The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, March 29, 2011

To Be or Not to Be Biopsied—That Is the Question


“When the final chapter of this disease is written, it will prove that never in the history 
of oncology will so many men have been so over-treated for one disease.”
That’s Dr. Thomas Stamey talking. Formerly Chief of Urology at Stanford University, he is the man who developed the PSA blood test, a remarkable tool that has transformed the management of prostate cancer over almost two decades. It is also the first stop on the Over-Treatment Express. 

Your ticket to ride is the biopsy.
The Big Question: When your PSA rises unexpectedly, how do you keep from becoming a statistic among the legions of the over-treated?

First, repeat the PSA. If it is still abnormal, rather than scheduling a biopsy, consider further testing with PCA-3, color Doppler ultrasound and/or spectrographic endorectal MRI.  If these tests fail to reveal anything worrisome, frequent monitoring may be preferable to an immediate biopsy.

Second, before you agree to a biopsy, be sure you have done your research and are up to speed on prostate cancer, the treatment options and the potential negative side effects.

Facts of Biopsy Life                                                                                        
A biopsy is a medical test in which cells and/or tissue are removed from some part of a living body—in this case, the prostate—for examination under a microscope by a pathologist, in order to establish the presence and extent of cancer. When only a tissue sample is removed, the procedure is called an incisional biopsy or a core biopsy.

Prior to being biopsied, you need to be aware that almost half of all men diagnosed with prostate cancer have a chronic Low-Risk type, a condition which, according to my writing partner, prostate oncologist Mark Scholz, doesn’t really deserve to be called “cancer” and can be safely monitored without immediate treatment. This reassuring knowledge helps to diffuse the inevitable fear that comes with a cancer diagnosis.                               
So what is the problem? The prostate cancer world is run by urologists. Urologists—and remember, a urologist is a surgeon—are the specialists to whom primary care physicians refer their patients for evaluation when the PSA rises. Nor is it an exaggeration to say that, to most urologists, an elevated PSA calls for a biopsy. And that a modest number of cancer cells in a few biopsy cores will be sufficient reason to reserve time for you in the operating room. The next time you see him, your urologist will probably be scrubbing up.                

Don’t get me wrong: I know a number of urologists I’d trust with my life. Moreover, I am aware that urologists have an obligation to detect any prostate cancer at the earliest possible stage because long-term survival is threatened if the cancer has spread beyond the confines of the prostate, into the regional lymph nodes or the bones. Before that happens, a biopsy serves to establish tumor grade and Gleason score which, along with the number of cores involved and the volume of cancer cells in each core, are useful indicators of aggressiveness. 

What Scares Us Most?                                     
Over the past five years, while writing Invasion of the Prostate Snatchers, I have talked with hundreds of men to get a sense of what worries them most about “that damn biopsy.” First, there’s the likelihood of serious pain. When performed by skillful urologists and interventional radiologists, the trauma is all but absent. When Dr. Duke Bahn, who is one of my heroes, performs a biopsy, I have experienced a small pinch when he “harvested” (a doc word) the tissue. However, if you fall into the hands of what one often biopsied veteran calls “the Class B urologists” (where “B” stands for “Butchers”), the experience can range from gross to grizzly. 

Then, there’s the rampant suspicion I share with many men that bleeding from a biopsy, or the needle itself, might spread the cancer. While multiple studies have shown that migrating cancer cells rarely result in metastasis, the suspicion and the fear it creates, persist.                                                
Finally, there’s the matter of impotence. The odds are pretty well established: In one study, a month after undergoing a biopsy, 41% of the men experienced erectile dysfunction. Six months later, 15% were still impotent. The results of another study are not quite so grim, but I have heard from men who still suffered from erectile dysfunction for 18 months following a biopsy.

One of the Most Important Decisions You Can Make
Before you even consider undergoing your first biopsy, find yourself a prostate cancer expert. Then have him or her (rather than your family doctor as is usually the way it’s done) select a urologist for you.
I’ll have more to say about biopsies. And if any of you reading this has a biopsy experience that could be useful to other men, we look forward to hearing from you.  Urologists welcome.