In this issue, we discuss the importance of continuous quality improvement in prostate MR with Andrei S. Purysko, MD, Clinical Assistant Professor of Radiology at the Cleveland Clinic Lerner College of Medicine, physician lead for the ACR Learning Network Prostate MR Image Quality Improvement Collaborative and faculty for the ACR Education Center prostate MR course.
Q. What is the importance of prostate MRI in the delivery of better patient care?
A. Prostate MRI has changed the paradigm of prostate cancer diagnosis. We've been steadily increasing the use of prostate MRI over the last couple of decades, and it has become integral to diagnosing and managing patients with suspected or confirmed prostate cancer. We're now using MRI from the initial cancer detection to define the most appropriate treatment for patients and evaluate disease recurrence. In this context, one of the most important benefits of MRI is to help triage patients for biopsy. Until recently, we used to perform biopsies taking random samples of the prostate in reflex to an abnormal PSA or digital rectal exam. The problem with random biopsies is twofold. First, it fails to detect aggressive forms of cancer in many patients, leading to a delay in diagnosis. Secondly, it detects many indolent cancers that are unlikely to progress and would not require any treatment. MRI has been proven to be a more accurate method for detecting clinically significant cancers and can direct the location where the biopsy samples should be taken. Additionally, MRI can rule out the presence of clinically significant prostate cancers, preventing many men from having an unnecessary invasive biopsy procedure and mitigating the overdiagnosis and overtreatment of insignificant cancers.
Q. Can you give us some examples of how quality process improvements can enhance patient care?
A. Better patient care relies on high-quality prostate MRI exams, which include using adequate equipment, correct imaging acquisition protocols, accurate interpretation of MRI findings and appropriately communicating that information to the referring physicians taking care of patients. With greater utilization of prostate MRI, however, there are concerns about variability in the quality of the MRI examination across different sites.
Toward that end, participating in ACR body MR accreditation and implementing the standards defined by the ACR Prostate Imaging Reporting and Data System (PI-RADS®) are good examples of processes that can reduce variation in the quality of exams and significantly enhance communication with referring physicians.
Q. What is the ACR Prostate Cancer MRI Center Designation and why is it an indispensable part of every quality and safety program?
A. The new ACR Prostate Cancer MRI Center™ Designation is the next step in the evolution of quality improvement by ensuring that sites use best practices beyond the technical standards that PI-RADS has defined. Using the ACR Mammography and Breast MR Accreditation programs and the Lung Cancer Screening Center Designation as references, a workgroup — led by Jeffrey C. Weinreb, MD, FACR, and Anthony J. Scuderi, MD, FACR, in collaboration with ACR staff member Dina Hernandez, BSRS, RT — developed a set of requirements specific for the Prostate Cancer MRI Center Designation. Two noteworthy requirements for the designation involve coordination of prostate biopsy and radiology-pathology follow-up to ensure that radiologists are engaged throughout the spectrum of patient care. This requires that the facilities forge a relationship with referral groups that perform the biopsy and receive feedback from the biopsy results. The radiology-pathology feedback mechanism provides an extra safety net to ensure that discrepant results between pathology and radiology are routinely reviewed and flagged. This mechanism is essential for radiologists to continuously learn and improve from every experience. As part of the evaluation process, each facility receives a comprehensive, confidential report from the ACR highlighting areas for improvement and recommendations for that facility.
Q. What are the benefits of achieving the designation?
A. In achieving the designation, facilities distinguish themselves as safe and effective diagnostic care providers. Facilities show patients, referring physicians, administrators and payers that they meet high-quality MR prostate imaging standards and are committed to patient safety and quality care beyond the accreditation norm. Facilities meeting the designation requirements will be identified as an ACR-Designated Prostate Cancer MRI Center by a symbol on the ACR Accredited Facility Search page.
Q. What are some of the other requirements for a facility to achieve the designation?
A. In addition to ACR Accreditation in body MR, there are some prostate-specific requirements. For example, physicians will have to demonstrate that they have experience with prostate MRI interpretation, either by showing that they have independently interpreted and reported at least 150 prostate MRIs in the last three years or 100 MR prostate examinations in a supervised situation. If sites want to apply for designation but do not have a high enough volume of prostate MRIs or if physicians have not had enough previous experience with prostate MRIs, they can take advantage of the ACR Education Center. There's a workshop dedicated to prostate MRI directed by Katarzyna Jadwiga Macura, MD, PhD, FACR, where physicians will have a chance to read enough cases to meet and exceed that requirement and learn from leaders in the field of prostate MRI who are current or past members of the ACR PI-RADS Steering Committee, such as Baris Turkbey, MD, Daniel Margolis, MD, Sadhna Verma, MD, and Clare M. Tempany, MD, FACR. There's also a requirement for demonstrated technologist expertise in prostate MRI. And sites will need to submit examples of their images to be reviewed by the ACR, which is an excellent opportunity for the ACR to provide feedback to the sites, which can help them improve their image quality.
Q. Where can you learn more and apply for the designation?
A. Applications for the ACR Prostate Cancer MRI Center Designation will be accepted beginning with the launch of the new ACRedit Plus system in the coming months. For more information, including requirements and how to apply, visit acr.org/MRIprostate.
Q. Tell us the ACR Learning Network Prostate MR Image Quality Improvement Collaborative.
A. Inadequate prostate MR image quality is associated with an increased chance of equivocal MRI results and can lead to diagnostic errors. For example, researchers have found that as many as 40% of the abbreviated prostate exams using just the two key pulse sequences — T2-weighted and diffusion-weighted images — have inadequate image quality for various reasons. The Prostate MR Image Quality Improvement Collaborative is one of four improvement collaboratives in the ACR Learning Network, which is led by David B. Larson, MD, MBA, FACR, Chair of the ACR Commission on Quality and Safety, and funded by a generous grant from the Gordon and Betty Moore Foundation. The collaborative is centered around a robust didactic program on improvement sciences led by Kandice Garcia, MS, RN. It provides a framework to help participating institutions identify the root causes of poor image quality and define the key drivers and interventions that can lead to sustainable improvement. Participants in the first collaborative cohort, which convened in spring 2022 and will conclude in November, came together to learn and share ways to develop image quality metrics, standardize protocols and ensure appropriate patient preparation to deliver high-quality prostate MR images consistently.
In 2023, the ACR Learning Network will convene two other prostate MR quality improvement cohorts comprised of four to six sites each. To apply, visit the Prostate MR Image Quality Improvement Collaborative.