In Conversation with Prof. Punwani: Innovations in Prostate Cancer Imaging and Management

At ECR 2025, one of the world’s leading medical imaging conferences, global experts will discuss how radiology transforms patient care through faster, more efficient, and more sustainable imaging solutions.

As part of our “In Conversation With” series, we spoke with Professor Punwani, a leading expert in MRI technology and prostate cancer management. Prof Shonit Punwani is Professor of Magnetic Resonance and Cancer Imaging at University College London (UCL) and a Consultant Radiologist at University College London Hospitals (UCLH).

From his early involvement in implementing mpMRI at UCLH in 2004 to his current work on national screening initiatives, Prof. Punwani provides a unique perspective on the challenges and breakthroughs shaping modern radiology.

Faster, More Efficient Diagnostic Workflows and Early Diagnosis

Reducing scan times and optimizing patient care pathways are essential for sustainable healthcare. How do advancements like LI-MRI contribute to faster diagnostic workflows and improve early diagnosis?

MRI plays a fundamental role in improving patient pathways for prostate cancer management. If we look at where we are now, multiparametric MRI (mpMRI) has completely revolutionized how we manage patients. We now use mpMRI to decide whether a biopsy is needed and to target biopsies more precisely, allowing us to detect around 90% of significant tumors, a major improvement.

However, gaps remain even with mpMRI in place. We still need to refine diagnostic pathways to reduce unnecessary biopsies, identify at-risk patients earlier through screening, and make better treatment decisions. New MRI techniques, such as luminal water imaging and short-sequence MRI protocols, are essential for filling these gaps.

For example, a 45-minute mpMRI scan is highly effective for diagnosis but impractical for large-scale screening programs. If we can achieve similar diagnostic accuracy with a 5- or 10-minute MRI scan, then prostate cancer screening becomes much more feasible. We are also developing diffusion MRI techniques that provide better tissue characterization, allowing clinicians to decide more effectively whether a biopsy is needed.

By integrating new MRI technologies into clinical practice, we can reduce unnecessary biopsies, which account for up to 50% of procedures. This would optimize healthcare system efficiency.

Ultimately, early diagnosis is the key goal. That’s why faster MRI techniques must be introduced at a stage where early detection can impact patient survival and treatment outcomes.

Which role do you anticipate real-world evidence (RWE) will have in transforming cancer management strategies?

Validating new techniques follows a structured process.

First, we must demonstrate that a new technique works in humans. Once proven, the next step is to ensure its accuracy in distinguishing disease from non-disease areas. The technique must then be applied to a cohort of patients to assess its real-world impact. For example, if we use a technique to decide on biopsy necessity, we must evaluate whether our decision was correct compared to standard practice.

Observational trials assess clinical performance, but to confirm clinical value, we need randomized controlled trials (RCTs). RCTs compare patient pathways with and without the technique. Conducting such trials—especially for MRI-based technologies—requires strong institutional collaboration.

A single institution may struggle to recruit enough patients, and the technology must be generalizable across multiple sites. Multi-institutional research collaboration is essential, but commercial partnerships also play a role. Rolling out a technique at multiple institutions is complex due to varying approvals.

Cloud-based reporting platforms streamline implementation, allowing centralized processing and NHS integration. This collaboration between research institutions, commercial partners, and healthcare providers is essential for moving MRI technology beyond research into clinical practice.

Prostate Cancer Screening and AI Integration

Prostate cancer is now the most common cancer in men in the UK. What innovations, such as AI, are most promising for screening programs?

Currently, the UK has no formal screening program for prostate cancer. Testing is opportunistic, meaning men only seek PSA testing if they develop symptoms. This delays detection, and 16% of men are diagnosed only after the disease has already spread.

A structured screening program for specific age groups would allow earlier detection. While PSA testing has benefits, it also has limitations, including overdiagnosis and unnecessary procedures. MRI presents a promising alternative.

MRI is highly effective for diagnosing clinically significant prostate cancer, but traditional 40-minute scans are impractical for widespread screening. Short-sequence MRI—lasting 10 minutes or less, contrast-free, and easily interpreted—could make screening feasible.

The ReIMAGINE Screening Study recruited asymptomatic men aged 50–75 for a quick MRI scan and PSA test. The findings were significant:

The prevalence of clinically significant cancers detected was twice as high compared to PSA-based screening alone.

Half of the men with significant cancer had entirely normal PSA levels, meaning that they would have been missed if only PSA screening were used.

This highlights the transformative potential of MRI for prostate cancer screening.

The Future: The TRANSFORM Study

The UK has secured funding for TRANSFORM, a national MRI-based prostate cancer screening study. This study could save lives by detecting at-risk men before the disease becomes untreatable.

Funded by Prostate Cancer UK and NIHR, the study will begin recruiting in the first quarter of next year, scanning 100,000 men to determine whether MRI-based screening should be nationally adopted.

Strong AI and imaging technology partnerships will be essential. AI could reduce costs and improve efficiency, making a national screening program sustainable. Breast cancer screening has already integrated AI, and we believe a similar approach could be applied to prostate cancer. If successful, this program could transform prostate cancer detection in the UK and serve as a global model.

Expanding MRI Accessibility Globally

How can we bridge the gap in MRI access in emerging healthcare markets?

Access to MRI is varied across nations. There are clear benefits to using MRI for diagnosis across a range of diseases. From a researcher’s perspective, it is important to demonstrate the clinical value of an MRI technique. This will help to make a case for access. However, we need to work towards making MRI hardware less costly and less expensive to run so that we can create capacity in emerging markets. Not all sites need the latest, most expensive MRI scanner. Most sites and emerging markets would benefit from more basic installations that are more than adequate for making important clinical decisions. There is also likely a real problem with the workforce to support conduct and reporting of MRI studies. I have no doubt that in the near future we will benefit from AI systems that are able to potentially auto-scan and auto report studies.

Healthcare Costs and MRI Sustainability

How are MRI technologies evolving to support more sustainable and cost-effective imaging protocols?

Widespread adoption requires economic justification, particularly in public healthcare systems. Cost-effectiveness analyses demonstrated that mpMRI-guided biopsies provide long-term savings, driving national recommendations. Adoption varies globally:

Privately funded systems prioritize market forces and reimbursement policies.

Public systems focus on cost-effectiveness, requiring level 1 evidence.

MRI is often seen as resource-intensive but advances in hardware and protocols are improving efficiency. New zero-boil-off helium scanners and shorter, contrast-free scans help reduce costs and environmental impact.

Beyond technology, MRI use must be optimized by considering:

Is the scan clinically necessary?

Can a lower-cost alternative provide the same value?

Can workflows improve MRI utilization?

While better MRI technology supports sustainability, appropriate use and efficiency are equally critical. Clinically necessary scans should not be avoided due to cost, as this may compromise patient care. The priority should be maximizing efficiency while maintaining high diagnostic accuracy.