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The PSA Story: It's A Lot More Than a PSA Score

There are problems with this study of Urologists’ Self-Referral For Pathology Of Biopsy Specimens-by Jean Mitchell –

1.     Mitchell’s main bone of contention is the 12-biopsy protocol. The 12-core biopsy protocol was validated in a large study of 2299 patients involving 167 community-based urologists, published in 2003[1]. The overall cancer detection rate in this referral-based population was 44%. If only a sextant 6-core biopsy scheme was performed, approximately 20% of the cancers in the series would have been missed. The 20% “miss-rate” by the 6-core biopsy protocol would be unacceptable by any standard and to any patient/physician.
2.     The problem with the Mitchell’s study is that an extended 12-biopsy protocol is standard for the prostate biopsy procedure. Adopted since several years, the protocol in 2011 was developed by a committee of leading urologists and pathologist Jonathan Epstein from 21 university medical centers/world’s leading cancer centers from across the country and is available from the National Comprehensive Cancer Network (NCCN). None of the researchers appear to have an in-office anatomic pathology laboratory. They continue to recommend a 12-core biopsy, with cores to be taken from specific areas of the prostate. Urologists have overwhelmingly adopted this protocol.
3.     The Mitchell study is old news (2005 to 2007). It completely ignores the state of the art in 2012 - the biology of prostate cancer such as multifocality, disparateness and capricious nature of prostate cancer diagnosis, its surveillance and treatment based on length of tumor, % each and total % of biopsy core(s) involvement etc., and follow-up biopsy protocols for HG-PIN and atypical glands suspicious for carcinoma.
4.     Conflicts of interest: Pathologists sponsored the study.

 [1] Presti JC, Jr., O'Dowd GJ, Miller MC, et al. Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study. J Urol 2003;169:125-129.