Dying for a Biopsy?

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