NEW YORK — National guidelines recommend conservative management for men with low-risk prostate cancer, but concern about misclassification and other issues could lead patients and physicians to pursue treatment. Recent in diagnosis and monitoring at the VA could simplify the decision for veterans.
“There’s been a ton of progress in terms of prostate cancer care in the VA across the whole spectrum from diagnosis to advanced disease,” said Stacy Loeb, MD, MSc, urologist and prostate cancer researcher at the Manhattan VAMC, assistant professor of urology and population health at NYU Langone, and host of “The Men’s Health Show” on SiriusXM.
For men with suspected or newly diagnosed prostate cancer, in particular, better imaging and more reliable biopsies have made a tremendous difference.
“At the VA, we have the newest equipment for targeted prostate biopsy, which is far superior to the traditional method,” she said. “Traditionally, prostate biopsy was not performed at a targeted lesion. We would do six needle samples on the left and six on the right around the prostate, which was very different from the approach to other solid tumors.”
She compared the accuracy of that method of biopsy to finding a bad section in a rotting apple. “If the entire apple is rotten, the 12 needles will hit it. If half is rotten, presumably some will hit, but if just a small portion is bad, the needles may not hit it at all,” Loeb said. “Consequently, prostate cancer biopsy had a lot of sampling errors. We simply didn’t have good enough imaging to see prostate cancer tumors at an early, curable stage.”
The transrectal ultrasound-guided biopsy Loeb described had a false negative rate of about 34% and a relatively high rate of detection of clinically insignificant disease.
In contrast, targeted prostate biopsies use multiparametric magnetic resonance imaging combined with real-time ultrasound to sample suspected tumors. “With advances in prostate MRI, we can now identify suspicious appearing areas in the prostate and target those areas in biopsy, just as in breast cancer,” she said.
A recent meta-analysis showed that the multiparametric MRI/ultrasound fusion biopsy had a 91% sensitivity for detecting significant prostate cancer and avoided low-risk prostate cancer twice as well as the TRUS biopsy.1
The higher resolution MRI has also simplified conservative management of prostate cancer in men at low risk for progression. Instead of requiring frequent biopsies, MRIs can be used to detect and monitor clinically significant lesions, Loeb noted.
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