{"product_id":"active-surveillance-for-prostate-cancer-how-mri-mri-guided-biopsy-and-focal-therapy-are-changing-the-approach","title":"Active Surveillance for Prostate Cancer: How MRI, MRI-Guided Biopsy, and Focal Therapy Are Changing the Approach","description":"\u003cp\u003eThis 12-year study from the University of California, Los Angeles (UCLA) followed 869 men with low- or favorable intermediate-risk prostate cancer who chose active surveillance (careful monitoring instead of immediate treatment). Researchers found that MRI scans were highly accurate at identifying which men could safely avoid follow-up biopsies, correctly predicting the absence of cancer progression in 90% to 95% of low-risk men. When cancer did progress, focal therapy (treating only the tumor, not the whole prostate) allowed 84% of men to avoid surgery or radiation for at least 5 years, compared with only 46% of men who did not receive focal therapy. The findings, published in \u003cem\u003eThe Journal of Urology\u003c\/em\u003e, support newer, less invasive approaches to managing early-stage prostate cancer.\u003c\/p\u003e\n\n\u003ch1\u003eActive Surveillance for Prostate Cancer: How MRI, MRI-Guided Biopsy, and Focal Therapy Are Changing the Approach\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eWhat Is Active Surveillance and Why Does It Matter?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#why-this-study\"\u003eWhy This Study Was Needed\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#methods\"\u003eHow the Study Was Conducted (Methods)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#participants\"\u003eWho Was in the Study?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#progression\"\u003eKey Findings: How Often Did Prostate Cancer Progress?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#predictors\"\u003eWhat Factors Predicted Cancer Progression?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#mri-value\"\u003eCan a Negative MRI Replace a Follow-Up Biopsy?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#focal-therapy\"\u003eFocal Therapy: A Middle Path Between Monitoring and Surgery?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#surgery-radiation\"\u003eSurgery and Radiation: A Decline in Anxiety-Driven Treatment\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eStudy Limitations\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#patient-care\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eIn a 12-year study of 869 men on active surveillance, MRI accurately predicted absence of cancer progression in 90% to 95% of low-risk men.\u003c\/li\u003e\n\u003cli\u003eFocal therapy allowed 84% of men to avoid surgery or radiation for at least 5 years, compared with 46% of men who did not receive it.\u003c\/li\u003e\n\u003cli\u003eFor men with GG2, a negative MRI was less reliable (about 70% negative predictive value), so biopsies may still be needed.\u003c\/li\u003e\n\u003cli\u003eAnxiety-driven treatment declined significantly over the study period, from 86% to 47% of surgeries or radiation without biopsy-proven progression.\u003c\/li\u003e\n\u003cli\u003eNo prostate cancer metastases or deaths occurred in the entire cohort of 869 men during the study.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eWhat Is Active Surveillance and Why Does It Matter?\u003c\/h2\u003e\n\n\u003cp\u003eActive surveillance (AS) is a management strategy for prostate cancer (PCa) that involves closely monitoring the cancer rather than treating it immediately. The concept was first proposed in the 1990s for men with what were then called \"insignificant\" cancers. At that time, selection criteria were very strict. However, as long-term safety data became available, those criteria have become less restrictive.\u003c\/p\u003e\n\n\u003cp\u003eToday, the term \"insignificant\" has largely been replaced by \"low and intermediate risk,\" and enrollment in active surveillance programs has grown dramatically over the past decade. This shift matters because about \u003cstrong\u003e1 in 8 American men\u003c\/strong\u003e will be diagnosed with prostate cancer in their lifetime, and with modern biopsy techniques, low- and intermediate-risk disease is now the most common type of prostate cancer found. Active surveillance is therefore becoming increasingly important for managing this disease.\u003c\/p\u003e\n\n\u003ch2 id=\"why-this-study\"\u003eWhy This Study Was Needed\u003c\/h2\u003e\n\n\u003cp\u003eActive surveillance is now a guideline recommendation for men with low-risk prostate cancer, but guidelines for follow-up are still evolving. Two relatively new tools were routinely incorporated into the UCLA active surveillance program and were the focus of this study:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMultiparametric MRI\u003c\/strong\u003e of the prostate, which became widely available only about 10 to 15 years ago — well after the active surveillance concept gained traction\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eFocal therapy (FT)\u003c\/strong\u003e, a tumor-focused ablation technique that destroys only the cancer, which evolved thanks to MRI's ability to localize tumors\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eOne of the study's key questions was whether using \u003cstrong\u003eMRI-guided biopsy (MRGB)\u003c\/strong\u003e at the start of active surveillance could help doctors predict outcomes in advance — and potentially reduce or even eliminate the need for repeated follow-up biopsies. The researchers also wanted to see whether focal therapy could help men delay or avoid surgery or radiation (radical prostatectomy\/radiation therapy, or RP\/RT) when their cancer did show signs of progression.\u003c\/p\u003e\n\n\u003ch2 id=\"methods\"\u003eHow the Study Was Conducted (Methods)\u003c\/h2\u003e\n\n\u003cp\u003eThis is an analysis of \u003cstrong\u003eprospectively collected data\u003c\/strong\u003e from \u003cstrong\u003e1,081 men\u003c\/strong\u003e who signed consent and enrolled in the UCLA active surveillance registry between 2010 and 2022. The registry has been approved annually by the UCLA Institutional Review Board since its creation in 2009. Of the 1,081 enrollees, \u003cstrong\u003e869 men (80%)\u003c\/strong\u003e formed the final analytic cohort after meeting all of these baseline criteria:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003eHad an MRI-guided biopsy at UCLA\u003c\/li\u003e\n  \u003cli\u003eThe biopsy showed \u003cstrong\u003eGrade Group (GG) 2 or lower\u003c\/strong\u003e (GG is a prostate cancer grading system; GG1 is lowest risk, GG5 is highest)\u003c\/li\u003e\n  \u003cli\u003eWere enrolled in the program for \u003cstrong\u003eat least 1 year\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe baseline biopsy was the first MRI-guided biopsy performed at UCLA. For 210 men, this was their first-ever prostate biopsy; for 659 men, it was a confirmatory biopsy after an earlier diagnosis elsewhere. The researchers defined a special category called \u003cstrong\u003e\"GG0\"\u003c\/strong\u003e: these were men whose prior diagnostic biopsy had shown GG1 or GG2 cancer, but whose baseline MRI-guided biopsy at UCLA was negative (no cancer found). This group was considered to have very low risk.\u003c\/p\u003e\n\n\u003cp\u003eThroughout the 12-year study period, patients were monitored with \u003cstrong\u003esemiannual digital rectal examinations and PSA blood tests\u003c\/strong\u003e (PSA stands for prostate-specific antigen, a protein produced by the prostate). Follow-up biopsies were performed using MRI-guided biopsy every 12 to 24 months. Each biopsy session took 12 systematic samples using a spatial template. Additionally, 3 to 5 samples were taken from any suspicious MRI lesions (graded PIRADS 3 to 5), and at follow-up sessions, 2 to 4 samples were also taken from any previously positive biopsy sites, which were tracked electronically in the fusion device. An experienced uroradiologist (with more than 1,000 prostate MRI readings) supervised all MRI interpretation.\u003c\/p\u003e\n\n\u003cp\u003eThe study used the \u003cstrong\u003ePIRADS (Prostate Imaging Reporting and Data System) v2.1 scoring system\u003c\/strong\u003e to assign MRI grades. Antibiotic prophylaxis was a quinolone until 2017, when — because of a \u003cstrong\u003e4% rate of post-biopsy sepsis\u003c\/strong\u003e (a serious bloodstream infection) — a single dose of ertapenem (500 mg) was substituted. After that change, no further sepsis was encountered. A fellowship-trained uropathologist performed all pathology analyses.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFocal therapy interventions:\u003c\/strong\u003e After 2016, focal therapy was offered to participants who were diagnosed with GG2 at any time point, or who progressed to GG3 during follow-up. Focal therapy was performed under general anesthesia in the outpatient surgery center. Two methods were used:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eHigh-intensity focused ultrasound (HIFU)\u003c\/strong\u003e, generally preferred for small prostates and posterior (back) lesions\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCryotherapy (CRYO)\u003c\/strong\u003e, generally preferred for prostates larger than 50 mL or anterior (front) lesions\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eEach treatment targeted up to 50% of one lobe of the prostate. All patients who underwent focal therapy were followed with mandated MRI-guided biopsies at 6 and 18 months after treatment.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOutcomes measured:\u003c\/strong\u003e The two primary end points were (1) progression to GG3 or higher, known as progression-free survival (PFS), and (2) any \"event\" — defined as progression to GG3 or higher, surgery or radiation without progression, prostate cancer metastases, or death from any cause. This was called event-free survival (EFS).\u003c\/p\u003e\n\n\u003ch2 id=\"participants\"\u003eWho Was in the Study?\u003c\/h2\u003e\n\n\u003cp\u003eThe 869 men in the study cohort had a \u003cstrong\u003emean age of 65 years\u003c\/strong\u003e (SD 7). About \u003cstrong\u003e70% identified themselves as White, 5% as Black, 5% as Asian, and 7% as Hispanic\u003c\/strong\u003e; 13% did not disclose their race\/ethnicity.\u003c\/p\u003e\n\n\u003cp\u003eAt baseline, the men were stratified by their MRI-guided biopsy result:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGG0: 190 men (22%)\u003c\/strong\u003e — prior diagnostic biopsy showed GG1 or GG2, but baseline MRI-guided biopsy was negative\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGG1: 505 men (58%)\u003c\/strong\u003e — lowest-risk cancer\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGG2: 174 men (20%)\u003c\/strong\u003e — favorable intermediate-risk cancer\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eBaseline characteristics including PSA level, PSA density (PSAD, the PSA level divided by prostate volume), PIRADS grade, MRI lesion (region of interest, or ROI) diameter, and maximum cancer core length (MCCL) were all significantly associated with the baseline Grade Group (all P \u0026lt; .01). For example, \u003cstrong\u003e75.8% of men had a PSA density of 0.15 or lower\u003c\/strong\u003e, while \u003cstrong\u003e24.2% had a PSA density above 0.15\u003c\/strong\u003e. The ineligible men (215) had similar baseline PSA levels but were more likely to be older (median age 67 vs 65, P \u0026lt; .01) and more often non-White (48% vs 37%, P \u0026lt; .01).\u003c\/p\u003e\n\n\u003cp\u003eThe study accrued a total of \u003cstrong\u003e3,500 patient-years of follow-up\u003c\/strong\u003e, with a \u003cstrong\u003emedian follow-up of 4.1 years\u003c\/strong\u003e (range 1 to 12.5 years). A total of \u003cstrong\u003e2,374 MRI-guided biopsies\u003c\/strong\u003e were performed: one per subject at baseline (869), plus another 1,505 in a subset of \u003cstrong\u003e664 men\u003c\/strong\u003e who were studied serially for more than 1 year. During follow-up, an average of 2.3 (SD 1.5) MRI-guided biopsies were obtained per subject (range 1 to 9). The median interval between baseline and first follow-up biopsy was \u003cstrong\u003e1.0 year\u003c\/strong\u003e, and between first and second follow-up biopsy was \u003cstrong\u003e1.5 years\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003ch2 id=\"progression\"\u003eKey Findings: How Often Did Prostate Cancer Progress?\u003c\/h2\u003e\n\n\u003cp\u003eAmong the 664 men who had serial MRI-guided biopsies, \u003cstrong\u003e132 (about 20%) upgraded to GG3 or higher\u003c\/strong\u003e during follow-up. The rate of progression varied significantly by baseline Grade Group:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003e7%\u003c\/strong\u003e of men with baseline GG0 progressed\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e19%\u003c\/strong\u003e of men with baseline GG1 progressed\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e34%\u003c\/strong\u003e of men with baseline GG2 progressed\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eFor the \u003cstrong\u003e532 men with GG0 or GG1 at baseline\u003c\/strong\u003e who did not progress to GG3, 190 (36%) did progress to GG2 during follow-up.\u003c\/p\u003e\n\n\u003cp\u003eProgression-free survival (freedom from reaching GG3) also differed substantially by group:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMedian progression-free survival:\u003c\/strong\u003e 10.2 years for men with GG0; 8.7 years (95% CI 7.1–9.6) for men with GG1; and 5.8 years (95% CI 3.8–10.9) for men with GG2\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eFive-year progression-free survival:\u003c\/strong\u003e 89% for men with GG0, 68% for men with GG1, and 42% for men with GG2\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe progression-free survival of GG0 and GG1 men was not significantly different from each other, but both were significantly longer than for GG2 men (P \u0026lt; .01). Only 9 out of 123 men with GG0 at baseline progressed to GG3 or higher, compared with 78 out of 409 men with GG1, and 45 out of 132 men with GG2.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEvent-free survival:\u003c\/strong\u003e Among all 869 men, there were 266 events that would terminate active surveillance: 132 men with GG3 or higher progression, 115 men who elected surgery or radiation without progression, and 19 non-prostate-cancer deaths. The median event-free survival was \u003cstrong\u003e9.0 years for men with baseline GG1\u003c\/strong\u003e and \u003cstrong\u003e3.5 years (95% CI 2.5–5.4) for men with GG2\u003c\/strong\u003e; men with GG0 never reached median survival. Importantly, \u003cstrong\u003eno prostate cancer metastases and no prostate cancer deaths were observed\u003c\/strong\u003e in the entire cohort.\u003c\/p\u003e\n\n\u003cp\u003eIn terms of how upgrades were detected: \u003cstrong\u003e45% of the 132 upgrades to GG3 or higher were detected by targeted biopsy only\u003c\/strong\u003e (sampling the MRI lesion), and \u003cstrong\u003e40% by systematic biopsy only\u003c\/strong\u003e (standard grid sampling). The electronic \u003cstrong\u003etracking biopsy\u003c\/strong\u003e — which re-samples previously positive sites — detected \u003cstrong\u003e51 (39%) of the 132 upgrades\u003c\/strong\u003e, and among those 51 men, \u003cstrong\u003e80% of the upgrades were found only by tracking\u003c\/strong\u003e. This means 40 upgrades would have gone completely undetected without the tracking technique. Among the tracking biopsies that showed GG3: 25 (49%) were within the targeted MRI region, 20 (39%) were from systematic biopsy sites, and 6 (12%) had a positive tracked core in both locations.\u003c\/p\u003e\n\n\u003ch2 id=\"predictors\"\u003eWhat Factors Predicted Cancer Progression?\u003c\/h2\u003e\n\n\u003cp\u003eThe researchers used a statistical method called Cox regression analysis to identify baseline factors associated with upgrading to GG3 or higher. The results, reported as adjusted hazard ratios (aHR), were:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMen with GG2 at baseline were nearly 4 times more likely to progress\u003c\/strong\u003e to GG3 or higher (aHR 3.8, 95% CI 1.7–8.7) compared with GG0 men\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMen with GG1 progressed at a similar rate\u003c\/strong\u003e to men with GG0 (not statistically different)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMaximum cancer core length (MCCL)\u003c\/strong\u003e was also a significant predictor: men with longer cancer cores had an 80% higher risk of progression (aHR 1.8, 95% CI 1.2–2.7)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eBaseline PIRADS scores were not significantly different\u003c\/strong\u003e from each other, so MRI was classified simply as positive or negative for the time-to-event analyses\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eIn plain language: the most important risk factor was starting active surveillance with a GG2 result, and the length of cancer in the biopsy core also mattered. A GG1 diagnosis at baseline was not meaningfully riskier than a negative baseline MRI-guided biopsy (GG0).\u003c\/p\u003e\n\n\u003ch2 id=\"mri-value\"\u003eCan a Negative MRI Replace a Follow-Up Biopsy?\u003c\/h2\u003e\n\n\u003cp\u003eA key finding of this study relates to the \u003cstrong\u003enegative predictive value (NPV)\u003c\/strong\u003e of MRI — that is, how accurate a negative MRI (no visible lesions) is at correctly identifying men who have not progressed to GG3 or higher.\u003c\/p\u003e\n\n\u003cp\u003eAt the time of the first follow-up biopsy, \u003cstrong\u003ea negative MRI was found in 341 out of 664 men\u003c\/strong\u003e (51%). For men entering active surveillance with low-risk disease, the MRI was highly reliable:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNear 95% NPV\u003c\/strong\u003e for men with baseline GG0\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e90% NPV\u003c\/strong\u003e for men with baseline GG1\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eOnly 70% NPV\u003c\/strong\u003e for men with baseline GG2\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eWhen the results were broken down by PSA density, the findings were even more informative. Regardless of PSA density, the NPV was \u003cstrong\u003e84% to 100% for men with GG0 or GG1 at baseline\u003c\/strong\u003e — meaning a negative MRI was highly reassuring. However, for men with GG2, the NPV was \u003cstrong\u003elower, at 59% to 77%\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eThe NPV of MRI at the time of the \u003cstrong\u003esecond follow-up biopsy was similar\u003c\/strong\u003e to that found at the first follow-up biopsy, suggesting the reliability of MRI persists over time.\u003c\/p\u003e\n\n\u003cp\u003eThe key takeaway: for men who enter active surveillance with low-risk disease (GG0 or GG1) and have a negative follow-up MRI, a routine biopsy may be safely avoided. But for men with GG2, a negative MRI is less reassuring, and doctors should maintain a lower threshold for biopsy. \u003cstrong\u003ePSA density above 0.15 favors performing a biopsy\u003c\/strong\u003e in indeterminate (unclear) cases.\u003c\/p\u003e\n\n\u003ch2 id=\"focal-therapy\"\u003eFocal Therapy: A Middle Path Between Monitoring and Surgery?\u003c\/h2\u003e\n\n\u003cp\u003eOne of the most striking findings of this study concerns focal therapy. Of the men who became eligible for focal therapy during follow-up, \u003cstrong\u003e370 were candidates, and 99 (27%) actually received it\u003c\/strong\u003e — 74 men received cryotherapy and 25 received high-intensity focused ultrasound. The prostate cancer characteristics of eligible men who received focal therapy were similar to those who did not, meaning the groups were comparable.\u003c\/p\u003e\n\n\u003cp\u003eWhen the researchers compared the two groups, the results were dramatic:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe \u003cstrong\u003e5-year probability of remaining free from surgery or radiation (RP\/RT-free survival) was 84% in the focal therapy group\u003c\/strong\u003e, compared with \u003cstrong\u003e46% in the no-focal-therapy group\u003c\/strong\u003e (P \u0026lt; .01)\u003c\/li\u003e\n  \u003cli\u003eThe \u003cstrong\u003emedian time to surgery or radiation\u003c\/strong\u003e (when half of the men had received RP\/RT) was \u003cstrong\u003e3.7 years for men who did not receive focal therapy\u003c\/strong\u003e — but men who received focal therapy \u003cstrong\u003enever even reached the median\u003c\/strong\u003e during follow-up\u003c\/li\u003e\n  \u003cli\u003eOf the 271 patients who did not receive focal therapy, \u003cstrong\u003e128 eventually underwent surgery or radiation\u003c\/strong\u003e, compared with only \u003cstrong\u003e10\u003c\/strong\u003e among those who did receive focal therapy\u003c\/li\u003e\n  \u003cli\u003eThe advantage of focal therapy \u003cstrong\u003epersisted throughout at least 10 years of follow-up\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eIn a sensitivity analysis, the timing of focal therapy (performed immediately at the time of eligibility vs delayed) did not significantly affect the outcome, suggesting that focal therapy can be used flexibly as part of an overall surveillance strategy.\u003c\/p\u003e\n\n\u003cp\u003eTo confirm the effectiveness of the treatment, \u003cstrong\u003e87 of the 99 men who received focal therapy underwent a follow-up biopsy at 6 to 12 months\u003c\/strong\u003e. Most of them — \u003cstrong\u003e59 out of 87, or 68%\u003c\/strong\u003e — had a favorable pathologic outcome on that follow-up biopsy (meaning no significant cancer remained at the treated site).\u003c\/p\u003e\n\n\u003ch2 id=\"surgery-radiation\"\u003eSurgery and Radiation: A Decline in Anxiety-Driven Treatment\u003c\/h2\u003e\n\n\u003cp\u003eOver the 12-year study, \u003cstrong\u003e181 of 869 men (21%) underwent surgery or radiation\u003c\/strong\u003e: 111 had radical prostatectomy (surgical removal of the prostate) and 70 had radiation therapy. However, the reasons for treatment shifted over time:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eOnly \u003cstrong\u003e66 out of 181 (36%)\u003c\/strong\u003e underwent RP\/RT because their cancer actually progressed to GG3 or higher\u003c\/li\u003e\n  \u003cli\u003eThe majority — \u003cstrong\u003e115 out of 181 (64%)\u003c\/strong\u003e — elected definitive treatment \u003cstrong\u003ewithout biopsy-proven progression\u003c\/strong\u003e, what the researchers call an \"anxiety event\"\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eEncouragingly, anxiety-driven treatment declined significantly over the course of the study. In the first quarter of the study period, \u003cstrong\u003e86% (30 out of 35)\u003c\/strong\u003e of RP\/RT procedures were performed without biopsy-proven progression. By the last quarter, that number had fallen to \u003cstrong\u003e47% (15 out of 32)\u003c\/strong\u003e — a \u003cstrong\u003e39% decline\u003c\/strong\u003e, with a linear trend that was statistically significant (P \u0026lt; .01). This suggests that as doctors gained more experience with MRI-guided surveillance, both they and their patients became more comfortable deferring treatment.\u003c\/p\u003e\n\n\u003cp\u003eNotably, among the \u003cstrong\u003e64 men with baseline GG1\u003c\/strong\u003e who underwent anxiety-driven RP\/RT, \u003cstrong\u003e34 (53.1%) had actually upgraded to GG2\u003c\/strong\u003e by the time of their surgery or radiation — meaning their decision to treat was at least partially validated by a real change in their cancer. At the other end of the spectrum, only \u003cstrong\u003e8 out of 123 men with baseline GG0\u003c\/strong\u003e received RP\/RT during the study period.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eStudy Limitations\u003c\/h2\u003e\n\n\u003cp\u003eAs with any research, this study has important limitations that should be kept in mind:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSingle academic medical center:\u003c\/strong\u003e The work is a prospective cohort study at UCLA, and the investigators' substantial in-depth experience with MRI and MRI-guided biopsy (more than 15 years) and focal therapy (more than 10 years) might limit how well the results generalize to other centers with less experience.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNon-standardized focal therapy selection:\u003c\/strong\u003e Patient selection for focal therapy was not standardized. While the characteristics of treated and untreated men appeared similar, this was not a randomized trial, so it's possible that unmeasured differences influenced the results.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eObservational design:\u003c\/strong\u003e The study cannot prove cause and effect — only associations between the surveillance approach and outcomes.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"patient-care\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eBased on these findings, the authors offer several practical messages for men considering or currently on active surveillance:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you enter active surveillance with low-risk prostate cancer diagnosed by MRI-guided biopsy, and your follow-up MRI is negative, you can safely avoid a follow-up biopsy.\u003c\/strong\u003e The negative predictive value of MRI was 90% to 95% in this group — a highly reassuring result.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you enter with GG2 (favorable intermediate-risk) disease, a negative MRI is less reliable.\u003c\/strong\u003e The negative predictive value dropped to about 70%, so biopsies may still be needed even when the MRI looks clear.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePSA density matters.\u003c\/strong\u003e If your PSA density is above 0.15, your doctor should lean toward doing a biopsy when the MRI is indeterminate — because the risk of hidden progression is higher.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf progression is found, focal therapy is a genuine option to consider.\u003c\/strong\u003e The authors describe it as \"a decisional crossroad, not a mandatory path to surgery or radiation.\" In this study, focal therapy extended the ability to stay on surveillance and defer surgery or radiation — with 84% of focal therapy patients avoiding RP\/RT for at least 5 years.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAnxiety-driven treatment is declining.\u003c\/strong\u003e Fewer men are choosing surgery or radiation without evidence of progression as MRI-guided surveillance becomes more refined — and that trend appears to be safe.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe bottom line: active surveillance for prostate cancer has evolved significantly. With MRI-guided biopsy at the start, MRI-based monitoring along the way, and focal therapy as a middle option when cancer progresses, many men can now avoid or substantially delay the side effects of surgery and radiation while still keeping their cancer safely in check.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is active surveillance for prostate cancer?\u003c\/h3\u003e\n\u003cp\u003eActive surveillance is a management strategy that involves closely monitoring prostate cancer rather than treating it immediately. It was first proposed in the 1990s for men with what were then called 'insignificant' cancers, but criteria have become less restrictive as long-term safety data emerged. Today it is a guideline recommendation for men with low-risk prostate cancer, and enrollment has grown dramatically over the past decade.\u003c\/p\u003e\n\u003ch3\u003eHow often did prostate cancer progress during active surveillance?\u003c\/h3\u003e\n\u003cp\u003eIn a 12-year study of 664 men who had serial MRI-guided biopsies, about 20% upgraded to Grade Group 3 or higher. Progression rates varied by baseline grade: 7% for men with a negative baseline biopsy (GG0), 19% for GG1, and 34% for GG2. No prostate cancer metastases or deaths occurred in the entire cohort of 869 men.\u003c\/p\u003e\n\u003ch3\u003eCan a negative MRI replace a follow-up biopsy?\u003c\/h3\u003e\n\u003cp\u003eFor men entering active surveillance with low-risk disease, a negative MRI was highly reliable: it correctly predicted the absence of progression in about 95% of men with a negative baseline biopsy (GG0) and 90% of men with GG1. However, for men with GG2, the negative predictive value was only about 70%, so biopsies may still be needed even when the MRI looks clear.\u003c\/p\u003e\n\u003ch3\u003eHow effective was focal therapy at avoiding surgery or radiation?\u003c\/h3\u003e\n\u003cp\u003eAmong men who became eligible for focal therapy, the 5-year probability of remaining free from surgery or radiation was 84% in the focal therapy group, compared with 46% in the no-focal-therapy group. Of the 271 patients who did not receive focal therapy, 128 eventually underwent surgery or radiation, compared with only 10 among those who did receive it.\u003c\/p\u003e\n\u003ch3\u003eWhat are the risks of MRI-guided biopsy?\u003c\/h3\u003e\n\u003cp\u003eThe study used antibiotic prophylaxis to prevent infection. Until 2017, a quinolone antibiotic was used, but because of a 4% rate of post-biopsy sepsis (a serious bloodstream infection), a single dose of ertapenem (500 mg) was substituted. After that change, no further sepsis was encountered. Each biopsy session took 12 systematic samples plus additional samples from suspicious MRI lesions.\u003c\/p\u003e\n\u003ch3\u003eI have favorable intermediate-risk (Grade Group 2) prostate cancer on active surveillance and my follow-up MRI is negative — should I get a second opinion before skipping a biopsy?\u003c\/h3\u003e\n\u003cp\u003eA negative MRI is less reassuring at Grade Group 2. The negative predictive value was about 70% for men entering surveillance with GG2, versus 90% to 95% for lower-risk disease, and it fell to 59% to 77% when broken down by PSA density. A PSA density above 0.15 favors biopsy in unclear cases. Because a GG2 baseline result carried nearly four times the progression risk of a negative baseline biopsy, an independent review of the MRI, biopsy pathology and PSA density can help clarify whether deferring biopsy is reasonable. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e martin-et-al-2025-evolution-of-active-surveillance-of-prostate-cancer-impact-of-magnetic-resonance-imaging-magnetic\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e Shannon C. Martin, Samantha Gonzalez, Lorna Kwan, Merdie Delfin, Anissa V. Nguyen, Wayne Brisbane, Ely Felker, Anthony Sisk, Alan Priester, Shyam Natarajan, and Leonard S. Marks\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eJournal:\u003c\/strong\u003e \u003cem\u003eThe Journal of Urology\u003c\/em\u003e, Vol. 214, pp. 177–187, August 2025. Published online April 21, 2025.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Object Identifier (DOI):\u003c\/strong\u003e 10.1097\/JU.0000000000004559\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c\/strong\u003e Supported in part by Grants R01CA158627, R01CA218547, and R01CA195505 from the National Cancer Institute; by the Jean Perkins Foundation; and programmatically by the UCLA Clinical Translational Science Institute and Jonsson Comprehensive Cancer Center.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics:\u003c\/strong\u003e The study was approved annually by the UCLA Institutional Review Board since inception. All subjects provided written informed consent with guarantees of confidentiality.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c\/strong\u003e This patient-friendly article is based on peer-reviewed research and was written for educational purposes. It does not constitute medical advice. Patients should discuss their individual treatment options with their health care providers.\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47699393478812,"sku":null,"price":0.0,"currency_code":"RUB","in_stock":true}],"url":"https:\/\/diagnosticdetectives.ru\/products\/active-surveillance-for-prostate-cancer-how-mri-mri-guided-biopsy-and-focal-therapy-are-changing-the-approach","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}