.
In 2018, a new type of TP prostate biopsy was introduced to the NHS using the PrecisionPoint™ Transperineal Access System. This simple, non-invasive technique enables transperineal biopsies to be done under local anaesthetic (LA TP) in an outpatient setting, using two simple skin punctures. This method is proven to provide more accurate cancer diagnosis through superior access to, and sampling of, the entire prostate. This means that clinicians can better categorise and grade those patients most at risk of delayed treatment for their cancer, while patients who are diagnosed with a less aggressive cancer can be reassured that their treatment can be safely delayed without impacting their overall health.
The technique for PrecisionPoint is free hand, thereby ensuring the practitioner is not restricted to biopsy locations dictated by a grid configuration. The practitioner can therefore freely maneuver the ultrasound probe to align the access needle to target the desired locations with certainty in a strategic and parallel direction. This therefore allows for a full and systematic biopsy of the entire prostate.
Particularly over the pandemic, this device has been crucial for continuing biopsy services, as it not only minimises the impact on staff, theatre space and hospital beds, but also maximises patient safety. With the increasing backlog of prostate cancer diagnoses and treatment as a result of Covid-19, as well as continued pressure on hospital resources and staff, this alternative method has never been more crucial.
Transforming the prostate cancer pathway
The device has already transformed prostate biopsies at Guy's and St. Thomas’ NHS Trust, and across the whole South East London Cancer Alliance, who removed TRUS biopsies from the prostate cancer pathway altogether in March 2019. This exit from the transrectal route was christened the TRexit Initiative. Other cancer alliances have followed suit, notably Peninsula; SWAG; Surrey and Sussex; Wessex; The Northern Alliance; Greater Manchester; Merseyside and Cheshire; East of England North and South; have either achieved TRexit or expect to do so by the end of 2021.
The Southwest of England, for example, has widely adopted PrecisionPoint™, with outcomes including an overall cancer detection rate of 60.7%, significantly reduced incidence of sepsis, as well as total theatre time and overall cost savings between January 2020 and March 2021. Initial audit data suggests theatre time savings of 450 hours and the potential to achieve significant income and resource benefits compared to the traditional TRUS method, are readily achievable.
This is echoed by Edinburgh’s Western General Hospital urology department, who successfully replaced the general anaesthetic (GA) grid template prostate cancer biopsy procedure, with LA TP biopsies using PrecisionPoint™.
Daniel Good, Consultant Urological Surgeon at the Western General Hospital, commented on the this transition: “I believe we have been able to show that LA TP with PrecisionPoint has the same accuracy as GA template (grid) prostate biopsies, gives a better patient experience, and has fewer risks. It has to be the way forward.”
The cost of bettering patient and clinical outcomes
But what are the hurdles stopping more hospitals from making this transition? Whilst some clinicians believe that TRUS should be eliminated as an intervention, the cost of GATP biopsies is one of the major barriers to this, as complete replacement would be prohibitively expensive and unfeasible given the level of additional resources, time and theatre lists required. LA TP using the PrecisionPointTM system offers a feasible alternative to TRUS biopsies.
TRUS biopsies on the face of it may seem an economical way of performing prostate biopsy - but it comes with associated costs. One being the cost of managing infections and sepsis. A recent paper estimated that the cost to the NHS of managing infections caused by TRUS biopsies for the period of 2017-19 was over £6.5M. In addition, as this type of biopsy is not able to easily sample the whole prostate, patients will potentially need to return to have another biopsy which is usually done as a transperineal biopsy under general anaesthetic, which ultimately adds more cost by using operating theatre space and expensive equipment.
There is currently very little understanding of how much impact the last year’s delays to elective treatments will have on the NHS and on patients’ health. It is therefore essential that patients, GPs and specialists act now to ensure the backlog of potential cancer referrals does not continue. It is imperative that the capability to undertake safer, better and more accurate biopsies using the PrecisionPoint device is maximised out of a duty of care for patients and for our limited NHS resource alike.
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