Consensus is a beautiful word, a beautiful concept. Anthropologist David Graeber describes it this way:

Consensus is not a set of rules. It’s a set of principles. Actually I’d even go so far to say that if you really boil it down, it ultimately comes down to just two principles: everyone should have equal say (call this “equality”), and nobody should be compelled to do anything they really don’t want to do (call this, “freedom.”)

Wow, equality and freedom are lofty ideals. You probably aren’t thinking about them when you see a doctor for a diagnosis, procedure, or a follow-up visit. You’re just thinking about wellbeing, and trusting the doctor is doing all the right things.

How does the doctor know the “right thing” to do? The answer lies in his/her training, supervision, experience, and continuing education (reading journals, attending conferences with leaders and peers in the field, etc.) Thus, individual doctors boost their knowledge and responsible decision-making, so we can trust that each one is providing the best possible care.

In addition, there’s a “shortcut” way to reinforce the right thing. It’s the agreed-upon guidance based on evidence that can be generated by a collaboration of experts, and published for everyone to access.

According to the Council of Europe a ‘medical consensus’ is a public statement on a particular aspect of medical knowledge that is generally agreed upon as an evidence-based, state-of-the-art knowledge by a representative group of experts in that area. Its main objective is to counsel physicians on the best possible and acceptable way to address a particular decision-making area for diagnosis, management or treatment. Consensus statements synthesize new information, largely from recent or ongoing medical research that may have implications for re-evaluation of routine medical practices.^[i]

I want to share a recent example of a consensus contribution that applies to us at the Sperling Prostate Center. A team of European and North American academic experts in focal therapy (urologists, radiologists, pathologists) identified a weak area in MRI-based follow-up. Their 2024 published paper opens, “Magnetic resonance imaging (MRI) can detect recurrences after focal therapy for prostate cancer but there is no robust guidance regarding its use.”^[ii] At our Center, we perform image-guided focal therapy, and we use multiparametric MRI (mpMRI) for follow-up to determine if prostate cancer (PCa) has come back in the treated area and/or a new tumor has begun elsewhere in the untreated part of the gland. Thus, the work of this team is of special interest to us. If we and our colleagues in other centers all follow a standard protocol, it not only benefits the doctor and patient but it also facilitates gathering apples-to-apples data for purposes of research and professional dialogue among practitioners.

The new recommended standards were established through consensus of 23 experts from both sides of the Atlantic. They began in 2022 by combing through 73 published studies to identify individual centers’ practices. With the aim of producing “consensus recommendations on MRI acquisition, interpretation, and reporting after focal therapy,” they began a 2-round consensus process in January 2023, based on 295 statements gleaned from the studies. Panelists scored each statement “agree” or “disagree”. At the end of round one, the panelists agreed with 227 of the statements.

Prior to round two, the statements were altered based on the results of round one, and 334 statements were then developed and discussed. This was followed by the opportunity for further modifications, resulting in 329 statements. At the end of round two, agreement had been achieved on 270 of them.

This process produced what is now called the Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy, or TARGET. Here are some of the key recommendations:

• Perform routine MRI at 12 months after focal treatment
• The protocol for capturing images should be compliant with PI-RADS v2.1
• To assess recurrence within the zone of ablation, a 5-point scoring system includes a major dynamic contrast enhancement (MRI-DCE) sequence and joint minor diffusion-weighted imaging (DWI) and T2 weighted sequences
• For the DCE sequence, focal nodular strong early enhancement detects the most suspicious areas
• Recommendations include minimum standards for data to be included in the MRI report.

It is the hope of the authors that the TARGET recommendations will “improve MRI acquisition, interpretation, and reporting after focal therapy for prostate cancer and provide minimum standards for study reporting.” At the Sperling Prostate Center, we follow the latest research and adhere to guidelines, as well as the integration of clinical Artificial Intelligence applications, in bringing our patients the highest standards of excellence. We also embrace the lofty principles of equality and freedom. We have equal respect for every patient and his loved one who comes to us, and we offer patients who are candidates for focal therapy the freedom of treatment choice: Focal Laser Ablation, TULSA-PRO, and Exablate MRI-guided Focused Ultrasound. Contact us for more information.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] De Boeck K, Castellani C, Elborn JS. Medical consensus, guidelines, and position papers: A policy for the ECFS. J Cystic Fibrosis. 2014;13(5):495-498.
[ii] Light A, Mayor N, Cullen E, Kirkham A, et al. The Transatlantic Recommendations for Prostate Gland Evaluation with Magnetic Resonance Imaging After Focal Therapy (TARGET): A Systematic Review and International Consensus Recommendations. Eur Urol. 2024 May;85(5):466-482.