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).[i] 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.