What’s your opinion on targeted biopsy for prostate cancer?

Dr. Spitz“The evidence coming out of the centers of excellence for these newer biopsy modalities is demonstrating a better yield at finding cancers that may have remained elusive, as well as predicting patients for whom the prostate cancer is not clinically significant, and therefore helping avoid many biopsies as part of screening and active surveillance. 

There is still a bit of time for more data to accumulate and the learning curve to be satisfied to where there is more confidence in interpreting the images so as to more safely and more competently predict which patients would not actually need a biopsy. Currently, many patients will continue to receive a similar number of biopsies, but before too long, we will be able to exclude patients from biopsies that as of now we’re not.

We will have the equipment in our office within the year. A couple of our urologists have undergone training, and I have a colleague at UC Irvine who I’ve referred several patients to receive the Artemis biopsy so I have that level of familiarity with it. I am looking forward to it. I think it will get better and better as we have more experience with it. As we get more data, I think it will really be a powerful diagnostic tool.”

Aaron Spitz, MD

Orange, CA

NEXT: "It is a positive thing."

“It is a positive thing. The technology we’re using now is not accurate. There is a significant chance of missing cancer. MRI has the potential of increasing the probability of finding a clinically significant cancer, so it does have a bright future to help diagnose prostate cancer and as a tool for surveillance of known prostate cancers. Currently, active surveillance depends upon repeat biopsies, digital rectal exams, and PSAs; MRI may help avoid unnecessary repeat biopsies.

It may also make screening more appropriate by differentiating significant from insignificant cancers.

Urologists will have to learn to use the MRI, especially if they will integrate it with their biopsy technique.  I don’t plan to purchase the equipment to fuse the MRI and ultrasound unit, but I suspect most hospitals and large urology groups will do so.

The technology is new and it’s evolving, but my gut sense is that it’s going to become the standard.”

Alan J. Stein, MD

Alton, IL

NEXT: "Eventually, I think all patients will be getting MRI/ultrasound fusion biopsies before other biopsies to resolve their biopsy status."

Dr. Poole“We started doing targeted biopsies in December, mainly for patients who had previous negative or low-grade cancer biopsies who were on active surveillance. Then we added a few patients who were biopsy naïve. Eventually, I think all patients will be getting MRI/ultrasound fusion biopsies before other biopsies to resolve their biopsy status.

We do the 12-core random biopsy as well as the targeted biopsy. NYU and some other places have gotten so good at reading MRIs that if they have a negative MRI, no matter what the PSA, they may skip the biopsy because they have that much confidence in the MRI.

Eventually, I think that will be the goal. The MRI/ultrasound fusion is another risk stratification tool. The MRI doesn’t tell you for sure whether you have cancer, but if you have a negative MRI and the 4K score is negative, the patient may possibly safely forgo a biopsy. But I made it clear to my partners, if they still had a suspicion a patient might have cancer, not to just rely on the MRI. If they wanted to do another biopsy, do another biopsy.

It’s going to take a lot of experience for the radiologist and urologist getting comfortable reading films to determine what looks benign and what looks malignant.

After the first hundred patients, we found that about 40% of the men who had a previous negative biopsy had cancer. That number is even higher where they do targeted biopsies on everyone.

The targeted biopsy is much better at detecting the Gleason 7s and higher. Gleason 6s are somewhat invisible to the MRI, which is good because you may not want to detect those. You will find more of the significant cancers and fewer of the Gleason 6s, which changes everything because at Gleason 7, patients usually go on to some type of treatment.

This is how things evolve when it comes to treating cancer. We used to do radical prostatectomies; now it’s robotic prostatectomy, and just around the corner-some people are doing it in clinical trials-is focal therapy. The MRI is going to be critical in identifying the size and location of lesions. We could potentially go in and just treat that area with cryotherapy or laser or other techniques for doing focal therapy. The jury is still out, but I think that’s coming. Big things are around the corner, and the MRI is really going to help jumpstart that.”

Bryant Poole, MD

Homewood, AL

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