I think you are making a good argument for an improved, and perhaps less costly AS protocol. Let's say that biopsies were only done after eliminating confounding sources of PSA, such as I proposed in an earlier post:Over-biopsying
This would eliminate many insignificant cancers that are now being treated or put on AS.
• Then add $600? for a Bostwick/Epstein re-read.
• Then a CDUS/mpMRI/saturation biopsy at one year (which might have picked up your Gleason 9). This would add maybe $700-$1,500? to the cost. (I'm guessing at the costs)
• Then, repeat every other year if there is sign of progression, or every 5 years if there is no sign of progression.
Since most GS6s do not progress, such a protocol might actually cost less
while detecting more progression.