You’ve just had a prostate biopsy, and you’re waiting for the results. You figure you’ll get a head start on researching your options. As you surf the internet, and watch YouTube videos, you encounter a lot of information on radical prostatectomy, several forms of radiation including proton beam and seed implants, and perhaps less material on focal treatments. You’re trying to be open-minded and somewhat rational as you jot down questions that come to mind. You also learn that Active Surveillance is increasingly recommended to men newly diagnosed with low-risk prostate cancer (PCa). “Gosh,” you say to yourself, “I sure hope I don’t have prostate cancer, but if I do, I can only hope it’s low risk and I can go on Active Surveillance. That way I can put off treatment so I don’t have to deal with side effects.”
Active Surveillance (AS) is on the rise for two basic reasons. First, the use of multiparametric MRI (mpMRI), targeted biopsy, and biomarkers qualifies AS candidates with greater confidence. Second, we now realize that untold thousands of men with low-risk PCa have been over-treated, leaving them with urinary and sexual problems as a trade-off in the quest for a cure.
Is it safe to wait?
A 2015 study published by University of Chicago researchers concluded that men diagnosed with low-risk PCa “… may safely use the time following their initial biopsy to consider management options and obtain a restaging biopsy, if recommended,” for up to a year without raising risk of recurrence.[i] And yet, 45% of the total 17,943 low-risk cases in their study were found to have adverse pathology (worse disease) at the time of surgery! Here are the timeframes:
- 16,818 patients had surgery within 6 months of diagnosis
- 894 had surgery at 6-9 months
- 169 had surgery at 9-12 months
- 62 had surgery at over 12 months.
Since all patients presumably had TRUS biopsy, which misses PCa roughly 30% of the time, I believe some diagnoses were underestimated to begin with. Still, with nearly half of cases ending up with higher grade, higher stage, or lymph node involvement at the time of surgery, how did the authors interpret that it is safe to use up to 12 months to “consider management options”?
Not so safe after all
A 2018 paper presented at the 33rd European Association of Urology Congress (Copenhagen, Denmark) underscores my concern. This was a much smaller study of 513 men at a single French medical center. The authors found that for patients with Gleason 3+4 PCa, a 90 day delay from biopsy to prostatectomy significantly increased their risk of biochemical recurrence (meaning a detectable or rising PSA after surgery, when PSA should drop to zero) vs. those who had surgery sooner.[ii] (They did not, however, identify a time threshold for Gleason 3+3 patients.)
It’s hard to compare both studies since the more recent one divided patient groups by Gleason grade. Nonetheless, I believe both studies cast doubt on the safety of Active Surveillance as a way to delay treatment if conventional TRUS biopsy and monitoring by PSA and repeat biopsy are used.
A better way
Let me approach this differently. Rather than ask, “Is it safe to delay treatment after prostate cancer diagnosis?” I would pose the question, “How can we make it safer to delay treatment after prostate cancer diagnosis?” The answer is, change the diagnosis and monitoring protocol. Instead of TRUS biopsy, PSA tracking, and repeat TRUS biopsy, at our Center we offer
- Baseline multiparametric MRI before biopsy to detect any suspicious area(s)
- In-bore MRI-guided targeted biopsy for the most accurate tissue diagnosis with the fewest needles
- Advanced diagnostics, including genomic/biomarker analysis if indicated
- If a patient is diagnosed with low-risk disease, use of mpMRI plus PSA tests to monitor
- Repeat in-bore targeted biopsy only if PSA and imaging detect tumor growth or progression toward aggressiveness
Finally, if growth or progression triggers a treatment decision, for qualified patients we offer Focal Laser Ablation (FLA) to treat the known cancer (plus a margin of safety). FLA is a treatment approach that tailors a cancer-destruction method to the tumor, with minimal-to-no risk of disrupting urinary and sexual function. In other words, we control the cancer without over-treating the disease.
Thus, the Sperling Prostate Center not only offers the safest way to delay treatment, but also preserves a patient’s dignity and manhood if treatment is needed.
Contact us to learn more about mpMRI for prostate cancer detection, diagnosis and treatment.
[i] Weiner AB, Patel SG, Eggener SE. Pathologic outcomes for low-risk prostate cancer after delayed radical prostatectomy in the United States. Urol Oncol. 2015 Apr;33(4):164.e11-7.
[ii] Charnow, Jody. “Biopsy-to-RP delay may up prostate cancer recurrence risk.” Renal & Urology News, Mar. 26, 2018. https://www.renalandurologynews.com/eau-congress/biopsy-prostate-surgery-biochemical-recurrence/article/753581/