Adding systematic prostate biopsies to targeted biopsy unnecessary, new UCSF study

By Howard Wolinsky

When I started on my cancer “journey” 14 years ago, prostate MRIs were just being made available, mainly to confirm the presence of lesions following a biopsy. Insurers wouldn’t cover a $1,000-plus MRI unless you had had a biopsy that showed you had prostate cancer.

One of my urologists at University of Chicago tried to target my two MRI-positive lesions with ultrasound and a single core prostate biopsy. He’d aim his ultrasound device generally in the area where a systematic biopsy—which critics have called a “blind” biopsy—had found positive cores.

Since then, things have become far more sophisticated and accurate with the availability of fusion biopsies with MRIs.

But even as the ability to target lesions has advanced, probably most urologists throw in some systematic biopsies to be safe and for good luck in the serial biopsies performed at various intervals in men on Active Surveillance.

But is that necessary? It’s been unclear whether a targeted biopsy alone reliably identifies the dominant lesion, thereby avoiding the need for systematic sampling, which potentially could increase the risk sepsis and urinary infections.

However, lead author Mary Fakunle, MD, a resident at the University of California San Francisco, and senior author Peter Carroll, MD, MPH, report in a new study in the Journal of Urology this month that the added systematic biopsies may be unnecessary when a fusion biopsy has been done.

(Mary Fakunle, MD)

In the study of 821 men who underwent MR fusion biopsies, 82% were had GG1 (Gleason 6) and 18% had GG2 (Gleason 3+4=7).

Sixty-two percent had their first MR fusion biopsy as diagnostic or confirmatory.

The findings between targeted alone and sytematic biopsies overlapped in 95% of the cases. The researchers said: “For 5% of cases, systematic biopsy was unique in detecting GG and location outside the target. Most unique lesions detected outside the target had marginally aggressive features: 73% GG2 of low-volume and favorable histologic subtypes.”

(Histology, also known as microscopic anatomy or micro-anatomy, is the branch of biology that studies the microscopic anatomy of biological tissues.)

The researchers noted that 25% of dominant lesions were contiguous to the target, suggesting that better sampling of the target improves detection.

The researchers concluded: “MR fusion targeting, without systematic sampling, may be sufficient to monitor men on AS. Few high-risk cancers are missed, all of limited volume and favorable histology.”

In an editorial in the journal, “Can We Be Less Active in Prostate Cancer Surveillance?,”Drs. Miko Filon and Brock O’Neil, of the University of Utah Huntsman Cancer Center, summarized: “As a whole, this analysis argues that simply increasing the sampling around the mpMRI target may be sufficient to improve detection of important disease instead of systematically sampling the remaining prostate.”

The Johns Hopkins Active Surveillance program is sticking with the added cores.

Christian Pavlovich, MD, head of the program, told me: “We still firmly believe in adding systematic cores as well… as does the Canary PASS group [which includes UCSF} by the way. [There is] very little added morbidity and actually none that I can find in the literature… especially since we are transperineal at this point.

“To be clear the target is the main thing to sample but unless one is a perfect shot it makes good sense of sample around it at least in the same side. That way you’d miss les than 5% of significant disease more like 2-3% in our hands (unpublished data).”

The UCSF team said the findings may have some bearing on patients undergoing focal therapy: “The results of this study may also have implications for men with MRI-detected, lower-risk cancers who are being evaluated for focal therapy, as upgrading or a change in volume is most likely (>90%) to occur on the same side of the lesion and be amenable to hemi-gland ablation even without improved sampling of the target. In this case, clinicians may feel that after an MR, targeted lesion with surveillance imaging is sufficient in determining necessity or timing of focal treatment. Given the findings here, they may opt for treatment including and surrounding the targeted lesion.”

The Utah researchers noted that the findings are limited because it was a single-center, retrospective study. They added: “…the outcomes reported are surrogates for what patients really want to know to make informed decisions. In the end, patients are likely most interested in understanding the risk of missing a curative window for treatment compared with the risks associated with confirmatory or systematic biopsies. This is much harder to determine.”

Promise DNA study reaching end to recruitment

If you have been diagnosed with prostate cancer and you want to spit for science and get a free germline test, you’d better hurry.

Christina Tran, MPH senior project manager for Promise, told The Active Surveillor the study has about filled its quota. She said Promise has tested 4,377 men with prostate cancer across the U.S. “We are aiming to test 5,000 to identify 500 men with prostate cancer and germline mutations of interest.”

So sign up soon: prostatecancerpromise.org

On his third round of cancer: ‘All My Children’ actor diagnosed with PCa

By Howard Wolinsky

My wife started to watch the TV soap “All My Children” back in high school and followed the story line for more than 40 years. Talk about dedication.

Now there’s bad prostate cancer news for fans of AMC. One of the hunks on the show has been hit by prostate cancer.

This is the third time actor Colin Egglesfield, 51, has been diagnosed with cancer.

He played Josh Madden from September 2005 until January 2009. He also appeared in the reboot of “Melrose Place.”

The former "All My Children" star announced on Instagram on Jan. 20 he had been diagnosed with prostate cancer, and posted a photo of him waving a peace sign in front of City of Hope Cancer Center Phoenix. Egglesfield had previously been treated twice for testicular cancer.

“It’s not the hand that you’ve been dealt because you can’t change that. It’s how you play the cards that counts,” Egglesfield wrote in the caption of his post, saying he found the quote from an interview he did when he was 25. "It has served me well throughout my life including recently."

He said the beginning of 2025 hasn't been the easiest, but it has been "another opportunity to decide who I choose to be in the face of uncertainty and challenges in my most recent cancer diagnosis."

Egglesfield was the second actor to play Josh Madden.

Fandom notes: “The character was initially the subject of a controversial and landmark abortion storyline back in the early 1970s, having been the fetus in which the abortion was centered. When the abortion storyline was rewritten to not have been an abortion after all, controversy ensued again, as viewers felt that it was an undoing of a groundbreaking event in television history.”

In his final story line Madden was involved in a “a hostage situation where Josh held Reese Marshall at gunpoint, Zach fired off a single round and shot Josh in the head. He then urged the medics to do everything they could to keep Josh's heart viable for transplant.”

The series ended in 2013, breaking fans hearts.

A final bit or two of trivia: Eglesfield was a graduate of Marian Catholic High School in Chicago Heights—not far from my house. He originally was headed for a career in medicine, but became a model and then an actor.

Best of luck to him and thanks to him or sharing his story.

In Instagram, he said: “… fellas, be sure to get your PSA checked regularly. It saved my life!”

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