Building a Prostate MRI Practice

Introduction to the Series

This is gonna be on building a prostate MRI practice.

And there's gonna be a series of three brief presentations.

And then we will have another panel discussion.

So the first one is going to be presented by Dr. Verma.

Dr. Verma's Presentation: Starting the Program

How I started my program is very interesting 'cause I ran the GU tumor board at my place and would sit there and see that most of these patients, it was prostate cancer patients that were on the list that nobody knew what to do with, or they said, oh, he was upgraded on prostatectomy.

And it just didn't make sense. It was the only organ that was not that we were treating and discussing without any imaging at all.

And to me, that sounded very bizarre.

So, initially, one of the private practice urologists, and it's interesting, who came and asked me, and he said, do you do prostate MR?

This was very early, and we did some, but I wasn't very interested because none of those results were very interesting.

And most of them I didn't really follow, so didn't know much.

And I said, no. I said, it doesn't work.

And after I did this GU tumor board for a while, I kept thinking, why not?

Why is this not working? So I started looking into it, and that's where all of this came up.

And then all of a sudden I wanted to try, and then there were no patients.

So I called up my this private practice urologist.

And by the way, most cities have these large group urologists that are separate from the university.

But there was this one guy who was very interested in this.

And he goes, well, I said, well, I really wanna try.

I think there's some good data, et cetera.

And he's like, well, I said, well, if you wanna try, I can, I'll scan 'em for free.

I mean, I'll, and I was talking to him without discussing this with my department, but I said, you know, I really wanna try.

I think this is worth trying because of all the cases that we see in GU tumor board.

And so he said, sure.

I said, and then he, I was going on vacation afterwards, so I did two scans and I left on vacation.

When I came back, there were eight on the list to be ordered.

So that's how I started with this private practice urologist.

And he did a lot of prostatectomies.

And so I, we, 500 cases, I got rad path correlation on, and that's how I learned prostate MR.

And that happened. Fair.

And by the way, all the university urologists were not interested in the beginning.

And soon, when I did the tumor board, I would now and then show them, by the way, this was interesting.

They're like, oh, very interesting.

Well, what did the pathology show?

And then slowly they started becoming interested to say, really, this sort of kinda works.

And that's how the program then developed.

But it was originally outside of the university.

And that, but the volume has just grown like crazy.

When 10 a week used to be a lot, now that's 10 a day sometimes.

And it just once you start working on this and get to have a good group of people and referral base, that changes everything.

Technical Issues and Quality Assurance

So in order to have a program, obviously you have to deal with technical issues.

And that goes with the quality assurance and improvement training is key.

Department hospital support, and I learned this along the way, how it happened.

And then the referral basis.

Obviously without that, you can't have any program.

And a few things about outreach and education that I learned along the way, and of course this is reimbursed, initially, obviously only MR spectroscopy was happening and that stopped being reimbursed.

So that was an issue. But now, MR pelvis, within without contrast has reimbursement.

There are some times when the urologist call that the insurance company has given them a hard time, but not anymore that I hear that anymore.

So you need a MRI obviously 1.5 tesla or higher.

I was very particular about prep instructions, just because I started my program with spectroscopy.

And I continue to do that, not as much as I used to, but I still do.

And so prep is key in that, and that's fleet enema.

And really having a clean rectum down the road.

When DCE started, then the software.

Now, I do have the software, but now I'm using it less 'cause I don't really need the parametric maps, et cetera.

But that's something you would have to consider.

And then if you once you start seeing these lesions and start going over, you wonder what to do about it and how to prove perhaps that you're right.

And so the biopsy devices came along and then started using that.

So this is just a whole gamut of how I went along in my program.

Technical QC, of course, if you're doing spectroscopy, you can't do spectroscopy.

So you learn very quickly that you need to have good quality assurance and get a buy-in from your physicist as well as your technologists really have to be on board with you.

And any issues with hardware you can't handle, you can't have that.

So even now, when I'm not doing spectroscopy, the techs are trained such that they're very particular about the coil positions.

I don't have to worry about telling them.

They will go and adjust it even if I'm not doing spectroscopy.

'Cause that's how they've they're used to quality improvement.

Multidisciplinary Meetings and Database

Obviously the multidisciplinary meetings have evolved.

Initially, I used to meet once a month, and this was with the with this urologist who was outside.

We would just go rad path with his one of his people in his office or the pathologist at the hospital.

Over time I started then developing at a university.

And then we started having more of our meetings.

And that even changed much more when I started doing the biopsies.

And then when they started doing the fusion biopsies, now it's become twice a month.

So that's just evolved over time.

And obviously very important.

And I learned this early on very quickly, especially 'cause I was doing this rad path correlation that you have to have some sort of a database for following these patients.

And now the indications have changed so much.

So active surveillance and used to be prostatectomy and radiotherapy, but now all kinds of reasons why we do MR.

So they need a good follow up database and obviously a hemorrhage, that's a big issue.

And then when you do biopsy, the false positive and negatives, and those are important.

That's how you learn and go back training.

Getting Started and Optimization

So if you're starting out, the vendors, whatever system you have will have some sort of a protocol, and that's where the vendors can help and get started.

If not, then you and then you optimize your protocol as you go along.

And if you at a university, it's important to have lectures.

And in my in our resident curriculum, I have a fourth year lecture that's core curriculum.

They do a one month rotation on prostate MR.

Obviously in the department, you need a dedicated radiologist, so somebody who can troubleshoot and minimize turnaround time because that obviously is important.

Also a physicist is great if you can have, because if you're gonna do spectroscopy, you really need them on board.

And then hospital support, because prostate MRI's new business never looked at it that way initially because my whole reason was different.

But really, this is a new business.

And they may use, these patients may use other departments in the hospital for care, and hospitals should recognize that.

For instance, these patients, when they come from pros for a prostate MR were coming from a different hospital to our center because this was originally, I started this with a private practice urologist.

And then they would get their bone scan there.

They would get their CT scan.

So they were getting all these other imaging stuff, sometimes just on blood work done so that they would not be there.

And they need to recognize that you're bringing in new business.

Technologists are key because they're the ones who were seeing the patients day in and out.

And initially I, when I did the coil placement, I placed the coil for the first year, and finally I had dedicated tech.

So at each place that we have the prostate MR, we have techs who do specifically that.

And they're not only trained to do the coil placement, but they also deal with issues that headphones.

And so it it's a lot of PR in some ways where the patient feels relaxed.

And I'll get emails from patients sometimes that, by the way, it was fine, but I didn't like the music they had or something.

These patients are high maintenance and you do need a little bit of a PR effort in there.

And then dedicated MRI slots.

'Cause once your volume starts to go up, the urologist calls and you don't have a slot, the patient wants a scan done.

And it's very frustrating.

So I have dedicated slots the numbers is increasing so much now that that's causing some issues, but that's just something you have to deal with.

And then a coordinator, okay, so that's really important.

I've been saying everything is so important.

But coordinator, my coordinator, Ramia pretty much is who my whole program is based along.

She does a lot of the work that otherwise I would be spending a lot of time doing.

She sends a prep information, checks the patient schedule.

She's my go-to person.

She calls me, unfortunately, she just moved to New Zealand, so I don't have her.

But certainly other people have taken over her role.

And now that it's been in place, others can jump in.

It could be a technologist who's very interested, et cetera.

But they're also the liaison between the radiology and clinical service, especially when you start a biopsy program.

'Cause a lot of these patients that need fusion biopsies, they have to be segmented and that information has to go along where you could be somewhere else and well the biopsy or they add in a biopsy the night before, and that sort of stuff happens a lot.

Referral Base and Collaboration

Alright, so referral based patients. Self-referral.

I really discourage that because you when you start working, you will get patients wanna come and get the MR and they have no urologist because one thing you don't wanna be doing MR.

And then you don't know who to send the information to.

So I specifically say, you need to have a urologist.

And then somebody I can send the information to go, what do you do with that info if you don't have a clinical person sending you this.

And then obviously urology and radiation oncologists, two groups that we work closely with.

And there you've seen today that there all these protocols are tailored towards so collaboration obviously is important with your referral base.

And I started mine with a private practice urologist, and then moved on.

And it's interesting in our in my setting, it was more of the university urologist.

It came on board first before the radiation oncologist did.

So it's just something how it worked in our department.

Standardized Reporting and Biopsy Considerations

And then standardized reporting template is very important because of the reasons you've seen where otherwise nobody knows you can't communicate in the same lingo.

And this is just an example showing, using, if you were to use PI-RADS, how it would show you where the lesion is in the left mid gland, and then you would know this is from the PI-RADS one version, but similarly, you could apply that for the PI-RADS too.

And biopsy considerations.

We went over that yesterday and these patients obviously need close follow up because if you're, especially if you have high suspicion lesions, PI-RADS four and five.

Outreach and Education

And there's a lot on outreach and education, and I find that the breast and the mammographers few people have done a much better job on this.

I don't think prostate cancer has the same recognition as breast cancer.

And of course there are two different diseases and being one, being more lethal than the other.

But younger men do get more aggressive prostate cancer, and I think there's not as much PR on prostate cancer as there could be.

However, there are foundations such as zero and PCF, et cetera that are working on that point.

And I think we should all in our local areas, if we champion that we could do a better job.

So one of the ways that I've worked on it in Cincinnati area is to, obviously I do the lectures to the multidisciplinary teams.

I run the GU tumor board.

I also have it on my website and pamphlets, et cetera.

I also am very involved in the local Cincinnati public where I work with the cancer wellness communities.

So I give them a lecture every six months or so.

And then discuss new issues.

And this is a group of men who have recently diagnosed prostate cancer that they come and visit.

Most places will have this cancer wellness communities also news, et cetera, if there especially November is coming, is here now.

And last year just because the PR effort, they had a big mustache at top of the hospital.

And you know, it's just those little things that say that hey, we do this we care about this and there's a need for this.

It is there are several CPT codes.

I don't know if you actually, you can bill for 'em and I don't know if you'll get paid or not, but this is, they're there.

Thank you.

Second Speaker's Presentation: How Our Prostate MRI Program Got Going

In terms of how our process MRI program got going as a little bit of a different story, I guess I was a little fortunate in comparison that I never really was in the position of having to sell it to our local urologists.

It actually started with them coming to us with urologists coming to the radiology department.

In around 2009, one of the urologists who was very keen in doing this, he actually came to our chair and expressed an interest in trying to get a program going for prostate MRI and sending patients for this.

And he was looking for collaborative radiology or was kind of somebody to work with.

And I was kind of joining the department at the time and was interested as well.

So we kind of partnered up, and initially it was just the two of us kind of meeting regularly, and he would send his patients in and we would go over the exams together.

And over time the our group kind of grew and the volume grew accordingly.

And I think so, I mean, at first it was just one primary collaborator in urology.

But I think what helped then was it spread throughout the whole department after the program got going that now it's essentially the standard of care throughout urology at our center.

And I think it helped to have a kind of an insider or somebody in the department to start out with who then served to kind of help facilitate its adoption throughout the center.

And it wasn't so much me always having to go and push for it.

So I mean, Satna has shown her growth at Cincinnati in prostate MRI volume.

This was our experience going back to 2010, just over our number of exams over three month intervals has continued to rise.

And this is very common type of very common trend.

And I'm sure all the speakers have similar data and probably people in the audience as well.

And it's actually interesting, more recent, it's been not just the our local urology group, even private prac in the last year or so, more private practices coming on board.

And there was the point about these referrals mostly coming from urologists and radiation oncologists, but interesting in the last year, we're even starting to get these from people in primary care.

Some internal medicine, for instance, just ordering prostate MRIs straight after a high PSA, just knowing that they refer to our local urologist.

That's what the urologist will start off with.

So it's actually starting to move out into more I think just the general medicine community.

Starting with Local Champions and Multidisciplinary Collaboration

So this point was made, I think you do have to start with the local champion in each department, and not just radiology and urology of course, but even pathologists.

A big part of this as you really want to do detailed follow up and QA on not just prostatectomy, but also on biopsy findings and looking into detail about your say PI-RADS four or five, they came back negative.

And you're gonna need a pathologist who's interested, committed to working with you.

So it's gonna need to rather a multidisciplinary conference.

Again, every multiple speakers have made that point.

And while initially starting out, it might not be the case that you're a collaborator will be sending all their patients, it might be select cases.

And I think emphasizing the cases where MRI is most likely to you don't want your initial cases to not go too well.

So I like the patients who have had a negative biopsy and rising PSA, that those could be a good exam to start with.

You'd have to be able to speak the urologist lingo.

You have to be able to communicate and with them well and kind of integrate with their practice.

So I think that burden kind of falls on us to collaborate.

Well, we have to learn the clinical aspects of prostate cancer in depth.

When reading these cases, we have to access and consider the full clinical history available.

PSA PCA three, any other laboratory data that's available, biopsy results.

We have to, if the urologist makes this available to us, if they give us biopsy results, and we're not taking that into consideration when we read the MRIs, it's not gonna sit as well.

Standardized Reporting and Follow-Up

And then I think establishing standard as template to ensure a consistency in reports between, if you have multiple readers, you have to make sure that whoever reads the MRI will generate reports that are comparable.

And even if you can't fully guarantee that each reader will necessarily give that same lesion a three versus a four for some tricky lesion, at least you're reporting through structure and wording and formats that the urologist doesn't worry that you know, know if this person reads it, I'm not gonna get the right report, then I'm gonna have to go and get a second opinion or show it to somebody else that have to, I mean, we we're, it's actually interesting in our department we did an audit and the only one exam in which we have a hundred percent adherence with the standardized template is prostate MRI.

And essentially, anybody who reads prostate MRI has to use our is really expected and is using the template that we put together.

If you're IT system can do it, there'd be very useful to communicate, not, and this is something I think that lends itself well, not just to standard prostate, but to communicate data in a tabular format or a diagram or capturing key images.

If you have a way of doing this in your EMR or in your PACS of actually sending captures of a table or diagrams of lesions, I think that can be very useful.

Just given the nature of this multiparametric data you have to be diligent in following up on your outcomes, right?

And this can't be stressed enough.

Otherwise, you can be continually making the same mistake over and over and not know that you have to follow up closely and see what you're missing or over calling and think how you can adjust for that.

So rigorous pathology correlation.

Identify the causes of your false positives and false negatives, and use that as a basis for systematic improvements.

And if you have multiple readers, it has to be brought back the readers and make everybody aware.

And so people can improve.

And this was a study from Sloan Kettering where they looked at the accuracies of different readers over time.

And then they did a comparison of just giving some standard didactic lectures versus true individualized feedback where they gave each reader follow up results after prostate detecting for their own cases and the exams that they themselves had read, and not just general didactic teaching.

And there was a big improvement in performance, again, with the individualized feedback.

So if you have multiple readers in your center, you need a mechanism to get that done.

Technical and Biopsy Considerations

Some technical considerations, these are points have been coming up numerous times.

So so far these last two days, what scanner you're using your coil section whatever patient prep you use, are you gonna routinely use DCE?

What system are you're using for fusion analysis?

And you have to decide what makes sense for you and your practice, what resources you have available to you and what support you're getting from your system.

Other things that will come up as you move into the into doing a targeted biopsies, it's gonna bring up a whole new layer of questions and issues to work through.

And I know we you know, we had started with our program basically in 2009, then after a couple years, and things were well established on the imaging standpoint.

Once the issue of biopsy came up, it led to again having to kind of work out our collaboration and how things would be done.

So again, just, it's gonna be a whole new set of questions.

So which patients will this be fusion or in-bore?

Who is going to do the biopsy?

You have to make sure you and your urologists are on the same page about this.

And then as we do biopsies, again, closely monitoring the results of the targeted biopsies at all different layers by suspicion score by comparing the systematic versus targeted cores your accuracy sensitivity for low grade versus high grade cancer, just so you can know, is there a certain score you're overutilizing or underutilizing is if is there some misregistration issue, which again, you can identify by comparing your different groups of cores financial consideration.

So there's gonna be initial capital expenditure and then ongoing cost to keep in mind.

And you can model the opportunity cost on your scanners with your local practice or department.

Again, unlikely you're gonna be doing this entirely on your own.

And keep in mind the coverage policies for your major local insurers.

Final Thoughts on Success

So just some final just finally.

So for any of us to be successful you know, we're gonna have the best of intentions, a very strong collaboration.

Having actually achieving accurate detection and characterization is gonna be essential for the practice to be successful.

If we're not doing good exams or reading them well none of this will really work.

So you need a technically robust multiparametric MR exam with dedicated, have to put the time into, have that and follow up to your interpretations to so you'll have the dedicated experience and expertise in reading these by your local group.

And again, I would emphasize this simply addressing this, but structured reporting, and again, through all of this, maintaining effective integration with your urology colleagues.

Thanks.

Third Speaker's Presentation: Teamwork in Building a Prostate MRI Practice

So I wanna tell you, first of all, I agree with everything that the first two speakers said.

But I maybe want to just share with you my own experience.

It might be useful to you.

And I realize that those of you who are in private practice are gonna have a little bit different journey if you're gonna develop this practice.

But I think there are still lessons here that you'll find valuable.

And really the key I think to building a prostate MRI practice is teamwork.

And as I mentioned earlier if you're not willing to do that, if you're not set up to do that, you're just not gonna be successful in this area.

And I'll relate to you my own personal experience.

So I got involved in prostate MRI a long time ago more than 20 years ago.

And when I happened to be at the same institution that Andrew is at currently, and it was the same chairman of urology.

And when he got to that institution, I talked to him about prostate MRI.

And what we were doing and what I thought the prospects were for it and where it might be useful.

And I was told point blank that MRI has no role.

And not only will he not send a patient, but he really didn't want anybody in his department to send a patient for prostate MRI.

So frankly, it died.

I left there and went to Yale and was still interested in prostate MRI.

I actually procured money to do prostate MR ultrasound fusion biopsies.

This is about five or six years ago, but really didn't have frankly, urology colleagues or relationships to make this work.

And so we never did it. And I just moved on to other things.

Now we have a very robust program going, and it's growing pretty rapidly over the last year and a half.

And the reason is not anything that I did specifically, it's that we have a urology chair who said we have to do this.

He's a great believer in it.

He hired a young urologist and said, this is your baby, make this work.

And now I and my colleagues Dan Kornfeld, Stefan Huber, and other people in the radiology department work closely with the urologist and with the pathologist.

So the point is I don't I think you need to do things, you need to do a lot of stuff to make this work, but it's not going to work unless you have people to work with.

Workflow and Teamwork

So let me just show you what the workflow is, and I think this also just brings home how much teamwork is involved here and why this is not something you can do by yourself.

So this is, first of all, the patient's gotta be scheduled, right?

And then they've gotta get prepped.

You already heard about this, but here, patient shows up, we talk to the patient, we insist on talking to the patient.

I explained to you we wanted to discuss them.

The whole issue about Endorectal coil and not using the endorectal coil, you need the radiologist around if you're gonna insert the endorectal coil, although there are places where they have techs or nurses aides that have been trained to do it.

But if you're gonna put an endorectal coil and you have to do a rectal examination, and frankly, in our institution, technologists are not allowed to do that.

And even the nurses aides aren't allowed to do that.

It's gotta be done by a physician.

Different rules in different places.

We need the scan supervised at our place, as I mentioned previously, to decide whether or not the images are adequate or not.

And part of that has to do with our technologists.

So we have some great technologists, and they're all very serious about their jobs, but not all of them are as experienced in prostate MRI in our situation, up until now, we can't say we want this technologist to do all of our prostate MRIs.

On this particular day. It just doesn't work.

And we're it's something I actually would like to change.

And I would strongly recommend if you can do that in your own practice, just have a limited number of technologists doing the prostate MRI, you'll get a lot more consistency in the examinations.

Okay? But the techs obviously are a big part of this.

They're doing the scans.

They really need to understand what prostate MRI is all about and really know what they're doing at the scanner.

Radiologist is gonna interpret the examination.

And here's another one. You know, I, we've been very in the way we work in our department, we wanted or I wanted all of our body radiologists to become facile at this and to become expert in it.

But frankly, I don't think that's happening, at least not at the rate I'd like.

And so I think a reasonable way to do things is to have the goal of having a lot of people being able to do this.

But when you're starting out, I think you just you're best off just starting with a very limited number of radiologists who really become expert in this.

And then the expertise can spread out.

'Cause I think that's how you're gonna get consistency and also get buy-in about your expertise.

Once you've done the examination if you're gonna do these targeted biopsies you there's a certain amount of contouring that has to go on.

So you have to sit at a workstation and outlined the target lesion and the prostate.

And in our place that's done by a radiologist.

There are other places that are doing higher volume than we're doing where they've trained somebody else to do it, a tech, for example.

And there's really no reason they couldn't do it.

But we're using, we have fellows and residents and attendings who are doing this.

It can take a lot of time.

The fusion has to occur.

We used to, when we started doing this, we actually had a terrific scientist who worked with us and he was doing the fusion.

The software was new, it needed a lot of tweaking wasn't so simple to use nowadays.

The urologist is doing this. It's much easier.

Then you have the targeted biopsy in our place.

It's a urologist. You've heard that in other places.

It's a radiologist.

There's no reason a radiologist couldn't do this.

But we decided early on based on experience, and I think reality, that there's no way that we're getting patients if we're cutting the urologist out of this, it's just not gonna happen.

Nor do we want to.

And then you gotta get the pathologist involved and all of these all of these people have to work together.

It's really and this is not so simple.

And I'd say the area that at least at my place we need work on, and you've already heard about this, is making sure that we get adequate follow up correlation between the biopsies and the MRIs so that we get feedback and we can learn from what we're doing.

And I'd say we're getting much better at that now.

But it's been very inconsistent and I think it's really impeded the progress that we've made at our own place.

And I've seen this at other places as well.

So I would say from the get go, build a close relationship with whoever whatever pathologist is involved in these things, and with the urologist or urologists that are gonna be doing this stuff with you.

Volume Growth and Drivers

So we're not doing anywhere near.

So you you've seen there there are people in this room in their practices.

They're doing 10 to 15 cases I'm hearing about per day.

We're doing four or so per day.

But prior to October of last year, we were doing about two to four per month until we started working more closely and we started doing these targeted biopsies.

And now we're doing, it's actually higher than this.

We're doing about four per day.

And it's growing rapidly.

And what's happened is the other urologists in the community realize that this is a good thing.

They're being very supportive, even if they're not doing the targeted biopsies that may be down the road, they wanna do them, but they have not had any reservation at all about sending their patients to have these studies done at our place and have one urologist do the targeted biopsies.

The other big driver is the patients.

This is very much being driven by patients.

The more patients know that there's an option of getting an MRI and that this will increase the yield of the biopsies.

They want it, and they're telling, they're not shy about telling their urologist that they want an MRI.

So again, what you heard previously is the more you can educate the community and the urologists and the internists and everybody else about this the more business you're likely to get, remember that for healthcare in general, it's mommy that drives the healthcare, right?

She decides where the rest of the family is going.

And so this has worked extremely well for mammography.

All the insurance companies you know, the affordable care the Affordable Care Act, singles out mammography.

Every insurance company has to cover mammography.

You know, why is that okay?

And the insurance companies didn't fight this.

It's because the mothers determine where the healthcare is given and what kind of healthcare is provided.

And so this is, you think that the men are your target audience, and what I'll tell you is probably the target audience is their wives and girlfriends, et cetera, and mothers.

So don't forget that in general, like anything else, if you're gonna build this practice, it's gonna come down to people and processes and resources.

So you need to get the right people involved.

And I absolutely agree with previous talks.

You need a champion in your radiology department.

You need a champion in urology.

You need a champion in pathology, okay?

It's just not gonna happen unless you have these people working together and pushing together and knocking and removing all the obstacles you need processes.

So you heard about standardization, but it also comes down to scheduling and all the other things that go into making this successful.

And you need resources, okay?

So you need a scanner that works, right, that can provide the adequate images with the right coils and the right vehicles to interpret these things and report them.

So I hope you found some of this.