Active Surveillance

Just hit the 8 year mark on Active Surveillance. It has been a mentally changed ride. You can see my signature for my statistics.

Happy for you! Denis

Toyoung, congrats on 8 years of AS success. Your story is really interesting...at least to me. If I understand correctly of all the biopsies you have had you only had one with a positive sample and that was a G6. I'm wondering if that sample had been re-read by Dr. Epstein and downgraded to no cancer (like the rest of your biopsies) if you would have done anything different, e.g fewer biopsies over the years. Also, even though your PSA as generally risen over the years the most recent PSA was lower than the previous year. Have you had one done in 2020?

Also, what is the size of your prostate, i.e. if it's large is this the "normal" amount of PSA for your prostate? And have you ever been treated for any sort of infection?

Just some rambling questions but generally I think it's great that you have avoided more invasive treatment for all these years.

Jim

Great news, here's hoping that continues for a long time.

Toyoung: congrats! You have officially become my second idol alongside ASA. I'm a babe in the woods with barely a bit over a year on AS featuring two biopsies and continued low PSA (fwiw...).

May we all continue to enjoy the treatment-free existence as long as possible.

Now, about that coronovirus....

Djin, I do not have a max psa value that would lead to treatment. A sudden increase in psa would promp me to have another biopsy or MRI. I had one core G6 in 2012, my immediate reaction was treatment. After the initial shock I wanted to see how this disease will progress and fortunately it must be progressing very slowly.

Good for you Toyoung. I'm only closing in on 3 years but taking it one day at a time.PSA staying low and MRI's looking good.

Toyoung said...
Djin, I do not have a max psa value that would lead to treatment. A sudden increase in psa would promp me to have another biopsy or MRI. I had one core G6 in 2012, my immediate reaction was treatment. After the initial shock I wanted to see how this disease will progress and fortunately it must be progressing very slowly.

Toyoung, i was actually referring to your protocol's max PSA (or PSA progression) -- you, of course, can decide to treat or not whenever you choose. What PIRADS grades did your last MRI assign to any targets? Was increasing the number of biopsy cores discussed? Finally, what do your docs say about your high, increasing but fluctuating PSA with a small prostate size?

Djin

Dopey me
Did not include signiture with info

Again congrats with many more yr

Toyoung said...
Djin, since I am not in a formal Active Surveillance program I do not have a specific protocol, max PSA or PSA progression. If there is a spike another MRI or biopsy would be in order. On my MRI's I was never given any PIRADS score. The MRI's were done at Memorial Sloan Kettering. I was told the MRI's looked clean. There were areas of interest which they targeted during the biopsy which came up negative. I have spoken to a few Dr.'s and nobody can give me a concise reason for the high PSA. Could be infection, low grade cancer, or I just have a high PSA.
....

I was the recipient of many biopsies over the years for BPH and a rising PSA-- all were negative, until the last. However, at various points my uros did more than the 12 cores (and as many as 24). Granted, my prostate was much larger than yours, but should you need another biopsy, I would ask about having more than 12 cores taken. And I advise that no one should allow a target-only biopsy after a mpMRI.

I wish you continued calm seas!

Djin

2019Guy said...
Djin - I'm wondering about your last comment there in re targeted biopsies. I hadn't heard that before and would love it if you had time to elaborate as I did indeed have an mpMRI followed by a targeted biopsy!

Thanks.

Be happy to. My comments were directed especially at biopsy-naive men, and not so much men on AS, BTW.

In favor of Targets (only):

MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis (2018, Full Text)

However:
"Fourth, it is possible that clinically significant cancers may have been missed by the omission of standard biopsy cores in men in the MRI-targeted biopsy group. Previous well-designed studies have highlighted that the percentage of cases of clinically significant cancer that are missed by MRI-targeted biopsy but detected by standard transrectal ultrasonography–guided biopsy is low, between 0% and 10%.12,13,23,28 Despite more than one quarter of the men avoiding a biopsy, this trial showed that when clinicians limited themselves to the use of MRI-targeted biopsies only, the rates of detection of clinically significant cancer were higher than those seen with the standard of care. Furthermore, because systematic biopsy was avoided, clinically insignificant cancer was detected in fewer men, which may have a substantial benefit in reducing the overtreatment of men with prostate cancer. If both systematic biopsy and MRI-targeted biopsy were carried out in the same man at the same time, the performance of one test could be influenced by the other, which would make it difficult to evaluate the unbiased performance of each test individually"

On the other side to various degrees:

Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging and Fusion Guided Targeted Biopsy Evaluated by Transperineal Template Saturation Prostate Biopsy for the Detection and Characterization of Prostate Cancer (2018)

"CONCLUSIONS:
Multiparametric magnetic resonance imaging alone should not be performed as a triage test due to a substantial number of false-negative cases with clinically significant prostate cancer. Systematic biopsy outperformed fusion guided targeted biopsy. Therefore, it will remain crucial in the diagnostic pathway of prostate cancer."

Targets missed: predictors of MRI-targeted biopsy failing to accurately localize prostate cancer found on systematic biopsy (2018)

"CONCLUSION:
Clinically significant PCa is rarely missed utilizing MRI/US fusion-guided biopsy. With the majority of missed tumors representing targeting misregistrations or cases of low-grade cancer in sextants immediately adjacent to MRI suspicious lesions. Lower MRI lesion volumes, lesion density, and PI-RADS are predictors of cases with targeted biopsies missing cancer, for which systematic sampling of the sextants containing MRI targets and adjacent sextants would most optimize PCa detection."

How many cores are needed to detect clinically significant prostate cancer on targeted MRI-ultrasound fusion biopsy? (2018)

"Conclusions: On a per-lesion basis, sampling two cores of mpMRI-evident lesions at the time of fusion biopsy misses nearly one-quarter of clinically significant PCa that would be detected on additional sampling."

A critical comparison of techniques for MRI-targeted biopsy of the prostate (2017, Full Text)

"The European Association of Urology advise performing a multiparametric magnetic resonance imaging (mpMRI) study when initial standard biopsy results are negative but the suspicion of prostate cancer persists (2). This has been echoed by a joint consortium of the American Urology Association and the Society of Abdominal Radiology, which states that where high quality mpMRI is available, it should be strongly considered for men in whom a repeat biopsy is considered (5). In addition, the National Comprehensive Cancer Network (NCCN) guidelines advise the use of mpMRI prior to repeat biopsy, with mpMRI-targeted cores to be considered in addition to standard cores (6)."

[Emphasis mine]

There Is No Way to Avoid Systematic Prostate Biopsies in Addition to Multiparametric Magnetic Resonance Imaging Targeted Biopsies (2020, Full Text)

"Results and limitations
In the European cohort, csPCa detection rate was 55%. The csPCa detection rate for TRUS-Bx was 41%. At MVAs, prostate volume, previous negative biopsy, and Prostate Imaging Reporting and Data System versions 4 and 5 were independent predictors for the presence of csPCa outside the IL. The multivariable model had an AUC of 0.78. Omitting TRUS-Bx in patients with a calculated risk of <15% would have spared 16% of TRUS-Bx at the cost of missing 7% of csPCa. Similar findings were obtained when the same analyses were performed in the North American cohort. No net benefit was observed for low-threshold probabilities (<15%) of the each model relative to the standard of care (performing TRUS-Bx in addition to MRI-TBx to all patients) in both cohorts. The study is limited by its retrospective design.

Conclusions
We failed to identify those patients who might safely benefit from MRI-TBx alone. The combination of MRI-TBx and TRUS-Bx should strongly be considered the best available approach.

Patient summary
In the presence of positive multiparametric magnetic resonance imaging (mpMRI) of the prostate, physicians should always perform systematic sampling of the prostate in addition to mpMRI targeted biopsy."

[Emphasis mine]

Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance (2019)

"CONCLUSIONS:
High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features."

(TB = Targeted; SB = Systemic)

MRI/Ultrasound Fusion Biopsy Versus Standard 12-Core Biopsy (2015)

"Combining targeted and standard biopsy led to the diagnosis of 103 (22%) additional cases, but the vast majority (83%) were Gleason 6 or low-volume Gleason 3 + 4, and only 5% were classified as high-risk. The authors estimated that 200 men would need to undergo standard biopsy in addition to targeted biopsy to find one case of high-risk prostate cancer. Meanwhile, 17 extra low-risk cancers would be detected per each additional high-risk cancer diagnosed"

[However, now we can use genomics to select G6 men who are not good AS candidates because they are high risk for forming higher-grade lesions with met potential]

Does the addition of standard systematic biopsies to targeted prostate biopsies influence treatment choices for patients and clinicians? (2016 Poster)

"Addition of standard systematic prostate biopsy to targeted biopsy in patients with elevated PSA and no prior systematic prostate biopsy within the preceding 3 years detected PCa GS ≥ 7 on the opposite side of the prostate from the target lesions (with no significant abnormalities on mp-MRI) in 13% of patients. This result may influence treatment choices, particularly for those patients considering focal therapy for PCa."

(I'm still looking for at least one other paper that concluded the standard cores should be added to the targets.)

For me this seems like a no-brainer. You are there on the table, numbed up, not going anywhere for the moment. You doc has his biopsy wand you know where. I've seen a number of forum Brothers whose PIRADS 5 lesion turned out not to be cancer, but whose random core(s) hit clinically significant PCa. We know both biopsies and MRIs miss existing cancer. I do not see any good reason for not taking the standard cores in all prostate zones.

Djin

Post Edited (DjinTonic) : 3/2/2020 2:53:49 PM (GMT-7)

Thanks, ASA. Sure, but I would double check that my quotes were representative of the papers' overall messages.

To be fair, there are studies touting target-only. And I believe the larger institutions with more experience have better results than others. But I think especially for biopsy-naive men at an average center would be better served with adding the standard cores to the targets.

Keep in mind the "random" aren't truly that. An experienced uro uses the ultrasound visual differences to identify suspicious areas. These can be caused by any condition that alters the density of healthy tissue and not only PCa, but still...

I did not have an MRI before my biopsy, triggered by a new nodule and slight PSA increase. I asked how many cores my uro planned on at that office visit and when he said 12, I asked if he could take a few extra. He said OK, and he took 14, with the extra in the nodule. The nodule behind the apex proved to be benign, but 2 random cores in other zones opposite, found two lesions, one G9 and one G10. Given my PCa turned out to account for only 5% of my prostate, that could have been luck, or my uro's good eye.

Djin

Tremendous stuff, Djin. Thanks a million. I hope everyone here on or considering AS will give it a careful read. In my case I had a standard 12-core TRUS biopsy followed by an mpMRI and a 6-core fusion biopsy. So I guess I'm in a more favorable place diagnostically (if I'm reading your post correctly - by no means a correct conclusion!). Well, at least for now. A second MRI in May. Should be interesting....