Your PSA is elevated. Now your doctor recommends a needle biopsy, 12 cores through the rectum to check for cancer in the prostate. Sounds icky, but also logical; after all who wants to miss cancer? But come on, do you really have to do 12 stabs via the rectum?
Each year over a million men submit their prostates for a biopsy. At an average cost of around four thousand dollars, the prostate biopsy business is a 4-billion-dollar-a-year enterprise. But it’s not merely the cost that gives pause. Three percent of men end up hospitalized with life-threatening infections. Around a 100,000 men every year get a confounding diagnosis of Grade 6 prostate cancer, a truly harmless entity, unless you get suckered into an unnecessary radical prostatectomy.
Obviously, prostate biopsy is an unpleasant proposition with notable risks. However, ignoring a high PSA incurs the risk of missing a diagnosis of a higher grade prostate cancer. As things stand now, of the million biopsies being done annually, over a hundred thousand men with Grade 7 or higher cancers are being detected. For these men, their early diagnosis is beneficial, leading to early, curative treatment in a timely fashion.
How can we detect the 100,000 men with higher-grade cancers that need to be detected without doing 900,000 “unnecessary” biopsies? The answer to this question continues to evolve as technology marches forward. Our latest thinking at Prostate Oncology (assuming the PSA is not wildly elevated, say over 20) is a three step process:
1.
Simply
repeat the PSA to confirm it is indeed abnormally elevated. All sorts of things can cause temporary
elevations of PSA ranging from nonspecific inflammation of the prostate, to
recent sexual activity, to simple laboratory errors.
2.
If
the PSA remains elevated with repeat testing the next step to consider is an
OPKO-4Kscore blood test. The OPKO test reports a percentage estimate of the
likelihood of higher grade cancer being present. The test is not perfect, but it performs
pretty well. For example, if a specific
patient receives an OPKO report with an estimated risk of high grade disease of
less than 15%, a standard random biopsy (if he elected to do one) will confirm
the absence of high grade disease 92% of the time. Not bad.
3.
Our
next step at Prostate Oncology, in the cases where a patient has an OPKO test
indicating that the risk of high grade disease is over 15%, is to obtain a prostate scan with high-resolution color Doppler
ultrasound or with a 3-Tesla multiparametric MRI. With scanning, the location
of the high-grade disease can be determined over 90% of the time so that a targeted biopsy with 2 or 3 cores can be
substituted for the traditional 12-core biopsy.
The business of
prostate biopsy has become so out of control the US Preventative Services Task
Force advocates against PSA testing
altogether. The Task Force’s
scientifically-based arguments that PSA testing is causing more harm than good
are really quite convincing. However,
back in 2011 when they published their recommendations, the OPKO test and
3-Tesla multiparametric prostate MRI were unavailable. With the advent of these new
technologies, PSA screening to detect higher grade prostate cancers at an early
stage when they are still curable makes perfect sense.
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