Repeat Biopsy is the Key to Active Surveillance

Epstein: Without repeat biopsy, cancer can be missed.

You may be one of the lucky guys whose prostate cancer never needs to be treated. Then again, what if you choose active surveillance — monitoring the cancer closely for any sign of change — and the cancer develops more rapidly than anyone expected?

You need a yearly follow-up biopsy, says Jonathan I. Epstein, M.D., the Rose-Lee and Keith Reinhard Professor of Urologic Pathology. “Obviously, nobody wants to over-treat very low-risk prostate cancers,” he says, “but the repeat biopsy is essential to help detect cancers.”

Hopkins is one of the few centers in the world where repeat biopsies are a routine part of the active surveillance program.

Some aggressive cancers are
so small that they don’t make
enough PSA to set off any
warning bells on a blood test.

In recent research, Epstein studied the surgical specimens of 48 men who were being closely monitored, but whose cancer eventually progressed and needed to be treated with radical prostatectomy. “We made three important findings,” he says.

They are:

  • Repeat biopsy can detect changes even in tiny bits of cancer. “We showed that we can follow men with very limited cancer on our active surveillance program, and when they show more advanced disease on repeat biopsy, most of them still have curable disease when they undergo radical prostatectomy.”

  • Size doesn’t matter. Years ago, Epstein showed that very small tumors can be fairly aggressive. These cancers are so small that they don’t make enough PSA to affect the level noticeably — which means a blood test alone would not set off any warning bells that the cancer had changed. “Without repeat biopsy, they may not have been detected until they were too advanced.”

  • We know where the cancers are most likely to be overlooked. “The largest tumors in our study that were missed on active surveillance were in the anterior (front) part of the prostate,” says Epstein. “This would be missed, or difficult to sample, on a routine prostate biopsy and would be impossible to feel on a digital rectal exam.” Because of these findings, Epstein has modified the protocol for repeat biopsy in men undergoing active surveillance, to make sure this tricky part of the prostate gets adequately tested. Which means that “men on active surveillance can be monitored more effectively than ever.”

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