Originally published 3/1/2015
Ongoing research since we posted the blog below continues to support the need for more diagnostic indicators before performing repeat biopsy after an initial negative biopsy.
Repeat biopsies increase the risk of side effects, with a “3.9-fold increase in serious infectious complications and a 16.1-fold increase in noninfectious urological complications…”[i]
After a first negative biopsy, patient’s multiparametric MRI (mpMRI) findings offer general guidance: PI-RADS 3 suggests high unlikelihood of clinically significant PCa, but for PI-RADS 4 or 5 “MRI scans should be double checked, followed by standard checkups or repeat prostate biopsy, especially in highly suspicious cases.”[ii]
Finally, thanks to new biomarkers, before deciding on the need for repeat biopsy, higher risk mpMRI findings should be supplemented with new blood or urine tests such as “… PCA3 and mpMRI -, as well as new PC biomarkers used in the clinical practice (PHI and 4K score).”[iii]
In short, look (deeper) before you leap into a repeat biopsy.
It’s always affirming to find peer-reviewed data that confirms my professional experience, convictions, and commitment to patients. A newly published study based on over 1800 men reveals some hard facts about the incidence of repeat biopsies, and how unproductive they often are.
The study is out of New York University (NYU).[iv] The authors reviewed the records of 1,837 men whose initial biopsies occurred between Jan. 1995 and Jan. 2010. Any repeat biopsies were reviewed along four characteristics:
- Why a repeat biopsy was indicated
- The number of repeat biopsies performed
- The number of core samples taken in each biopsy
- The total PSA prior to each biopsy.
They examined the features of prostate cancer diagnosed as a result of a repeat biopsy (Gleason score, number of cores positive, percent of tumor involvement per core, and treatment choice.)
Of the 1,837 patients, 1,213 had a negative first biopsy. Of those, 255 men underwent a total of 798 repeat biopsies (meaning that there were as many as 4 repeat biopsies for some of them). Ultimately, 63 were diagnosed with prostate cancer as follows:
Gleason score < 6 – 33 men (52%)
Gleason score 7 – 22 men (35%)
Gleason score 8 or 9 – 8 men (13%)
As you might expect, the rate of detecting clinically insignificant prostate cancer (Gleason score < 6) “decreased substantially” by the 3rd and 4th repeat biopsies. This implies that while repeat biopsies were continuing to miss hitting the tumor(s), the aggression level of the disease was progressing. The likelihood of finding PCa was greatest according to three factors: a) repeat biopsy in men older than 70, b) biopsies of more than 20 cores, and c) the fourth repeat biopsy.
The authors conclude with a suggestion that once a first biopsy is negative, if a repeat biopsy is warranted consideration might be given to either a saturation biopsy, or image-guided biopsy as a way to increase the chances of finding PCa at the earliest possible stage.
Personally, I would add the suggestion of using 3T multiparametric MRI in one of two ways after a negative first biopsy. Either wait for the blood artifacts from the biopsy to heal (up to 8 weeks) and have a 3T mpMRI, or simply have the patient continue routine screening (PSA/free PSA, and DRE) until those tests trigger a referral for biopsy—in which case, have the mpMRI before a needle biopsy.
In either case, today’s 3T mpMRI is so accurate that it can rule a biopsy in or out. This is medically cost-effective, and much kinder to patients. It can be so simple to eliminate unproductive repeat biopsies.
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.
References
[i] Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Is repeat prostate biopsy associated with a greater risk of hospitalization? Data from SEER-Medicare. J Urol. 2013 Mar;189(3):867-70.
[ii] Grivas N, Lardas M, Espinós EL, Lam TB et al. Prostate Cancer Detection Percentages of Repeat Biopsy in Patients with Positive Multiparametric Magnetic Resonance Imaging (Prostate Imaging Reporting and Data System/Likert 3- 5) and Negative Initial Biopsy. A Mini Systematic Review. Eur Urol. 2022 Nov;82(5):452-457.
[iii] Gil-Sousa D, Oliveira-Reis D, Tavares C, Teves F et al. Prostate biopsy evolution and the need for repeat biopsy – The role of image and new prostate cancer biomarkers. Arch Esp Urol. 2019 Sep;72(7):677-689.
[iv] Abraham N, Mendhiratta N, Taneja S. Patterns of Repeat Prostate Biopsy in Contemporary Clinical Practice. J Urol. 2014 Oct 18. doi: 10.1016/j.juro.2014.10.084. [Epub ahead of print]
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
