MARK SCHOLZ, MD
Screening for
prostate cancer is big business. The PSA blood test, first implemented in the late 1980s, resulted in a doubling in the
number of new cases, from 100,000 a year to more than 200,000 annually. The
cost of simply diagnosing prostate cancer—after adding up doctor, lab and
pathology charges—easily surpasses a billion dollars annually.
Cancer is diagnosed
by a specially-trained doctor, a pathologist, who examines the prostate tissue
under a microscope. Tissue is extracted by needle biopsy, a procedure that is
performed in a doctor’s office. The patient lies on his side and an ultrasound
probe is inserted into the rectum. Then after Novocain is injected, 12 to 14 tissue
samples are removed using a spring-loaded needle gun that is fired in a grid
pattern over the surface of the prostate . The tissue samples are then transported
to the pathologist who determines whether or not cancer is present.
Over a million men
undergo a prostate biopsy each year. Immediate biopsy at the first sign of PSA
elevation has been the standard approach for more than 30 years. However, this
policy needs to be reconsidered. Last year the US Preventative Services Task Force reconfirmed their strong warning against
PSA screening, pointing out that it leads directly to an egregious degree of
overtreatment in men with microscopic amounts of harmless low-grade prostate
cancer. The problem is that surgery and
radiation induce shockingly high rates of permanent sexual dysfunction and loss
of urinary control. These are distressingly serious problems when considering
that treatment is frequently unnecessary in the first place.
Until recently, the
needle biopsy procedure itself was perceived as being reasonably safe. However,
two just-released studies indicate that it is nowhere near as innocuous as most
physicians had assumed. For example, at
the American Urology Association meeting in May, doctors from Memorial Sloan
Kettering reported that infectious complications requiring hospitalization occur 2.8% of the time.* In a separate
study at the American Society of Clinical Oncology meeting, Dr. Boniol from the
International Prevention Research Institute reported that 1.3 deaths occurred for every 1,000 men who
undergo biopsy. To put this latter finding in perspective, Dr. Boniol
commented, “This prostatic biopsy mortality
would occur earlier than any benefit from a screening program and could reverse
any potential gain from screening…”
Fortunately, there is
an alternative to immediate biopsy. MRI
scanners can guide a biopsy needle directly to the area of the prostate gland
where the disease is located, thus allowing a reduction in the number needle
biopsies by 90%. While there are
drawbacks to this new technology—it requires special training and the equipment
is expensive—the risk of serious infections should be much lower.
Change is often
resisted by the status quo, especially when it involves a major shift in
reimbursement patterns. Doctors who do
random prostate needle biopsies will likely view these technological
advancements with suspicion. Even so, the 30-year old methodology of puncturing
the prostate with multiple random needle sticks is overdue for replacement.
Noninvasive MRI imaging technology to detect prostate cancer is a far more
sensible way to evaluate men with rising PSA levels.
*Abstract 1244 -The Impact of Repeat Biopsies on Infectious Complications in Men with Prostate Cancer on Active Surveillance: a Prospective Study
5 comments:
That was my thinking before having an multi parametric MRIS on a 3.0 Tesla. The Radiologist determined I have equivocal findings on two small lesions of 8 and 5mm each.No ECE, PI-RADS score of 3 each. Yet he told me I probably score between gleason 6 and 7. I am 58, have a small prostate, (13cc), no symptoms. Last PSA is 5.4, Free PSA 10.6%. PSA density is 0.42ng/ml. Spectroscopy didn't turn out Choline+C/Citrate due to "low volume". So by some measures I should be low risk except for the HIGH PSA Density and low free psa? I was told by the urologist to seriously consider total ablation and hope to spare one of the two neuro vascular bundles. Everywhere I've called for a 2nd opinion, insists I need biopsies if I want to be seen... So now I have great pics on a DVD of my prostate and mid body anatomy, but I can only go out of the country for a treatment I may not need. Catch-22 and confused. Would love Dr Scholtz' opinion or guidance...
Thanks,
JTM
PCRI, The Prostate Cancer Research Institute is a charitable not-for-profit organization whose mission is to improve the quality of men’s lives by supporting research and disseminating information that educates and empowers patients, families and the medical community.
They havea a helpline you may call 800-641-PCRI and a public forum called "blue community"
http://prostate-cancer.org/whats-your-shade/
To consult with Dr. Mark Scholz, you may fill out a new patient request here:
https://prostateoncology.com/patients/application
There is also information written by Dr. Scholz on our web site that may be helpful: http://prostateoncology.com/education/fundamentals_of_treatment
Wouldn't a PCA3 test be the best next step before any kind of biopsy?
If you have a negative prostate biopsy but continue to have an elevated or rising PSA or have abnormal DRE, family hx, etc. would you consider having the ConfirmMDx test done? Urologist said it's a non-invasive test that uses the tissue from your prostate biopsy to confirm that your biopsy was truly negative. It has a high negative predictive value and could help forego an unnecessary repeat prostate biopsy. Your thoughts??
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