Last August, I railed against too many biopsies. However, my experience at a recent prostate cancer meeting prompted me to revisit the topic for today’s blog. There is now general agreement among experts that prostate cancer is over-diagnosed. I believe this results from the excessive use of random prostate biopsy and, all too often, leads to radical over-treatment.
More than a million men in the United States have prostate tissue extracted by transrectal needle biopsy every year. Of all those biopsied, one-fourth, about 240,000 men, are diagnosed with prostate cancer. Of these 240,000, between one-third and one-half—that is, from 80,000 to 120,000—are diagnosed with a harmless condition destined to remain dormant for life. And yet, despite the innocuous nature of low-grade prostate cancer, the great majority of these unfortunate men still undergo radical treatment with decidedly negative impact on their quality of life.
The unwillingness of surgeons and radiation therapists to withhold treatment for low-grade prostate cancer is not entirely surprising given that doctors are specifically trained to treat cancer. Understandably, patient enthusiasm for treatment is also a major contributing factor, considering how dangerous it would be to withhold treatment of most any other type of cancer.
The overtreatment of prostate cancer is giving experts sufficient concern that editorials are appearing in prestigious scientific journals, such at the Journal of Clinical Oncology and Lancet Oncology, discussing the possibility of renaming low-grade prostate cancer something besides “cancer.” Everyone seems to agree that it’s unreasonable to name a condition cancer when we know this low-grade form doesn’t usually metastasize.
Given these daunting issues, I was interested to survey a group of twenty male experts at a prostate cancer meeting last month about their attitudes toward biopsy. Because the average age of the group was around sixty, everyone in the group readily agreed that if all of us underwent a standard random biopsy at least five would be diagnosed with prostate cancer. With such a high statistical risk of finding cancer, I then asked by a show of hands if anyone was interested in having a biopsy.
While an unnecessary cancer diagnosis is one risk of biopsy, there is one other significant risk: the possibility of toxic effects of biopsy itself. The Journal of Urology this month reports that with prostate biopsy the rate of infections serious enough to require hospitalization has quadrupled to approximately one in fifty. One out every twenty of these infected men admitted to the hospital actually dies—making the risk of death from biopsy is one in a thousand.
Not a single doctor raised his hand.
Fortunately there is an excellent alternative to random biopsy. Modern prostate imaging with 3-Tesla MRI or color Doppler ultrasound, is just as accurate for detecting high-grade disease. When an abnormality is detected through imaging, it can be targeted with just one or two biopsy cores instead of randomly shooting a dozen cores throughout the gland. And yet, despite the obvious advantages of imaging and targeted biopsy, practically all biopsies done in the United States are being performed randomly.
Sadly, the general public—including most primary care physicians and even perhaps the majority of urologists and radiation oncologists—remains uninformed about the advantages of modern imaging technology. For more information about biopsy and Imaging Technology see my March 27, 2012 blog, Biopsy, Biopsy Everywhere: http://prostatesnatchers.blogspot.com/2012/03/biopsy-biopsy-everywhere.html