Prostate Cancer: Are We Over-Diagnosing—or Under-Thinking?

Transrectal prostate biopsy

Grayscale transrectal ultrasonographic prostate biopsy using local anesthesia remains the standard approach to the definitive diagnosis of prostate cancer. Careful patient evaluation and preparation are essential to maximize the results and minimize the complications of the biopsy procedure.

Prostate cancer detection after a negative prostate biopsy: lessons learnt in the Cleveland Clinic experience

Urologists are often faced with the dilemma of managing patients with a negative initial prostate biopsy in whom clinical or pathological risk for prostate cancer still exists. Such real-life challenging scenarios might raise questions such as: Who should undergo further biopsies? What are the optimal predictors for prostate cancer on subsequent biopsies? What is the optimal biopsy protocol that should be used? When to stop the biopsy cascade? The last decade has witnessed numerous studies that have analyzed factors conferring a significant risk for cancer discovered on repeat biopsies. We and others have developed predictive models to aid decision-making regarding pursuing further biopsies. For decades, high-grade prostatic intraepithelial neoplasia has been considered a strong risk indicator for subsequent cancer. However, it has been recently shown that only through segmentation of this heterogeneous population does the real risk profile emerge. Biopsy templates underwent modification regarding the number and location of cores with emergence of the transrectal or brachytherapy grid transperineal saturation biopsy. However, the best biopsy protocol remains controversial. We have refined the initial biopsy template to a 14 core initial biopsy template that optimizes cancer detection, and have shown that transrectal saturation biopsy significantly improves cancer detection for repeat biopsy. Another concern is the overdiagnosis of clinically insignificant cancer on repeat biopsies, so we explored ways to limit this, and to deal with its ramifications. Through carrying out a Medline literature search, we critically evaluated pertinent articles together with emphasis of our own journey in this arena to assist in the decision-making process for repeat biopsy population.

Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature

CONTEXT

The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate.

OBJECTIVE

Our aim was to review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy.

EVIDENCE ACQUISITION

A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Results were restricted to the English language, with preference given to those published within the last 3 yr.

EVIDENCE SYNTHESIS

At initial biopsy, a minimum of 10 but not >18 systematic cores are recommended, with 14-18 cores in glands ≥ 50 cm³. Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (≥ 20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3-6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound-guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative.

CONCLUSIONS

The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.

Active surveillance or active treatment in localized prostate cancer?

BACKGROUND

At present, one in six men over age 50 carries the diagnosis of prostate cancer, but only one in 33 will die of the disease. In view of these facts, conservative strategies such as active surveillance (AS) are important in the management of prostate cancer.

METHODS

To obtain information on active surveillance, the Medline database was searched from January 2002 to April 2008 for the terms "prostate cancer" OR "prostatic neoplasms," AND "active surveillance" OR "expectant management". In addition a manual search was performed in the reference lists of relevant publications on the treatment of prostate cancer and on active surveillance.

RESULTS

88 relevant publications about active surveillance were found. The studies varied in methodological quality but consistently showed low rates of tumor progression and high rates of tumor-specific survival with active surveillance (99% to 100%). All 7 guidelines on the treatment of prostate cancer that have been published since 2006 list active surveillance in their recommendations as a therapeutic option for prostate cancer if there is a low risk of progression. In fact, the National Institute of Clinical Excellence (U.K.) recommends the active surveillance exclusively as the treatment strategy for such cases.

CONCLUSIONS

The guideline recommendations reflect a changed attitude toward the treatment of prostate cancer in the light of the early detection of these tumors and the data now available regarding active surveillance. A corresponding change in actual medical practice would be desirable. The treatment of prostate cancer should always be adapted to the individual needs of the patient, and risky treatments should only be used when absolutely necessary.