Open Letter to the Rt Hon Matt Hancock MP – Re: Time for ‘TREXIT’

Dear Secretary of State,
Last year Mrs May pledged £75 million funding for prostate cancer research, paving the way for breakthroughs in the diagnosis, treatment and prevention of this most prevalent cancer in men in the UK. The recent NICE Guidance on prostate cancer has made a positive recommendation that all patients referred with suspected prostate cancer should have an MRI scan before a decision is made on prostate biopsy. The NHS has become one of the first health care systems in the world to make such a recommendation.
This is greatly welcomed, as it is well recognised and documented that improved diagnosis is associated with greater treatment options and improved survival rates.
However, whilst the use of MRI in the prostate cancer pathway has seen significant advances in recent years, the current ‘de facto’ standard method for prostate cancer diagnosis in the UK remains the transrectal ultrasound (TRUS) guided or transrectal biopsy – a process whereby the biopsy needle goes through the gut wall of the rectum. This is a technique that was developed over 35 years ago and has hardly changed. It is increasingly recognised that this method has risks compared to the alternative transperineal biopsy – both in terms of inaccurate identification of potential cancer cells as well as increased likelihood of infection associated with the biopsy and the necessity for routine antibiotic use – increasing the risks of the spread of antibiotic resistant microorganisms.
There is now an effective alternative solution that allows more accurate, safer biopsies and could facilitate the elimination of the use of antibiotics and make this the single largest contributor to the NHS target to reduce gram negative septicaemia by 50%[1].
The transperineal (TP) approach where the biopsy needle is inserted into the prostate through the skin between the scrotum and the anus (perineum), provides a more thorough sampling of the prostate with less risk of infection than transrectal biopsies. Whilst not a new procedure, due to its need for complicated equipment TP has historically been conducted under a general anaesthetic. The techniques of transperineal biopsy are now available under local anaesthetic through a freehand approach, using a perineal biopsy device.
Over the last year this procedure has transformed our practice at Guy’s & St Thomas’ Hospital; we have stopped transrectal prostate biopsies altogether and deliver outpatient based transperineal biopsies in a timely fashion within the confines of the timed prostate cancer pathway.
We have called this initiative – TREXIT. By March 29th we expect to have delivered a Network TREXIT across the hospitals within the South East London Accountable Cancer Network. The long term ambition is that by 2023 we will have delivered a UK TREXIT and we would become the first Health Care System in the world to not only offer pre-biopsy MRI but to also abandon the transrectal (or transfaecal) biopsy.
On Friday 30th November 2018, in a meeting hosted by myself and my colleagues at Guy’s and St Thomas’ NHS Foundation Trust, a group of 35 of the UK’s leading urologists, clinical nurse specialists and thought leaders in the field of prostate cancer diagnosis congregated and arrived at a consensus decision that we would work together to phase out TRUS biopsy in favour of transperineal biopsy under local anaesthetic (LA TP). Our chief goals are to improve the patient experience, better patient outcomes and achieve NHS cost savings. Indeed, we pledge to reduce the incidence of biopsy-related sepsis and infection by 50%, an issue that the NHS England and DoH have identified as being high priority. However, there is an urgent need for support in terms of resource, particularly in the training of clinical nurse specialists, to cope with the increasing demand for prostate biopsies.
We are being supported by professional bodies including the British Association of Urological Surgeons, The Royal Society of Medicine, Prostate Cancer UK, The British Association of Urological Nurses and many others. We are establishing training programmes to roll these techniques out across the cancer networks and strongly believe that a UK TREXIT is an achievable ambition.
We call upon you to allocate some of this £75 million funding for prostate cancer research to support us in the scaling up and rolling out of this proven methodology to deliver TREXIT.
I would be very happy to welcome you to Guy’s & St Thomas’ at any time to demonstrate something of what we have achieved. We are calling the campaign ‘TIME FOR TREXIT’, the next meeting of which will take place on Friday 29th March 2019, to which you are warmly invited.
Yours truly,
Rick Popert, Guy’s & St Thomas’ NHS Foundation Trust;
Timothy O’Brien, Vice-President, the British Association of Urological Surgeons;
Alastair D Lamb, MBChB, PhD, FRCS(Urol) Cancer Research UK Clinician Scientist, Senior Fellow in Robotic Surgery & Honorary Consultant Urologist, Oxford;
Raj Persad, Uro-Oncology surgeon, Southmead Hospital;
Prof Stephen Langley, Professor & Clinical Director of Urology, Professional Director of Cancer Services, Royal Surrey County Hospital, Co-Chairman Surrey & Sussex Cancer Alliance for Urology;
Jim Adshead, Consultant Urological Surgeon, East & North Hertfordshire NHS Trust;
Stuart McCracken, Consultant Urologist, Newcastle University and Sunderland Royal Hospital;
John McCabe, Consultant Urological Surgeon & Assistant Medical Director, St Helens & Knowsley Teaching Hospitals.