Active Surveillance: MpMRI instead of re-biopsy

You can look at my statistics below, but my 3t MpMRI only showed anything except for one suspicious spot. So I had the standard biopsy of 12 core plus one for the suspicious spot. Results was that the suspicious spot was nothing, whereas other areas had cancer.

My two cents worth of insight is that MpMRI is great tool for spotting higher yield cancer and solid tumors, but low yield cancers like my prostate cancer it was ineffective.

The only true diagnostic tool is the infamous biopsy. Even then it can be a hit or miss situation.

Thanks guys. It is really helpful to have some good feedback that can make you feel more sure of your decision...which can be one of the hardest parts.

Guess those guys relying on Mpmri's and 3d sonograms for a followup of even low grade PC are kind of keeping their head in the sand.

They always say how they are so much more advanced in Europe...and in many ways they are...

But I couldn't find much data online backing up this type of strategy or that its wildly being used in Europe. Even if Europe doctors did have Mpri first and are pioneers in many advances that our slow moving business driven FDA mandates.

Many of the protocols are similar.

Its the protocols that many of the men that don't believe even a repeat biopsy is needed. They think its more of a business model and a one size fits all method that is not always needed.

A confirmatory MRI fusion biospy within six months is mandatory in the AS protocol at Johns Hopkins. Yes, it can seem stringent, but consider that JH's program, which started in 1994, has the best outcomes of any AS program, anywhere.

A recent European study found that mpMRI did not recognize 23% of all index tumours, and 30% to 50% of intermediate/high-grade tumour foci.

Prostate Cancer Biopsy for Active Surveillance
by Dr. Mark Scholz

"Dr. Mark Scholz believes that men on active surveillance for prostate cancer can avoid having yearly biopsies if their doctors use imaging studies instead.
many are asking why can’t we do imaging studies instead of biopsies? The answer it seems to me is mostly well, we just have not done it that way. We have always done it the other way and that’s what we are comfortable with doing it the way we’ve always done it. That’s the doctor is speaking, of course, and about a million men are getting biopsied every year. So there is an existing business plan that men get regular biopsies as a part of monitoring.

However, I don’t ascribe to that anymore. "

http://www.prostatecancerlive.com/monitoring-prostate-cancer-active-surveillance/

Mri or biopsy....I wonder how guys would choose if they were paying for the procedures out of their own pocket?

I think you're right that we don't have a lot of data to support decision-making, although there is some. Lacking that data, why would anyone take the risk? Scholz is expressing his personal opinion, not the evidence. The reason why a confirmatory biopsy is done and not just an mpMRI is because mpMRIs miss enough significant cancer to make relying on it alone very risky. Active surveillance protocols are designed to minimize the risk of living with ostensibly low risk cancer. He is absolutely wrong that they are doing it because that's the way it's always been done. In fact, AS was ongoing long before mpMRIs became available.

The question the patient wants answered is this:

Having had a TRUS-targeted biopsy that was positive for insignificant cancer only, what is my risk that an mpMRI that is negative for significant cancer (PIRADS 1-2) would really be found to be positive on a targeted biopsy. A new study from Washington University tried to answer that. They found that among men given a TRUS-guided biopsy in spite of a negative mpMRI, 13% were found to have Gleason score ≥ 7.

Determination of the Role of Negative Magnetic Resonance Imaging of the Prostate in Clinical Practice: Is Biopsy Still Necessary?

In the following NIH study, they found that 16% of men with a negative mpMRI were found to have biopsy-proven progression to Gleason score ≥7

Multiparametric prostate MRI and MRI/ultrasound fusion biopsy as tools to follow prostate cancer progression for men on active surveillance.

It would also be a mistake to rely only on a positive confirmatory mpMRI to find the significant cancer. In the following study, they took cores from the suspicious regions (PIRADS 3-5) but found significant cancer in completely different areas in 17% of men with PIRADS 3, 12% of men with PIRADS 4, and 10% of men with PIRADS 5. Additional mpMRI misses are found when a saturation biopsy is given.

The Efficacy of Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance

If a patient wants to roll the dice that he is not among those who got a false negative mpMRI, that is certainly his call, but it's hard to see why he would accept such a risk compared to the low risk associated with a second biopsy. If it were me, my confirmatory biopsy would be transperineal template-mapping. After that, I might forgo biopsies for the next 5 years or so.

The follow up is similar at JH, but the timing is within six months, and using the same mpMRI as the first biopsy. At least, what it was several years ago, when I was enrolled in their AS program.

OK Allen..

I sent the Dr. the link. I'm sure he has read this study as he is very heavily involved in research.

At first I didn't want to have any repeat biopsy at all. Now you are advocating a more thorough one in addition. The reasoning is solid.

Many PC warriors would rather have the most minimal biopsy possible.
Less needles...less chance of infection.

I know you can't be too cautious though. I will see what he says.

by the way...I posted on the inspire forum. Not trying to start a forum war here....but its funny...like you said.....some guys just don't do their research.

This is the first response I got.
(My doc supports serial MRI's and TRUS's with no repeat biopsy unless changes are noted. I have not read "any" reports on men doing "serial" MRI's that missed a significant cancer progression.)

Tall Allen said: "If a patient wants to roll the dice that he is not among those who got a false negative mpMRI, that is certainly his call, but it's hard to see why he would accept such a risk compared to the low risk associated with a second biopsy. If it were me, my confirmatory biopsy would be transperineal template-mapping. After that, I might forgo biopsies for the next 5 years or so."

TA does not need my or others endorsement/reinforcement of his opinion but I will add my two cents.
This Biopsy discussion is within the context of how to be confident AS is a valid protocol.
It has equal validity within the context of whether someone should consider a focal therapy .
In both cases men have to make a decision relating to the number, volume, and grade of cancerous lesions.
We know that prostate cancer is typically a mutifocal disease. That being the case a random Trus Biopsy can easily misss all or much of the cancer. Whenever I see a signature that says : "3 of 12 cores said Gleason 6 and I am going on AS or having a Laser zap those 3 cores" I think: " you sampled less than 1 per cent of your gland and that 1 percent had a 50 percent hit, how do you not know 50 percent of your entire gland is not cancerous with some at a higher grade?
Whenever I see a signature that says: " my 3 T MRI showed two lesions in the left lobe that were biopsied at Gleason 6 and I am going on AS " , I think : " what makes you think that the MRI saw all significant Cancer? "
The answer is that in both instances men are relying on protocols that phycisians led by insurance companies have deemed " the standard of care".
Few people realize that the " standard of care" is a mathmatical model that balances cost against efficacy.
If 80 percent of significant cancer can be visualized on a 3 T MRI and 95 percent can be visualized on a 3 D Template Mapped Biopsy which costs 3 to 5 times more, the insurance company says in effect it does not make sense to pay for Mapped Biopsies because the incremental amount of cancer found will not justify the additional expense.
That of course is irrelevant to those that fall into that 15 percent category of men who had the cancer that was unseen.
If someone can not afford the out of pocket expense of a Mapped Biopsy that is understandable .
However, they should be counseled on the risk they are taking by basing their decision on incomplete information.

I've met with Dr. Scholz and Dr. Lam (I haven't met Turner) several times. They are both medical oncologists in Marina del Rey, and I think they are excellent at that. That means they are trained to treat patients who are managing their prostate cancer rather than attempting to cure it. However, like other medical oncologists, he does not turn away patients just because the patient's major need does not coincide with his specialty. He also wrote a very anti-surgery book called "The Invasion of the Prostate Snatchers."

When a patient goes to him for active surveillance, Scholz often refers him to my urologist, Leonard Marks at UCLA, who actually does the surveillance. I'm not sure what value Dr Scholz adds for such patients - perhaps his confidant manner inspires them to stick with AS. To my knowledge, he has never published any studies related to active surveillance. But you're right, his patients do like him. He is very personable and he runs a big patient-oriented prostate cancer show in September at the LAX Marriott. When I want a well-informed opinion about the protocols of a specialty, I go to specialists. You can decide for yourself whether his opinions on this subject carry weight with you.

fuzzboxman-

I think you are right to be suspicious of doctors who express opinions without offering evidence. Dr. Marks (who publishes frequently on this subject) never relies on an mpMRI alone in place of a confirmatory biopsy. One has to be skeptical about anecdotal evidence too. The majority of men on AS do well even if they do absolutely nothing - and far too many do just that. That does nothing to recommend one protocol over another. What we have to look at is what happens when men are randomized to protocol A vs. protocol B over the course of 15-20 years. We will never have that data from a randomized trial. Using monadic comparisons, however, we can see the danger of not having confirmatory biopsies.

You may be interested in the discussion of monitoring of men on AS in the ProtecT trial - Section 3B:

/pcnrv.blogspot.com/2016/09/the-first-randomized-clinical-trial.html