Speaker 1: Good evening Jacksonville and happy Saturday. I’m Danielle Lee, welcome to the conversation with Dr. Ali Kasraiean. As always you too can join the conversation 340-1045. How are you doing today, Dr. Ali?
Ali Kasraeian: I am doing wonderfully.
Speaker 1: Great, great. And before the show we were talking. We have a long distance guest today.
Ali Kasraeian: We are very fortunate, we have our guest calling in from London. It’s professor Ahmed [inaudible 00:00:23]. Hash is a dear friend, a mentor, who actually helped me and our team here start our MRI fusion biopsy program here in and our ability to start doing MRI studies, it’s called a multi-parametric MRI, the prostate, back in 2013. It’s actually where my now wife and I met. Our first trip together was to London to go spend a week with his former group, the university of College London where he and his partner at the time Mark [Hamberton 00:00:58] and Clair Allen. They were spear heading a lot of great work with multi-parametric MRI, doing targeted biopsies of regions in the prostate, things like focal therapy with high intensity focused [inaudible 00:01:14]. All those things that I was really interested in when I made my fellowship in Paris and was first exposed to this amazing concept of looking within the prostate and biopsying an area that I had never seen before.
First, before anything else, I want to thank him for that. By now, he’s a chair of urology at Empirical of college in London and he’s internationally renown for this work and his expertise in prostate cancer imaging and biopsy and this concept of advanced diagnostics, so doing better at diagnosing prostate cancer in a smarter way. Really, our focus of our show today is that smarter way of figuring out what prostate cancer, a diagnosis can be in the future. He’s also renown for his pioneering work with minimally invasive management of prostate cancer with concepts like focal therapy with technologies like high intensity focused ultrasound, which we’ve discussed on this show before. Again, for us in the world of urology, he’s always a part of and a pioneer in leading well thought out and ground breaking research that answers questions that we need answered, in a disease that needs a paradigm shift. Hopefully those answers allow us a diagnosed prostate cancer in a way that shapes the future of this disease.
I’m beyond honored that you’re here today with us, Ahmed and thank you so much for being here today.
Ahmed: It’s a pleasure and a delight for me too, so thank you for the very kind introduction. The second time I’ve been on your-
Ali Kasraeian: I know.
Ahmed: -program. I really do appreciate the return invite. I must have done something good last time.
Ali Kasraeian: Well, I’ll tell you, every time we speak I learn something interesting. It’s again, this idea of kind of pushing the envelope of thought and doing it through data which I think is very important. We can have great ideas and we can have things that make sense to us and what we think may just be intuitively logical, but if we can’t show it in the literature and we can’t prove it so to speak, the world at large and the world of our colleagues here in the prostate cancer community and for patients, it’s difficult to move that spectrum forward.
There are two studies that are beginning to open the door of that conversation in a meaningful way. One of which is a promise study in the recent European association of urology, the EAU meeting. This year you guys won a wonderful award for the research that that provided. The EAU, the European association of Urology, prostate cancer research award this year was for the promise study. Lan said, which really compared a diagnostic accuracy of the multi-parametric MRI, the study we were discussing with the [inaudible 00:04:18] ultrasound of the prostate, which is the standard way with which we, at least here in the United States, diagnosed prostate cancer. A gentleman has an elevated PSI or an abnormal rectal exam and we go and use an ultrasound of the prostate and we biopsy 10 or 12 areas of the prostate and hope to find cancer. What is inherently wrong with that pathway, and why should we look for better ways?
Ahmed: It’s something that we’ve been used to. We’ve used it for decades and we’ve got used to doing this test. It’s because we really didn’t have a better way of imaging the prostate. We weren’t able to see the cancer, if they were present in a man. We came up with this strategy, which is to the outside would look quite bizarre. We effectively threw 10 or 12 biopsy needles into the prostate, one after the other in the hope that we would find the cancer. Often, we would miss it. Often we would find little bits of very low risk cancer that wouldn’t hard the man, but that man or his family or his physician would choose treatment for him and those treatments were harmful. Something that’s not spoken about a lot is that the biopsy test used to miss a lot of important cancers, those cancers actually left alone would actually progress, would grow, would cause problems.
The promise study last year showed that, that test was about 50% sensitive, so it picked up only half of the important cancers. Whereas if you did an MRI scan, the MRI scan would pick up about 90, just over 90% of those cancers. The other things that promise showed last year, was that about a quarter of men, so just over a quarter of men would have a negative MRI scan. In other words, the MRI didn’t show anything suspicious. In those men, the chance that they still had important cancer was pretty low. It was between five and ten percent. Most men when they hear of those odds, when you have negative test, the odds are there’s a five percent chance we might still find something on a random biopsy. Most men that I come across say, those odds are low enough that I’d rather avoid a biopsy at this moment in time and keep on watching my PSA blood test. If it rises again, I’ll come back to you.
There’s two things that promise showed. One was that you could avoid a biopsy if your MRI was negative. That’s about if we bring it down to the US. That’s about a quarter of a million men every year, that could avoid a biopsy that, at the moment, are having a biopsy. Then in those men that have a suspicious MRI, we increase our odds of finding the important cancer because now, we can see where it is.
Ali Kasraeian: The amazing thing about that is, along those lines, the technology has advanced, which allowa us to look within the prostate and use technologies in the multitude of different ways to potentially now target within the prostate, which lends us to the next study which just came out in the New England journal of medicine which actually compares the multi-parametric MRI targeted biopsy with that same standard trans-rectal ultra sound guided [inaudible 00:08:28] biopsy to see if there’s a difference between that and the MRI guidance and in a very nice randomized study, which again for our audience. The important thing about randomization is that there’s no bias to this. The subjects, the patients, the men are assigned to one pathway or the other and so it’s random which direction go. The outcomes are thought to be more pure and the results unbiased by any factor. A lot of times in those studies, the patient populations are fairly equal in their characteristics.
In this study, the very interesting thing is, very similar findings where the MRI pathway is a triage is a first test similarly about 28% of the men had a negative MRI scan and so that would be another significant decrease in avoided biopsies for people that, it wasn’t just avoiding the biopsy for the sake of avoiding the biopsy, it was avoiding the biopsy because there was not necessarily something clinically significant to find. What are your thoughts on this new study?
Ahmed: This is a fantastic study, it was led by Caroline Moore and Mark Emberton in London. It was really the next stage of the promise. After promise, as you and I know Ali, the medical fraternity is quite conservative so they had a few questions. They said, okay we get it that