Good PSA/MRI active surveillance results still require fusion biopsy?

You are in a confusing situation. Active surveillance is used when the Gleason score is a six because that’s not really considered cancer (a doctor meeting recently trying to change the nomenclature).. The problem is at any time the tissue can become cancerous. The only way to find out is to do additional biopsies.

A high PSA alone can happen without cancer being active. I know someone who’s PSA went up to 50, he had more than one biopsy and it was never cancerous.

Some people can be on active surveillance for many years and they never get to the point where they needed to be treated for cancer. I have recently heard from someone who had their biopsy shows that they have a Gleason eight even though they had only been on active surveillance. Things can happen quickly and you want to be on top of it.

At least the fusion biopsy allows them to look in spots that are suspected of being a problem. You really don’t want to wait until your tissue becomes highly cancerous,, better to get occasional biopsies. My brother was on active surveillance for six years, then his biopsy showed he was 4+3 a Gleason 7. Time for treatment.

My situation is quite similar to your situation:

06/17/2022: PSA = 5.0
11/01/2022: PSA = 5.1
05/31/2023: PSA = 7.8

10/01/2023: mpMRI found three lesions
Lesion#1 - 2.1 x 1.1cm PI-RADS 5
Lesion#2 - 0.7cm PI-RADS 4
Lesion#3 - 0.9cm PI-RADS 3

10/16/2023: MRI Fusion guide biopsy of 15 cores, found:
5 cores w/5%-10% (3+3)
2 cores w/20% (3+4) involving 10%-20% pattern 4
Decipher Score = 0.22 (Luminal A - Differentiated)
Clinical-Genomic Risk Model dropped risk from “Favorable Intermediate” to “Low Risk”
- AS recommended

11/01/2023: Began running three 5K’s (~9 miles) per week and prostate healthy diet.

02/06/2024: Lost 25 lbs since 10/16/2023 biopsy and PSA = 5.95
05/15/2024: PSA = 5.87 & 6.57 (taken 15 minutes apart – different labs)
08/14/2024: PSA = 6.20
10/11/2024: PSA = 6.81

10/16/2024: mpMRI found:
Lesion#1 reduced to 1.9 x 1.1cm with “T2 hypointense focus” reduced to “mild T2 hypointense focus”” and DWI/ADC signal reduced from “moderate abnormal” to “mild abnormal”
Lesions#2 and #3 could no longer be “visualized” in follow-up MRI (suggesting potential regression).

I will be discussing my latest mpMRI with my urologist in my upcoming appointment in 7 weeks.

In the interim I formulated all my PCa data and information into a complex and lengthy question at https://www.perplexity.ai and received a comprehensive answer, complete with many referenced sources, that can be summarized as:

“The reduction in size and decrease in signal abnormalities suggest a potential stabilization or minor regression of Lesion#1, which is generally associated with a better prognosis.

"The changes observed align with lower PRECISE scores (1-3), which have a high negative predictive value for disease progression.”
https://www.europeanurology.com/article/S0302-2838(24)02232-2/fulltext
“The observed changes support continuing active surveillance, as they suggest a stable or slightly improving condition."

"Regular follow-up mpMRIs and possibly repeat biopsies will be crucial to monitor for any future changes or progression."

My urologist has already suggested that he will only recommend another biopsy IF the non-invasive testing suggests progression. In other words, I don’t expect him to recommend another biopsy (at this time), based on my current status.

In my case, my Decipher score played a large part in my decision to pursue AS AND I believe my aerobic exercise program is the primary reason for the stable to minor regression observed during the past year (based on multiple RCTs demonstrating the benefits of aerobic exercise in slowing PCa progression).

I will be continuing my AS plan for another year, without undergoing another biopsy.

All the best with your decision.

jeffmarc, thanks for your reply-
Yes: "confused" is where I'm at trying to understand all this.
This progressing could require far more invasive procedures than a biopsy, but recent PSA's of 3.7 then 1.9 along with my stable/unchanged MRI after 14mos lead me to question whether wanting another biopsy regardless of the good results is an extremely conservative decision by my urologist, possibly driven by desiring protection against malpractice litigation(?) I need a better understanding of the risk rolling with current results and avoiding the biopsy -and also don't understand why other less invasive testing (free PSA, MiPS, etc) not considered first, to collaborate the good results.
Not cool with having another biopsy just to check that box when everything else indicates no advancement -unless for some reason that's justifiable regardless of my good test results.

handera, thanks for your reply-
Was your exercise/diet for prostate health prescribed by your urologist? I'm active (though don't run 3 wkly 5K's!), and in good health. My urologist provided no exercise/diet recommendation for prostate health.
You posted:
"My urologist has already suggested that he will only recommend another biopsy IF the non-invasive testing suggests progression. In other words, I don’t expect him to recommend another biopsy (at this time), based on my current status. "
-very useful info -similar scenario with a reasonable biopsy trigger IMHO!
May I ask your age?
Thanks again-

With your PSA down to 1.9 it does seem like a biopsy could be delayed. Have you asked your doctor why with a 1.9 PSA he doesn’t think you could wait, at least until your PSA starts rising again.

I think his concern is about this “ 19% likelihood of adverse pathology at Radical Prostatectomy". He might want to check other areas of the prostate to see if there is an issue.

It’s always your decision, see what he has to say about the fact that your PSA has dropped so much.

I'm 68 y/o, diagnosed with PCa at 67 y/o...close to your age.

My urologist did not prescribe my exercise/diet program; however, he knows all about it and has been generally encouraging.

I would be surprised if any urologist would "prescribe" an exercise/diet plan...they are usually not trained in this area and "exercise/diet plans" have the disadvantage of taking a lot of time to personalize and require dedicated effort over a long period of time (years)...not things the medical establishment or most Americans are inclined to accept, much less implement.

A quick decision to surgery, radiation and/or drugs are easier to prescribe and implement (not to mention...more profitable). Don't get me wrong, these things definitely have their place for PCa in the "Unfavorable Intermediate Risk", stage or worse.

However, it's also abundantly clear, from the scientific research, that AS is the most appropriate decision for those diagnosed with "Low Risk" PCa. The problem is more of a psychological one...some men simply stay freaked out upon being diagnosed with a condition that has the word "cancer" associated with it..even if "low risk".

I'm a retired chemical engineer who spent most of my 45 year ChE career doing scientific research. I've probably read and studied more than many urologists, regarding exercise/diet for PCa...it's an inherent weakness in the practice of Medicine 2.0...read "Outlive", by Dr. Peter Attia for a comprehensive treatise...https://peterattiamd.com/outlive/

I'm not naive enough to believe that any particular exercise/diet program will cure PCa...the research does not support that conclusion. However, there are hundreds of studies and 6 random control trials demonstrating aerobic exercise slows down the progression of PCa. A good meta study to begin with can be found here https://www.nature.com/articles/s41391-024-00801-7

At the end of the day, every man decides (or allows another to decide for him) as to what level of risk they are willing to accept.

All the best with your decision.

jeffmarc, thanks for your reply -and I agree w/your recommendation.
Based on the good results, I was disappointed at the MRI follow-up appt. when my urologist said the biopsy was still necessary and passively let them know that. I was surprised, and therefore not prepared to ask for details regarding the basis for their decision to proceed with scheduling the biopsy -I let it roll.
Then, after the 2nd PSA test for my annual GP physical lowered from 3.7 to 1.9, I have messaged the office twice in the past 2wks regarding that and asking for a "shared decision-making" explanation for why the biopsy is still necessary: No response. First biopsy appt. is soon, therefore plan to call the office tomorrow -and the reason why I came here for more perspective.
I greatly appreciate the prompt responses - impressed with this forum so far!

handera, thanks for your follow-up, details, and links-
I respect your engagement taking on your own research and exercise/diet program, and hope that you continue seeing positive results.
I'm aligned with your comment regarding quick decisions on surgery/radiation/drugs and the potential related profit motive. I do have a somewhat cynical nature. I've seen this urologist for 5yrs -have high regard for them but at the same time don't know to what degree they may be pushed to do biopsies for profit and/or malpractice protection.
As you say, the level of acceptable risk is ultimately up to me -I greatly appreciate the perspective provided here and plan to have a detailed discussion w/my urologist regarding the risk regarding postponing the biopsy.
I'm perfectly fine with AS -only think about this when appt's come up, and have had no panic from the start. I fear a diminished post-treatment life (if treatment ends up req'd) more than I fear death. Just how I am.
Thanks again-

Understand your concern regarding your urologist's push to schedule another biopsy.

You may make him feel more comfortable with waiting on a follow-up biopsy, by pointing him to pages (47-51) of the NCCN Prostate Cancer guidelines Version 4.204 - May 17, 2024.

Specifically:

"Active Surveillance Program:
Patients who choose active surveillance should have regular follow-up, and key principles include:
◊ PSA no more often than every 6 months unless clinically indicated.
◊ DRE no more often than every 12 months unless clinically indicated.
◊ Repeat prostate biopsy no more often than every 12 months unless clinically indicated. While the intensity of surveillance may be tailored based on patient and tumor factors (eg, grade, tumor volume), most patients should have prostate biopsies every 2 to 5 years as part of their monitoring."

Note that every 12 months is the MOST often recommended and NCCN indicates that the majority on AS should have repeat biopsies every 2 - 5 years!

I could only wish my PSA level was down to 1.9 AND that only 1 of 18 cores showed 3+3 Gleason involving 10% of the tissue...that's amazing! I'm perfectly comfortable waiting another year (or longer) for another biopsy with my much higher prior indications...as you have seen.

It took 8 weeks for me to fully recover from my October 2023 biopsy to get back to my "pre-biopsy" performance. It was not a "minor procedure" and had significant impact.

Interestingly, in my last appointment, my urologist slipped in a comment that the reason he waits for clear non-invasive evidence demonstrating the need for a follow-up biopsy because of "increased risk"...I didn't ask for further explanation, but I appreciated his comment... he does not jump to do another biopsy simply because of the clock.

BTW: I have not (yet) had this following test, but it might be worth considering as an "up-and-coming" non-invasive alternative to biopsy. I plan to ask for this test before submitting to another biopsy.
https://www.lynxdx.com/my-prostate-score/patients/

handera, you're an amazing wealth of info!
We apparently have similar perspectives regarding avoiding a needless biopsy -I need my urologist to provide a very good reason to endure another before that 2-5yr NCCN timeline.
Your NCCN link requires creating an account -assume no privacy issue/etc doing that?
Also appreciate MPS2 test link. Rather than proceed with a biopsy with MRI/PSA results that don't seem to require one, I'd prefer more tests (ie: aforementioned free PSA/MiPS, etc.)
Hope that my urologist will adopt your urologist's requirement for "clear non-invasive evidence demonstrating the need for a follow-up biopsy". I like that policy.
You and jeffmarc have made me glad that I selected this forum after looking at my options.
Thanks-