If you’ve been diagnosed with low-risk prostate cancer, chances are your doctor has said you may be a candidate for Active Surveillance (AS). The National Cancer Institute defines AS as a cancer management strategy to avoid or delay treatments with side effect risks. It “involves closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse.” The conventional monitoring protocol for PCa patients on AS always involves scheduled PSA blood tests, usually beginning 6 months after going on AS.
Repeat monitoring biopsies – yes or no?
In addition to regular PSA tests, most conventional protocols include repeat biopsies as a necessary monitoring component. These are called surveillance biopsies. In fact, the first repeat biopsy can be as soon as 1 year from starting on AS, though the interval between biopsies may lengthen provided the cancer is holding steady. This position has long had the support of U.S. professional urology and oncology communities, but there’s a problem. Patients often fail to comply with this requirement because they grow to dread the procedure, which can be painful and comes with risk of infection and other side effects. As a result, there is growing debate over benefits vs. costs of surveillance biopsies.
What sparked the debate is the addition of multiparametric MRI (mpMRI) to AS protocols. MRI is literally changing the course of urologic history. The European Association of Urology (EAU) recommends PSA testing every six months, with at least annual mpMRI scans. According to their new guidelines, if the scan does not show significant PCa (PI-RADS score ≥ 2), and PSA is not rising quickly, the doctor and patient can discuss the merits of a repeat biopsy (shared decision-making). However, a shift toward cancer progression triggers a biopsy because tissue verification is necessary.
The EAU is not alone in opening up the possibility of as-needed (triggered) biopsies. An Australian research team designed a 3-year clinical study to explore PCa-related outcomes during the study term by replacing a scheduled biopsy with annual multiparametric MRI (mpMRI) at the end of the 1st and 2nd years following initiation of AS. 172 patients were enrolled. Prior to going on AS, each patient had a baseline mpMRI and a baseline template biopsy (plus or minus a targeted biopsy).[i] During the study period, a biopsy would be automatically triggered by “abnormalities on multiparametric magnetic resonance imaging and/or increases in prostate specific antigen density.” Then, at the end of the 3-year study period, all participants study would have another template biopsy for comparison with baseline.
At the Sperling Prostate Center, we are very interested in published studies coming from other countries. For instance, a British group conducted research on 672 patients who were on AS.[ii] They found, “The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr.” In other words, incorporating MRI into the monitoring protocol had similar outcomes as those with scheduled surveillance biopsies. They concluded that the MRI-based surveillance strategy could safely avoid routine biopsies.
While we respect urology experts’ views, in our own experience with low-risk PCa patients who understand the pros and cons of mpMRI monitoring as a way to avoid scheduled biopsies, our patients are comfortable trusting their bloodwork and the excellent imaging we offer. We never take chances with patient lives. At the slightest sign of cancer progression, we provide real-time, in-bore MRI-guided targeted biopsy for the most accurate diagnosis of tumor activity.
The AS repeat biopsy debate may yet continue in the world of urology. In our own world, informed low risk patients are empowered to weigh in on the option of MRI monitoring.
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.
[i] Doan P, Scheltema MJ, Amin A, Shnier R et al. Final Analysis of the Magnetic Resonance Imaging in Active Surveillance Trial. J Urol. 2022 Nov;208(5):1028-1036.
[ii] Stavrinides V, Giganti F, Trock B, Punwani S, et al. Five-year Outcomes of Magnetic Resonance Imaging-based Active Surveillance for Prostate Cancer: A Large Cohort Study. Eur Urol. 2020 Sep;78(3):443-451.