New consensus statement on monitoring for prostate cancer risk after a first, negative biopsy

There has been no really clear and formal guidance available on how to monitor patients for risk of prostate cancer after a first, negative, standard, 12-core, systematic biopsy. New guidance from the American Urological Association (AUA) and the Society of Abdominal Radiology (SAR) may be helpful in addressing this situation.

Exactly how each individual patient who may still be considered to be at risk for prostate cancer should be monitored after a first, negative biopsy is clearly going to vary a great deal from patient to patient. The patient with a PSA of 25 ng/ml and a father who died with or from metastatic prostate cancer  is rather obviously is a very different category compared to a man with a stable PSA of 3.5 ng/ml and no other indication of risk.

However, the most important development that is now recommended in the joint consensus statement is about the role of prostate-specific MRI scanning and MRI-targeted biopsies in appropriately selected patients believed to be at risk for prostate cancer after a prior, negative biopsy. For the full text of this new consensus statement, please click here.

Fundamentally, the joint panel of the AUA and the SAR is stating that it recommends the use of prostate-specific MRIs and MRI-targeted biopsies “for any patient in whom prostate cancer is suspected, despite a prior negative biopsy, and who is under evaluation for a possible repeat biopsy.” However, …

One of the problems that the panel acknowledges in making this recommendation is “a lack of standardization of image quality and individual radiologist’s interpretation abilities.” They go on to note that,

As of this writing there is no formal mechanism for radiologists to become certified in prostate MRI interpretation, nor an established number of examinations that must be interpreted for radiologists to achieve sufficient experience.

The panel’s chairman is quoted as stating that

… if expertise is lacking, the proposed clinical usefulness of prostate MRI is unlikely to be achieved, and misleading information and harmful consequences are possible.

The consensus statement addresses a range of related issues, including:

  • Cancer detection rates using MRI targeting
  • Which patients can benefit from MRI methods
  • Specific techniques and methods and other related factors in the conduct of MRI-targeted biopsies
  • When patients should undergo immediate repeat biopsies after MRI
  • What follow-up should be done after a negative MRI-directed biopsy result

In addition, the statement recommends

  • Adherence to Prostate Imaging Reporting and Data System (PI-RADS) Version 2 and strict quality standards
  • The potential usefulness of MRI/TRUS fusion or so-called “in-gantry” or “in=bore” MRI targeting technologies (even though visual targeting may remain a reasonable approach for some physicians with extensive skill and experience)
  • Close clinical and laboratory surveillance when deferring repeat biopsy based on MRI findings.

The “New” Prostate Cancer InfoLink welcomes this new, joint consensus statement from the AUA and the SAR, while also recognizing that access to high-quality, prostate-specific MRI scanning is not yet widespread outside major urban centers, and, as noted by the panel, there are still a limited number of radiologists (and very few urologists) who have a high level of skill and experience in “reading” this type of prostate-specific MRI scan.

We have a ways to go before the appropriate use of high-quality MRI scans and MRI targeting could be expected to become a routine exercise in the diagnosis of prostate cancer — even if only among men who have already had a first, negative, systematic biopsy.

3 Responses

  1. Great to see teamwork and collaboration among the specialties.

  2. New guidance from the American Urological Association (AUA) and the Society of Abdominal Radiology (SAR)

    Of course those organisations with their conflicts of interest are going to recommend ongoing testing of men who, if they were initially picked up with PSA screening as is most likely, should never have been given PSA screening in the first place. PSA screening is an unproven strategy which has never been shown to produce an improvement in overall survival compared with usual care but motivates a lot of harmful treatment.

    The “New” Prostate Cancer InfoLink welcomes this new, joint consensus statement

    How can you welcome such a conflicted statement for something that will cause physical, psychological, and emotional cost in terms of complications, side effects, quality of lives and even increased risk of death from CVD and other causes that will add to the millions of men who never needed to be treated but were as a consequence of PSA screening? Your welcoming of this statement demonstrates clearly to me that you have either no or almost no appreciation of the devastating effects of those “side effects” on many men and their families. This is not about a few “side effects”, it is about 30 years of major loss of quality of life. The two things aren’t even close to comparable.

    Apparently you have absolutely no understanding of the simply massive size of that cost. If you don’t understand that cost (for whatever reason), then clearly you are not going to understand why a lot of people, including other patients (and not just me) had such a viscerally negative reaction to your support of this statement and the PSA based screening in any unproven form that leads to this statement.

  3. Dear Chris:

    Since we have said, over and over again, that we do not believe there are — at this time — any data to support the idea of mass screening for risk of prostate cancer, you are clearly misunderstanding why we support this statement from the AUA/SAR.

    We support it because if a patient and his doctor believe that a repeat biopsy is advisable for a specific patient based on his individual presentation, then it almost certainly should be done only after an MRI scan and under some form of MRI or MRI/TRUS guidance. Please understand that this is very different from (a) whether any biopsy in any specific patient is necessary at all and (b) whether any patient needs treatment based on the results of such a biopsy.

    There is no implication in our support for this statement that we think screening is a good idea. Nor is there any implication in our support for this statement that we think all the repeat biopsies that have been given in the past were either a good idea or necessary.

    As we carefully noted in the second paragraph of the commentary, the range of patients for whom a repeat biopsy might be considered is vast. We are not in the business of deciding which of those patients actually need a repeat biopsy. That’s up to an individual patient and his doctor.

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