Should all low-risk prostate cancer patients be re-biopsied prior to implementation of active surveillance?

Centers apply a variety of inclusion criteria in evaluating the eligibility of patients for management using active surveillance (AS) protocols. The applicability of an immediate, transrectal ultrasound (TRUS)-guided re-biopsy is recommended by a number of centers, but there is no consensus about the need for re-biopsy at this time.

AS is a well-understood option for the management of low- or favorable-risk prostate cancer. However, we still have a lot to learn still about which patients are most appropriate as candidates for AS. We are also still learning how best to make decisions about the management of men with signs of possible progression of disease after the initial decision to follow an AS protocol. One of the key questions is whether men who appear to be candidates for AS after their initial biopsy and diagnosis should have an “immediate”  second biopsy (i.e., within 3 or 6 months of diagnosis) before actually being accepted onto an active surveillance protocol.

King et al. identified 67 patients (from a total series of > 560 men diagnosed with prostate cancer) who met their institutional criteria for AS:

  • Gleason score < 7
  • PSA level < 10 ng/ml
  • PSA density < 0.15 ng/ml/cm3
  • Three or fewer positive biopsy cores
  • Less than 50 percent involvement of prostate cancer in any one core

Of these 67 patients, 52 (78 percent) agreed to a 12-core, TRUS-guided re-biopsy at their clinic within 6 months of the initial diagnosis.

Here is a summary of the resultant findings:

  • The average (mean) age of these 52 men was 63.9 years (range, 56 to 72 years).
  • Their average (mean) PSA level was 5.9 ng/ml (range, 4.1 to 10.0 ng/ml).
  • Their average (mean) PSA density was 0.12 ng/ml/cm3 at initial biopsy.
  • Tumor involved an average of 1.1 cores and 3.2 percent of the total tissue (range, 1 to 5 percent).
  • Average time from diagnosis to re-biopsy was 2.7 months.
  • 29/52 men (56 percent) showed no evidence of prostate cancer on re-biopsy.
  • 14/23 men with a positive repeat biopsy (61 percent) showed an increase in cancer volume (mean increase, 2.8 percent).
  • 9/23 men with a positive repeat biopsy (39 percent) were upgraded to Gleason pattern 3 + 4 = 7.
  • 9/52 patients (17 percent) exceeded AS criteria on re-biopsy.
  • 9/52 patients (17 percent) chose radical prostatectomy with curative intent based on
    • An increased cancer volume or grade (n =  4)
    • An elective desire for treatment (n = 5).
  • All 9 patients who elected radical prostatectomy had organ-confined prostate cancer with negative margins on final pathologic analysis.
  • The initial Gleason score, PSA density, and number of positive cores at first biopsy were not predictive of men with higher volume or grade on re-biopsy.

The authors conclude that an “immediate,” 12-core, TRUS-guided  repeat biopsy after diagnosis was able to confirm the favorable-risk nature of disease burden in this group of men being considered for AS and can identify a subset of men who do not meet widely accepted eligibility criteria for AS.

This study by King et al. appears to validate other studies that suggest the value of an “immediate” repeat biopsy (within 3 or 6 months) as a key element in the decision to manage a patient through active surveillance.

4 Responses

  1. I’m impressed by the effectiveness of repeat biopsy as an additional indicator for active surveillance.

    Would a color Doppler ultrasound repeat biopsy, which can reveal new blood vessel growth to support the tumors as well as clues to shape and size, be even better?

  2. Patients meeting the above criteria could find MRI an alternative, either with or without a subsequent biopsy. Click here for more information.

    I believe this approach is gradually being accepted in N. America.

    (No affiliation, besides being a patient, under AS, with annual MRIs.)

  3. The use of things like MRIs and color Doppler ultrasound in addition to a repeat biopsy in the identification of men who might be appropriate for active surveillance might well be valuable in individual cases. Whether it would be valuable en masse (i.e., in the work-up of every patient who might be a candidate for active surveillance) is a rather different question. Then one has to start asking how good the equipment being used is, how much experience the users of the equipment have, how much experience the readers of the scans have in reading the MRIs, whether the overall increase in cost is justified, and to what extent the additional information actually changes the clinical decisions of the physicians and the patients. That can get complicated very fast.

  4. I find it most interesting that 56% of the men showed “no” evidence of prostate cancer on re-biopsy! Makes you wonder if they were mis-diagnosed originally, or if the prostate cancer was just missed on the second biopsy, or did it just vanish?

    (On self-managed AS since 04/2010.)

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