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

Recommendation not to use MPS 2.0 for those on AS seems conservative. Understand that testing for those on AS is not completed, but seems logical to expect similar good results that could help those on AS avoid additional biopsies.
Encouraged by what appears to be a growing list of good alternatives to avoid biopsies- (personal goal of mine!)

OP here -update after my appt. Urologist:
Agreed that >30% of MRI-diagnosed PI-RADS-5 determined benign by biopsy, and that typically inflammation mimics PCa.
Agreed that MRI-guided biopsies are very accurate.
Said my new low PSA result is disregarded b/c already diagnosed w/cancer.
Agreed that my 2nd MRI after 14mos showing stable/no change is a very good sign.
Regardless, needs 2nd biopsy within 18mos. to provide a confident diagnosis.

They expect the 2nd biopsy to confirm, as 1st biopsy did, that MRI results are wrong/not cancer.
Assuming verified not cancer: no more biopsies, start monitoring PSA again.
So, proceeding while hoping it will be my last biopsy -for now anyway.
Still seems very conservative. Since they are set on the biopsy, rolling with it and hope for good news.

Thanks again for all your replies. I appreciate the engagement on this forum.

Interesting observations by your urologist!

I did find another study that attempts to specifically answer your question.

Harvard Health Publishing summarizes the results of a 3 year study here:
https://www.health.harvard.edu/blog/prostate-cancer-can-imaging-substitute-for-repeat-biopsies-during-active-surveillance-202210072825
“ Upon analyzing the results, the team found that mpMRI scans were better at ruling out cancer progression than at detecting it. Specifically, the odds that an mpMRI scan would detect clinically significant cancer (the kind that needs more immediate treatment) that a biopsy would later confirm ranged from 50% to 57%. By contrast, the odds that a scan would correctly show the absence of worsening cancer ranged between 82% and 86%.

Based on these results, the investigators concluded that men with negative mpMRI scans can safely omit the one-year confirmatory biopsy. However, men should still get a standard three-year biopsy, they wrote, "due to occasional MRI-invisible tumors." The team plans to follow the men and present 10-year data at some point in the future.”

Others are still taking a more conservative approach:

"This study adds to better understanding the utility of mpMRI in the continued evaluation of men on active surveillance," says Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center. "The upside of the study is that more biopsies can potentially be avoided. The downside is for patients to understand that the MRI is not an equal substitute for biopsy: a negative MRI finding may have missed a clinically significant cancer. In my own practice, I have used MRI to monitor men, along with digital rectal examinations and PSA evaluations on active surveillance instead of repeated biopsies, but only with the patient's full understanding that a small number of potential clinically significant cancers may not be detected by this practice."

Sounds like your urologist is in the later camp.

Here’s a link to the paper and the “final analysis” conclusion.
https://www.auajournals.org/doi/10.1097/JU.0000000000002885
Conclusions:

“Final analysis of the Magnetic Resonance Imaging in Active Surveillance trial indicates that there is minimal risk to omitting 1-year confirmatory biopsy during active surveillance if baseline magnetic resonance–targeted + saturation template biopsy was performed; however, standardized 3-year systematic biopsy should be performed due to occasional magnetic resonance imaging–invisible tumors.“

All the best!

I just heard a lecture from Dr. Klotz at the PCRI conference in September where I believe he said MRI invisible tumors are indolent and of no concern.

Thanks Handera-
My urologist said there's no suitable alternative to the biopsy, and that not having the 2nd biopsy was not considered an option. The carrot was their perception that the 2nd biopsy is expected to confirm MRI false positives. That would mean no more biopsies for now, so maintaining a positive perspective.
I hold my urologist in high regard -based on their firm stance, would have been hard to decline the 2nd biopsy.

That said, their communication could have been better regarding AS-related projections/expectations based on my results. Also wish they'd provided perspective on MRI and biopsy accuracy, and the studies regarding what IMO is a high proportion of MRI false positives. I had to go down the Google Rabbit Hole to learn about that, including your help here.

Hope for all our benefit that continued research leads to improvements that provide much more accurate testing, and fewer biopsies.

oct172024,

Agreed that there is "no suitable alternative" to the biopsy, however, the investigators of this 3 year study concluded that men with negative mpMRI scans can safely omit the one-year confirmatory biopsy, BUT should still get a standard three-year biopsy.

Your urologist simply disagrees on the timing...that's his prerogative and I'm glad to hear you hold him in high regard and intend to follow his recommendation.

The good news is that there is an extremely high likelihood (at least 82% - 86% - but probably higher because of your very low PSA level) that you'll get additional confirmation from a 2nd biopsy, at this time, that nothing has changed.

BTW: What do you attribute your very low PSA level, as compared to those taken prior to your 1st biopsy? I think the PCa patient probably has a better sense of the reason(s) for their lower PSA level, in their particular case, after a PCa diagnosis.

Good Q.
Maybe the PSA that spiked to 9 and started this journey was false/lab error.
Or maybe was inflammation-related, since that's what "lesions" on MRI's could actually be?
Also, read that dehydration can affect PSA.
If 2nd biopsy confirms no PCa, then I question the 9 PSA.

After last year's biopsy, my urologist said PSA no longer needed b/c PCa diagnosed.
Very glad that I ignored that by requesting PSA with recent blood panels, and getting the 3.7 and 1.9 results. Those results support my MRI being stable/unchanged after 14mos.

Was thinking today about a friend who's a GP that told me they don't get PSA tested. Years ago their father had a prostatectomy that messed up their life, and the GP apparently decided that something else will eventually alert them to PCa if serious enough to require treatment.
A personal decision that I found very interesting -what I was thinking today: assuming 2nd biopsy confirms "no PCa", I could have avoided all this if I also didn't have PSA tests!
Regardless, glad that I test PSA despite all the mental gymnastics/tests over the past 18mos.

Interesting comment...."urologist said PSA no longer needed b/c PCa diagnosed". My urologist indicates the complete opposite....get a PSA test at least every 3 months.

I've had 5 PSA tests between February and October, averaging 6.3. One morning in May I was tested at two different labs within 15 minutes of each other...5.87 and 6.57...a clear indication that any particular number is at least +/-0.35.

PSA doesn't exactly correlate to PCa progression, but it's a fairly good (and low cost) proxy....especially when combined with annual mpMRI's.

In my 1st year after diagnosis, frequent PSA checks allowed me to investigate the short-term efficacy of various changes in my exercise/diet protocol.

Found two significant noninvasive test changes in 12 months:

1) PSA dropped from 7.8 (prebiopsy) to 6.0 (four months after biopsy) and has stayed fairly constant (averaging 6.3) ever since.

2) Second mpMRI (same machine, same radiologist) indicated lesions had either disappeared or shrank and the T2 hypointense focus and the DWI/ADC signal were both downgraded from "moderate" to "mild".

Regarding a confirmational biopsy, I plan on going with the recommendation of the expert physician investigators who spent three years studying the question - if PSA and/or mpMRI tests show progression get a biopsy or no later than 3 years from initial biopsy.

I have 2 more years (assuming no progression) for the PCa community to find a SUITABLE alternative to repeat biopsies for AS patients.

All the best in your upcoming biopsy...I'll be praying for a no PCa detected outcome....keep us posted!

Agree regarding my urologist's apparent PSA double-standard, for the same reason. I let it slide at my appt, but if the 2nd biopsy leads to further adventures that will be a topic for discussion.

If my 2nd biopsy was not promoted as expected to disprove the PCa diagnosis, I'd also have pushed back regarding using the longer time span before the 2nd biopsy.

You're a great example of the importance for patients or their rep to educate themselves and be engaged advocates to get the best care. Based on my experience advocating for a relative and for my own care, it's absolutely necessary these days.

Glad that your engagement has led to encouraging test results. Good to know that after diagnosis, it's not uncommon to go many years on AS with no impact on leading a normal life. And, as you noted: more time means more testing and treatment breakthroughs are possible.

Should have biopsy results late November -plan to provide an update.
Thanks again -hope your good trend for test updates continues!

pdcar4756,
Thanks for your post! Just listened to Dr. Laurence Klotz lecture and the follow-up Q/A (2024 PCRI conference). You can find it at 1:36 - 2:50 in the video here https://pcri.org/2024-conference

Dr. Klotz is one of the "fathers of AS", with 25 years of AS experience. Anyone considering or participating in AS would benefit from this lecture and also the follow-up Q/A.

The fact that PCa tumors, that don't show up on a MRI are indolent, don't metastasis and don't result in PCa specific death is depicted in the attached summary slide.

This Sloan-Kettering study stratified 1449 men who had RP, due to GG2 or greater, based on their MRI PIRADS score according to the observed level of BCR, metastasis, PCa specific mortality and other-cause mortality.