UCLA Study Finds New Way to Select Prostate Cancer
Patients for Active Surveillance
Too many men in surveillance programs find their
cancer more aggressive than they had assumed – see video
Targeted Prostate Biopsy using MR-Ultrasound Fusion
May 19, 2014 - Too many men with prostate cancer
are opting for “active surveillance” and later finding their cancer is
more aggressive than earlier assumed. UCLA researchers say they have a
better way of determining which patients should be selected for the
More and more men who believe they have low-risk
prostate cancer are opting for active surveillance – avoiding immediate
treatment and watching for signs of cancer growth with prostate-specific
antigen (PSA) tests, digital rectal exams and regular ultrasounds. But
the methods used to determine which men should be in active surveillance
are being challenged by UCLA researchers who see too many men
discovering they have more aggressive cancers than assumed.
The new UCLA study indicates selection of men for
active surveillance should be based not on the widely used conventional
biopsy, but with a new, image-guided targeted prostate biopsy. The new
biopsy method, pioneered by a multi-disciplinary team on the Westwood
campus, is now a routine part of the UCLA active surveillance program.
Nearly 400 men are now enrolled in the UCLA Active
Surveillance program, the largest in Southern California.
UCLA researchers found that conventional "blind"
biopsy failed to reveal the true extent of presumed low-risk prostate
cancers, and that when targeted biopsy was used, more than a third of
these men had more aggressive cancers than they thought.
Their aggressive cancers were not detected by
conventional blind biopsy using ultrasound alone, and the men were
referred to UCLA's active surveillance program thinking they were at no
The study appears in the May 19, 2014 issue of the
peer-reviewed Journal of Urology.
The targeted biopsy method, under study at UCLA
since 2009, is performed by combining magnetic resonance imaging (MRI)
with real-time ultrasound, a method of fusion biopsy, in a device known
as the Artemis.
Previous work from UCLA demonstrated the value of
the new procedure in finding cancers in men with rising PSA who had
negative conventional biopsies. This study is the first to show the
value of using it early in the selection process for men interested in
"These findings are important as active
surveillance is a growing trend in this country," said study senior
author Dr. Leonard Marks, a professor of urology and director of the
UCLA Active Surveillance Program.
"It's an excellent option for many men thought to
have slow-growing cancers. But we show here that some men thought to be
candidates for active surveillance based on conventional biopsies really
are not good candidates."
Marks and his team identified 113 men enrolled in
the UCLA active surveillance program who met the criteria for having
low-risk cancers based on conventional biopsies. Study volunteers
underwent an MRI to visualize the prostate and any lesions. That
information was then fed into the Artemis device, which fused the MRI
pictures with real-time, three-dimensional ultrasound, allowing the
urologist to visualize and target lesions during the biopsy.
"Prostate cancer is difficult to image because of
the limited contrast between normal and malignant tissues within the
prostate," Marks said. "With the Artemis, we have a virtual map of the
suspicious areas placed directly onto the ultrasound image during the
biopsy. When you can see a lesion, you've got a major advantage of
knowing what's really going on in the prostate."
Of the 113 volunteers enrolled in the study, 41 men
- or 36 percent - were found to have more aggressive cancer than
initially suspected, meaning they were not good candidates for active
surveillance. The findings should result in a re-evaluation of the
criteria for active surveillance, Marks said.
"We are hesitant now to enroll men in active
surveillance until they undergo targeted biopsy," Marks said. "Fusion
biopsy will tell us with much greater accuracy than conventional biopsy
whether or not they have aggressive disease."
Michael Lewis, 70, of Channel Islands Harbor, had a
slightly elevated PSA, but was told after a conventional biopsy that he
had no cancer. Six months later, his PSA had jumped 50 percent and he
was given another biopsy, which again found no malignancy. A third
biopsy showed a tiny amount of cancer, which qualified him for active
surveillance at UCLA
However, six months later, as part of this study, a
targeted biopsy revealed more cancer in Lewis' prostate than originally
suspected. Despite what he thought at first, he had an aggressive tumor.
"It was a shock. No one wants to hear they have
cancer," said Lewis, who recently finished stereotactic body radiation
therapy at UCLA. "With the targeted biopsy system, we were able to find
my cancer early. It might have been missed otherwise – it actually was
missed. Before I came to UCLA, I was told I didn't even have cancer. I
could have been dead - simple as that. Frankly, I owe my life to UCLA."
Lewis' prognosis is good, Marks said, because the
cancer was detected early. Had he continued to receive conventional
biopsies, the cancer may have spread before it was detected.
Prostate cancer is the most frequently diagnosed
cancer in men aside from skin cancer. An estimated 233,000 new cases of
prostate cancer will occur in the United States in 2014. Of those,
nearly 30,000 men will die.
"For men initially diagnosed with low-risk prostate
cancer, MRI-ultrasound confirmatory biopsy including targeting of
suspicious lesions seen on MRI results in frequent detection of tumors,"
the study states. "These data suggest that for men enrolling in active
surveillance, the criteria need be re-evaluated to account for the risk
inflation seen with targeted prostate biopsy."
On the other hand, Marks said, for men with a
negative targeted biopsy, a degree of reassurance is provided that is
much greater than that offered by the older, blind biopsy method.
The study was funded by the national Cancer
Institute, the Beckman Coulter Foundation, Jean Perkins Foundation and
the Steven C. Gordon Family Foundation.
UCLA reports that for more than 50 years, the
urology specialists at UCLA have continued to break new ground and set
the standards of care for patients suffering from urological conditions.
In collaboration with research scientists, UCLA's physicians are
pioneering new, less invasive methods of delivering care that are more
effective and less costly. UCLA reports to be one of only a handful of
urology programs in the country that offer kidney and pancreas
transplantation. For more information, visit
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