Process Check

From what you have posted, you are an ideal candidate for active surveillance. I have been on AS for eight years, and am very glad that my doctors recommended it. That said, you will need to have more testing within the next year, including an mp-MRI, a confirmatory fusion biopsy, and a genomics test on any positive biopsy slides. That's the strict protocol used at Johns Hopkins, and your doctors should not deviate too far from it. Why? because the strictest protocols have the best results for AS.

Dr. Walsh's book is fine for someone who has researched and firmly decided on a prostatectomy, but is outdated on other forms of treatment, and on AS. Make sure to acquire other sources.

It sounds like you have received great advice, and are following the appropriate course for your pathology. Best of luck to you.

I was hoping that having another MRI/Ultrasound guided biopsy would be necessitated by PSAs that went in the wrong direction. Are you saying it's advisable to have another biopsy within the next year, regardless of my PSA draws.

Also, I realize that any books that I get will be dated to one degree or another, but it will lay down a foundation of general information that I won't need right away but would like to be aware of. Besides, they keep coming up with new stuff so this is more like a life sentence. Also, I have a cousin that just going through all this stuff now and I fear his results will be less favorable. I'll known next week...

Thanks all!

Yes- I do consider a confirmation biopsy within a year to be a necessity. A single TRUS biopsy can miss up to 40% of significant cancers, and even the best mpMRI imaging with expert radiologists may miss some:

www.tandfonline.com/doi/abs/10.1080/21681805.2017.1313310?journalCode=isju20
pubs.rsna.org/doi/10.1148/radiol.2017152877
The Efficacy of Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance

The question the patient wants answered is this:

Having had a TRUS-targeted biopsy that was positive for insignificant cancer only, what is my risk that an mpMRI that is negative for significant cancer (PIRADS 1-2) would really be found to be positive on a targeted biopsy. A new study from Washington University tried to answer that. They found that among men given a TRUS-guided biopsy in spite of a negative mpMRI, 13% were found to have Gleason score ≥ 7.

Determination of the Role of Negative Magnetic Resonance Imaging of the Prostate in Clinical Practice: Is Biopsy Still Necessary?

In the following NIH study, they found that 16% of men with a negative mpMRI were found to have biopsy-proven progression to Gleason score ≥7

Multiparametric prostate MRI and MRI/ultrasound fusion biopsy as tools to follow prostate cancer progression for men on active surveillance.

It would also be a mistake to rely only on a positive confirmatory mpMRI to find the significant cancer. In the following study, they took cores from the suspicious regions (PIRADS 3-5) but found significant cancer in completely different areas in 17% of men with PIRADS 3, 12% of men with PIRADS 4, and 10% of men with PIRADS 5. Additional mpMRI misses are found when a saturation biopsy is given.

The Efficacy of Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance

If a patient wants to roll the dice that he is not among those who got a false negative mpMRI, that is certainly his call, but it's hard to see why he would accept such a risk compared to the low risk associated with a second biopsy. If it were me, my confirmatory biopsy would be transperineal template-mapping. After that, I might forgo biopsies for the next 5 years or so.


Walsh's book, for example, was last edited over 5 years ago. My concern is that you may be misled by outdated knowledge. Current peer-reviewed journal articles (like those above) are the best source of knowledge. There is a sticky at this site for the newly diagnosed that covers the basics.

GaryDouglas said...
Thank God I appear to have time to digest this all...

Very true - based upon your biopsy report, you have plenty of time to absorb your situation, learn about AS and, if you choose, about the other treatments available for your diagnosis. It will be worth your time to learn while you are not being pressed for a decision. It is easier to take it all in while you're calm.

As for the books, I was one of the louder critics of them when I was first learning about my treatment options. When I read Dr. Walsh's book, I asked out loud "Where has he been for the last 5-10 years?" Of course, I reminded myself of the typical publication cycle, and it became obvious that what I was reading was written 5-7 (or more) years prior, so the surprise vanished. All that was left was my opinion that if you are considering surgery, Dr. Walsh is THE reference for most of us. If you are considering ANY other form of treatment (and there are quite a few), then it is up to you to meet with the experts who offer those treatments to learn about them.

I thought parts of Walsh's book were good for general background reading, although I didn't touch the parts on treatment because 1) it was out of date, 2) I understood that he had a bias toward surgery, and 3) I'm not yet at the point of considering treatment options -- I'll cross that bridge when I come to it (if I ever do).

As far adding to your reading list, I've been working my way through Active Surveillance for Localized Prostate Cancer: A New Paradigm for Clinical Management (Laurence Klotz, Ed.), which is so new that it lists its copyright date as 2018. Be warned that this is a book meant for clinicians though -- a lot of the writing is very dry and technical, assuming a background in medicine or biology. (I was completely lost on some of the stuff involving genetics.)

GaryDouglas-

You probably misunderstood. Please show me the websites that say a confirmation biopsy in 2-5 years. That's a very dangerous practice because about a third of significant cancers may be missed on a first biopsy.

ASCO said...

3. The AS protocol should include the following tests:

• A PSA test every 3 to 6 months

• DRE at least every year

• At least a 12-core confirmatory transrectal ultrasound guided biopsy (including anterior directed cores) within 6 to 12 months, and then serial biopsy every 2 to 5 years thereafter or more frequently if clinically warranted. Men with limited life expectancy may transition to watchful waiting and avoid further biopsies.

The AS protocol may include ancillary tests that are still under investigation. These could include multiparametric MRI (mpMRI) and/ or genomic testing. mpMRI and genomic testing may be indicated when a patient’s clinical findings are discordant with the pathologic findings and could be useful in identifying occult cancers or changes indicative of tumor progression in patients at risk. These tests may also be helpful when the decision regarding AS versus active treatment is uncertain (eg, in cases of low-volume Gleason 3 + 4). mpMRI should not be used as a replacement for rebiopsy.

Oops, i was remembering the later part of the recommendation:
"and then serial biopsy every 2 to 5 years thereafter"

http://ascopubs.org/doi/full/10.1200/jco.2015.65.7759

At least a 12-core confirmatory transrectal ultrasound guided biopsy (including anterior directed cores) within 6 to 12 months, and then serial biopsy every 2 to 5 years thereafter

https://www.health.qld.gov.au/__data/assets/pdf_file/0029/426935/wp203.pdf

Offer a reclassification repeat prostate biopsy within 6–12 months of starting an active surveillance protocol. Offer repeat biopsies every 2–3 years, or earlier as needed to investigate suspected disease progression

So excuse my oops, but I'm still looking for more links with similar recommendations as the first link above. Need it for amo for my next uro visit...