Too Many Prostate Biopsies

BY MARK SCHOLZ, MD

Every year in the United States one million men undergo a prostate biopsy.  Biopsy has a number of potential complications including serious infections requiring hospitalization and bleeding severe enough to require transfusions. One-percent of urologists have had a patient die from a biopsy-induced infection.

Despite these daunting risks, the real danger men face is the diagnosis of cancer.  In the United States, ninety percent of men who are diagnosed with prostate cancer undergo radical treatment, even when they have the Low-Risk variety of the disease that can be safely watched.  Treatment for prostate cancer is hardly innocuous, commonly causing impotence and urinary incontinence.

Misguided but well-intentioned experts have cogently argued that the rampant overuse of unnecessary biopsies and radical treatment have become so egregious that PSA screening should be discontinued. However, evidence is strong that PSA screening does reduce prostate cancer mortality.

So how can this dilemma be resolved? Is there a way to spare the men with Low-Risk disease while still detecting High-Risk prostate cancer while it is still curable?

Historically, biopsy has been the only accurate method for detecting prostate cancer.  However, for every case of High-Risk cancer detected, four or five men get the unpleasant news that they have Low-Risk disease, a diagnosis that usually leads to unnecessary treatment.

Two reports at this year’s American Urology Associate meeting indicate that modern multi-parametric MRI detects High-Risk prostate cancer very accurately.

In Abstract #2051 Dr. Noboru reported his findings in 320 men with PSA levels less than 10. They compared MRI with a standard 14-core biopsy. Only one man with very low volume disease in the Gleason 8-10 category was missed by MRI.

In Abstract # 1444 Dr. Emberton found that MRI accurately predicted the absence of any High-Grade cancer (Gleason score of 3 + 4 = 7 or above) with 95% accuracy.  Both Dr. Emberton and Dr. Noboru used a standard 1.5 Tesla MRI.  Enhanced, more accurate three Tesla MRI is available select centers.

High-quality prostate imaging is the only potential solution to the PSA screening conundrum.  Imaging detects High-Risk cancer that needs treatment. Men with Low-Risk disease can use the same technology for ongoing monitoring.

PSA screening is not the culprit for overtreatment in the U.S.   The policy of performing an immediate random, multi-core biopsy on every man with a PSA above 4.0 is the real problem. Fortunately, MRI imaging offers a viable alternative.