Part 2. So Why So Many Biopsies?

 BY RALPH BLUM

 

“No More Unnecessary Biopsies . . . ” The first four words of the sub-title of our book, Invasion of the Prostate Snatchers,” are a clear statement of our objective. I am no fan of biopsies. At the same time I know that a biopsy is an essential diagnostic tool when appropriately used. The problem is that too many doctors schedule an immediate biopsy if there is only a slight rise in PSA, when it would be more appropriate to explore less invasive diagnostic methods first.

The Liability Factor: More and More Biopsies

One million men are biopsied annually in the United States. Yet only about one in five will be diagnosed with prostate cancer, and the majority of those will have Low-Risk disease—the type that will never become life threatening. Even so, most of these men will undergo some form of radical treatment. Having a biopsy is like opening Pandora’s box.

Doctors know that biopsies actually miss cancer about 20% of the time, especially in men with enlarged prostates. Which is one reason why, when an initial biopsy is clear of cancer, urologists often want to perform a second or even third biopsy, in order to confirm their initial findings. Naturally urologists are concerned about missing cancer in their patients; they don’t want to be responsible for a delayed diagnosis. They are also concerned about their vulnerability to lawsuits. In 2010, according to the Physicians Insurers Association of America (PIAA) the leading cause of malpractice claims against urologists was the failure to diagnose prostate cancer in a timely manner.  When in doubt, perform the biopsy.  “Better safe than sued.” So the number of biopsies continues to mount up.

If you and your doctor have done your due diligence, and the indicators suggest the possibility of an aggressive cancer, you need to get a biopsy. Transrectal Ultrasound (TRUS), preferably with color Doppler, is the most common method used to provide visual guidance for biopsy. A small ultrasound probe, inserted in the rectum, emits sound waves that bounce off the prostate and return to the probe with an image that is developed on a TV screen. Since cancer cells produce less reflection of the sound waves (a condition referred to as hypoechoic) the area will look different from normal prostate tissue, and thus show the urologist the precise locations to biopsy. The procedure, usually done in the urologist’s office, lasts approximately 20 minutes, should cause minimum discomfort., Total it up: a million of those procedures produces a gross revenue approaching half a billion dollars annually. Prostate cancer is a multi-billion dollar a year industry and growing. A significant portion of that industry’s growth is biopsy driven.

Prostate Oncologists: A Special Breed

After reading my first Biopsy blog (To Biopsy or Not to Biopsy—That is the Question) my screenwriter friend, Harvey Frost, reminded me that he was diagnosed with metastatic prostate cancer in 1996, and warned twice by his urologist that he had less than 5 years to live. “Since then,” Harvey told me, “I have been treated at USC’s Norris Cancer Center by a world class prostate oncologist. I was sentenced to death from prostate cancer when I was in my forties. Well, I plan on dying from something else in my 80s—no, make that my 90s!”

My best advice to any man newly diagnosed with prostate cancer is to find himself a prostate oncologist, if only for a consultation. The problem is that out of more than 15,000 medical oncologists practicing in the continental US, fewer than 60 appear to have taken a particular interest in prostate cancer, which makes them almost as rare as hen’s teeth. And even if the nearest prostate oncologist is 150 miles from where you live, make an appointment for a consultation, pack a lunch, gas up, and go!

Bottom line, when a biopsy is recommended, do your own research, and be aware of what you’re getting into. If there is any indication that your cancer is the aggressive type, a biopsy is still the best diagnostic tool available.