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. 


Anonymous said...

On the recommendation of my urologist last year, I read your book. It has brought considerable comfort, knowing there are others who support alternate therapies. Biopsies, in spite of the risks, are still the only direct method practitioners have of determining the state of cancer in an in situ prostate. After an 8 core TRUS biopsy, a single core of mine was positive. If I were in my eighties, that would not have troubled me, but I am in my fifties. In my case, that knowledge became the catalyst for making some lifestyle changes that may have broader health benefits.

Declining the recommended prostatectomy at my local hospital, I opted instead for a trial program of high intensity focused ultrasound (HIFU) at a research hospital. That entailed undergoing an MRI, a bone scan, and importantly, a second biopsy, one that required 55 cores done on template grid which, together with the MRI, would pinpoint the precise location of any tumours. Though the template biopsy has even higher risks of short term side effects, I was happy to accept those since precise targeting is required for HIFU to work, a treatment without the permanent effects one would most likely experience following surgery.

When I received my positive diagnosis, being a typical male, I was sure that there must be a way to beat this disease. The more I read, the more convinced I became that there may be easily available therapies that can help prevent prostate cancer and in some cases of early cancers, cause prostate cancer cells to die. Between my first and second biopsy, 6 months elapsed. All 55 of the second biopsy’s cores were benign. If cancer is found in one core, it is likely to be located in other parts of the prostate. The chances of a single “lucky shot” being followed by 55 later misses are very slender, though the template biopsy needle goes in at a different angle than the TRUS. A mix-up in the biopsies was ruled out by a DNA comparison. One explanation is that the cancer was in an early stage and could be eliminated with alternate therapies, though which therapy would be anyone’s guess. I would not want to suggest that what might have worked in my case should work in anyone else’s. I am a single data point. When you are the patient, therapeutic cocktails are preferable but make for bad science.

Immediately after my initial diagnosis, I adopted an Indian/Asian/Italian diet – no red meat, very little dairy, low fat and 30 minutes of brisk walking each day. A month later, I started taking each day, 4.5g of Ganoderma lucidum broken spore capsules (Reishi mushroom), 2.5g of curcumin (derived from turmeric), 0.4g of Indole-3-carbinol (found in cruciferous vegetables) and 10mg of piperine (black pepper extract) – in other words an encapsulated mushroom and broccoli curry. A year after the second biopsy, I am still on that regime, under active surveillance. A second recent MRI showed no change over the first. I may still have cancer and it is likely that more biopsies lie ahead. But short of having the thing out and having a good look at it, I would still prefer to know the state of those cells with the degree of certainty that only biopsies provide.

Mike W. said...

Great blog idea! I was biopsied in 2000 with results indicating a faster growing type. Gleason score was just above the comfortable line (I forget the numbers). A random PSA test at 50yrs old (in late 1999 actually)indicated a higher PSA than recommended (just above the 4.0..I think 6 or 7) which led to the "treatments". Surgery, radiation AND Lupron Depot (no fun at all). Ok for several years then rise to 1.8 and back on Luperon. 3 years then (this month) a very small PSA detected (.4) which led to retreatment with 6 month version of Lupron. Will be continued for 2 years or so. All this to ask "How would I have known about the cancer without the biopsy?" The rise in PSA alone was not enough. What might have happened if I had done nothing? (I am 62 now by the way). It is ALWAYS a hard decision as a "patient" since any of the treatments are worse than the disease (at least early stages..I'm not talking about metasticized). The treatments affect intimacy, energy and a range of other things.

Steve Jordan said...

The biopsy, as Doctor Scholz must surely know, is the ONLY test that informs the patient and medic that there exists / does not exist prostate cancer.

The oft-repeated claim that a biopsy is painful is IMO the product of ignorance and a too-subservient attitude toward the urologist. All one must do is insist upon anesthetic medication. It will always be administered if the patient is firm in his demand.

I would very much appreciate references to whatever supports the claim that ED results from the biopsy in a large percentage of patients. Where is the "study" that supports that astounding number?

Ed Dwulet said...

Would appreciate the authors response to these: (Rather than provide http use google if you want to find the source material where not cited)

The findings by Michael Karin, Ph.D., professor of pharmacology in UCSD’s Laboratory of Gene Regulation and Signal Transduction, and colleagues may help solve the puzzle of why it takes so long for cancer to metastasize, as well as what causes it to do so. Furthermore, this new work may lead to development of anti-metastatic therapies. A major hypothesis in cancer research has been that whether the cancer metastasizes or not is determined by genetic changes within the cancer cell itself. But this hypothesis didn’t explain why metastases appear many years after the initial tumor. “Our findings suggest that promoting inflammation of the cancerous tissue, for instance, by performing prostate biopsies, may, ironically, hasten progression of metastasis,” said Karin. “We have shown that proteins produced by inflammatory cells are the ‘smoking gun’ behind prostate cancer metastasis.

From the Economist 12/11/2010: Better safe than sorry Medicine: A new type of needle provides a better way to collect samples from tumours, without the risk of spreading the cancer. The researchers report in the British Journal of Cancer that in the 57 cases where standard needles alone were used, the droplets of blood that came out of the puncture wound contained tumour cells 77% of the time. In the 31 trials where both methods were used, the figure for standard needles was 68%.

Prostate cancer is the only cancer where they will do a biopsy, find cancer and offer the option of watchful waiting. The following comments are from a New York Times article: "Old Ideas Spur New Approaches in Cancer Fight." Published: December 28, 2009 Some excerpts: "Over and over, doctors and patients tell stories of injuries that seemed to spur a cancer. A blow to the breast, an operation, and suddenly cancer takes off. It may mean nothing, just an effort to explain the seemingly inexplicable. "... mathematical modeling indicates that surgery at the site of a dormant tumor can spur it to grow." "if wounding or inflammation has an effect, it happens only under unusual conditions and if tiny cancers are already present at the site of the wound." "Most likely, if there is an effect, it happens only if tiny cancers are already present at the site of the injury. " "It made her ask about biopsies ... “Frankly, this has not been studied extensively,” Dr. Polyak said. The inventor of the PSA test was quoted as saying: "All you need is an excuse to biopsy and you'll find prostate cancer."

Ed Dwulet said...

To comment on Mike W's situation, I know too many men this has happened to. PSA showing up 13 and 15 years after radical prostatectomy for "organ confined" PC.

Please consider: Google "An elusive tumor in a man who has evidence of prostate cancer metastasis" the mediacl journal article is about imaging techniques (which Mike W. might want to consider rather then masking the cause with Lupron treatments) but the interesting thing is the patient's case history: A radical prostatectomy 11 years ago at 54, PSA only 3.0, Gleason only 6, he was told his "disease was organ-confined with no lymph nodes involved and now he's suffering from metastatic prostate cancer in his lung! The lung metastasis, it came from somewhere -- was it the biopsy or his surgery.

Makes me wonder if Mike W's and a lot of other men might have been better off and their PC still be organ-confined if they had never had a PSA test and been told they have cancer.

A good analogy may be the observer effect in quantum physics (it refers to changes that the act of observing will make on the phenomenon being studied). Take two identical twins with identical prostate tumors -- one is unobserved (not biopsied) and the observed (biopsied). The current medical establishment still considers both tumors identical -- but the research I cited in my first post suggests that the biopsied prostate may be forever changed with respect to metastatic potential -- having being affected by the inflammation caused by the biopsy.

Just some more food for thought for those considering a biopsy.

Anonymous said...

Another risk of biopsies? I just wonder how many times something like this happens and we never hear about it:

From the Las Vegas Review Journal Mar. 31, 2011 | 3:21 p.m. : " Second doctor tells medical board he reused needle guides in biopsies.

"A source close to the state's infection control efforts said Newman, like Kaplan, told authorities that a vendor had said the plastic needle guides could be used more than once. A vendor told Kaplan, whose medical license has been suspended, that the plastic needle guides could be used three to five times, according to an ad written for the Review-Journal by Kaplan attorney Dominic Gentile. Authorities said Kaplan, against whom the board filed a more detailed formal complaint Wednesday, stopped using single-use endocavity needle guides only when they became "too bloody."

Gentile said he expects that many more doctors than Kaplan and Newman have reused the single-use needle guides in Southern Nevada: "I have had five or six doctors call me and confirm that's what they were told, too. " Gentile now believes, however, that the problem is a national one, not just one affecting Nevada. He said Providian distributes CIVCO equipment throughout the nation. "My best guess is we're talking about thousands, maybe tens of thousands of people, who have had biopsies done with reused single-use devices,"

"After procedures using the disposable needle guides, medical assistants would attempt to clean and disinfect the needle guides by running them under water, attempt to scrape out any remaining tissue or blood without using a brush and would then soak them in Cidex solution and allow them to dry," the complaint states. "Often bits of tissue or blood would remain after attempted cleaning and disinfecting. Guides were disposed of after becoming too bloody."

I'm not a doctor and I know enough that since the age of AIDS and widespread hepatitis you don't reuse needles! Tens of thousands? Can there really be that many dumb doctors out there?