In recent years, there’s been a huge shift in understanding the difference between insignificant and significant prostate cancer (PCa). Over 15 years ago, Albertsen, et al. (2005) established that clinically insignificant PCa could be defined as cancer that “will not affect the patient during the natural course of his lifetime. The indolent course of localised low-grade PC means that active surveillance (AS) is considered a good treatment option.”[i]
Since this recognition, the proportion of newly diagnosed low-risk PCa patients who go on AS has increased dramatically. According to CancerNetwork, the increase in the use of active surveillance for patients with low-risk prostate cancer has grown dramatically from a low of 6.7% in the years from 1990-2009, to 40.4% in the period 2010 to 2013.
While AS enables men to defer radical treatment and its associated risks of incontinence and sexual dysfunction, over 25% of AS patients show signs of disease progression within 5 years (many of them may not have been properly qualified for AS initially). Furthermore, at least 13% of AS patients opt to convert to treatment even though they have no signs of progression.[ii] In part, this is because uncertainty can be nerve-wracking; the idea of cancer growing in one’s body is uncomfortable for many men. So is the idea of a repeat systematic (conventional TRUS-guided 12+ needle) biopsy. This anxiety can be allayed by improving monitoring during AS with better imaging—which can help eliminate unnecessary repeat biopsies—and by reducing the number of biopsy needles using image-guided targeting.
Improving AS monitoring
The National Cancer Research Institute is the nation’s leader in cancer research. Its establishment in 1937 “represented the culmination of nearly three decades of efforts to formalize the U.S. government’s place in cancer research.” The passage of the National Cancer Act in 1937 not only inaugurated the Institute, but incorporated the resources of the Government to ensure the Institute’s authoritative, groundbreaking research and collaborations.
The National Cancer Institute has now published data on 369 AS patients who were monitored for disease progression by multiparametric MRI, imaging-targeted biopsy and standard systematic biopsy (12-core TRUS guided)[iii]. Grade progression was monitored by all three modalities at 2, 4 and 6+ years. At 2 years, here’s what each biopsy modality found:
- MRI targeted biopsy detected grade progression in 73 patients (26.4%)
- Standard systematic biopsy detected grade progression in 44 patients (15.9%)
- Combined biopsy (targeted + systematic) detected grade progression in 90 patients (32.5%)
Of all 90 grade progressions at the 2-year time point, 46 (51.1%) were missed by systematic biopsy, but were found by MRI-targeted biopsy alone. This was significantly more than standard systematic biopsy. The authors concluded, “Our results provide compelling evidence that prostate magnetic resonance imaging and imaging-targeted biopsy should be included in contemporary active surveillance protocols.”
At the Sperling Prostate Center, we are pleased to have been well ahead of the curve in monitoring excellence for PCa patients on AS. Our Center offers state-of-the-art multiparametric MRI, and precision biopsy targeting under real-time, in-bore MRI guidance. To learn more about why our AS monitoring program is better, visit our website.
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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] Cited in Shaw GL, Thomas BC, Dawson SN, Srivastava G et al. Identification of pathologically insignificant prostate cancer is not accurate in unscreened men. Br J Cancer. 2014 May 13; 110(10): 2405–2411.
[ii] Van Hemelrijck M, Ji X, Helleman J, Roobol MJ et al. Reasons for Discontinuing Active Surveillance: Assessment of 21 Centres in 12 Countries in the Movember GAP3 Consortium. Eur Urol. 2019 Mar;75(3):523-531.
[iii] Yerram NK, Long L, O’Connor LP, Wang AZ et al. Magnetic Resonance Imaging-Targeted and Systematic Biopsy for Detection of Grade Progression in Patients on Active Surveillance for Prostate Cancer. J Urol. 2021 May;205(5):1352-1360.