A Few Words About Prostate Biopsy by Someone Who Will Go a Long Way to Avoid Having One

BY RALPH BLUM

The large majority of men I meet are not aware that by agreeing to a prostate biopsy they are starting down a slippery slope. The biopsy is a pivotal step—not because it is painful— when expertly performed there should be minimal pain—but because, more often than not, if any of the tissue samples or “cores” taken from different sections of the prostate prove positive for cancer, the whole radical treatment process is set in motion.

Very few men understand that in most cases, prostate cancer is the more common Low-Risk type that is not life threatening and does not require immediate treatment.

So what can be done to prevent this rush to over treatment? Especially the panic to “just cut it out?”

First of all, family doctors need to refrain from recommending a biopsy at the first sign of an elevated PSA. You’d be surprised to learn how often this happens. But a slight increase in PSA does not justify an immediate biopsy. Instead, it should merely result in a risk assessment process to determine what is really going on in the prostate.

 

For instance, an enlarged prostate, the result of Benign Prostatic Hyperplasia (BPH), common in aging men, is often the cause of an artificially elevated PSA reading. Similarly, a random laboratory error, an underlying chronic prostate infection or even recent sexual activity, can cause a rise in PSA. I remember once, about ten years ago, my PSA was unaccountably elevated. Then I remembered I had helped a friend move some heavy carpets from his house to his truck the day before the test. We repeated the test a week later, and my PSA had dropped back again to its previous level. Could it have come from my vigorous exertion?

 

So an obvious first step, when there is an unexplained shift upward, is to make certain that all the above reasons are ruled out and have your doctor repeat the PSA. If on retesting your PSA is still elevated, additional testing with PCA-3, color Doppler ultrasound or mulitparametric MRI should be considered before resorting to a biopsy and starting down that slippery slope to unnecessary radical treatment—treatment that all too often leads to incontinence and loss of sexual potency.

 

If further testing indicates that you should to go ahead with a biopsy, remember that some margin of error is always present. Biopsies fail to spot cancer about 20% of the time, especially in men with enlarged prostates. So even when an initial biopsy comes up free of cancer, you are not off the hook.  Naturally doctors are concerned about missing cancer in their patients, so chances are they will recommend a second or even a third biopsy, and one of these follow-up biopsies is likely to show something that was missed in the first go-around.

 

A better approach is to consider an image-guided, targeted biopsy with MRI or Color Doppler Ultrasound. Not only is high grade disease located more frequently, low-grade disease can be overlooked.

 

However, if this should happen, don’t panic. As Mark pointed out in our book, Low-Risk prostate cancer is so common that the likelihood of the average man harboring some degree of microscopic disease can be estimated by putting a percentage sign after his age. Low-grade disease is a normal part of aging, not something to be frightened of.

 

So if your PSA is only slightly elevated, my advice to you—depending on your age, your life expectancy, your overall health and your family history—is to think very carefully about the risks inherent in radical treatment, and don’t allow yourself to be rushed into getting a biopsy before less invasive diagnostic methods have been explored.

 

In the meantime, put that percentage sign after your age, and know you are in good company. Just remember: The odds are on your side. Time is on your side. For my part, I am doing my best to live up to the sub-title of our book: “No more unnecessary biopsies, radical treatmentor loss of sexual potency.”

Biopsy, Biopsy Everywhere

BY MARK SCHOLZ

A month ago I promised to expound more concerning our national passion for prostate biopsy. A million men are biopsied every year. Two hundred thousand will be diagnosed, the majority with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, most will undergo prompt radical treatment. Irrational fears drive most men into taking immediate action.

Since diagnosis overwhelmingly portends overtreatment, some experts have suggested that we put a stop to PSA testing. Practically speaking this will never happen. Patients and doctors alike are unwilling to forgo the information that PSA provides, imperfect as it may be.

  

Realistically speaking, PSA testing per se is not the real problem.  The problem is doctors and patients overreacting to the information PSA supplies. The solution is not less frequent PSA testing, but rather convincing physicians to slow down the rush to immediately biopsy men with slight PSA increases. Diagnosing every single case of prostate cancer is of highly questionable value. Many men would rather be spared the unnecessary knowledge that they have a non-threatening Low-Risk prostate cancer.

Rushing into an immediate biopsy only makes sense when aggressive cancer is present and that is much less common.

So where is the middle ground between immediate biopsy of every PSA elevation and forgoing PSA testing and biopsy altogether?

Before deciding to do a biopsy, the prostate gland should be measured with an ultrasound scan to determine whether it is abnormally enlarged.  If the amount of PSA elevation is proportionate to the degree of prostate enlargement, then the PSA elevation is due to benign cause. Rather than proceeding with an immediate biopsy, additional PSA monitoring and a urine test called PCA-3 may be helpful. 

PCA-3 is a relatively new test that measures ribonucleic acid (RNA) secreted by the cancer cells into the urine following manual massage of the prostate. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size and aggressiveness of a man’s prostate cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate. Low amounts of PCA-3 in the urine, say less than 40, indicate that the presence of an underlying aggressive cancer is less likely.

If the PCA-3 and PSA density are favorable, further monitoring with some form of imaging offers additional insurance against missing the diagnosis of aggressive cancer.  Modern 3-Tesla endorectal MRI and high-resolution color Doppler ultrasound, while not perfect, are reasonably accurate methods for detecting aggressive cancers. 

So in summary, biopsy should be reserved for men with elevated PSA levels that can’t be explained by a prostate infection, laboratory error or recent sexual activity. Here are some signs that a biopsy may be needed:

1.                  A PSA elevation out of proportion to the size of their gland or

2.                  Abnormally elevated PCA-3 levels or

3.                  An abnormality felt on digital rectal examination or

4.                  Imaging studies suggestive of underlying aggressive cancer.

PSA is a remarkable tool that has transformed the management of prostate cancer over the last 20 years. Rather than triggering an immediate biopsy, an elevated PSA should lead to further investigation. Rushing to a biopsy simply because PSA is elevated frequently leads to unnecessary radical treatment with detrimental lifelong consequences.

Discontinue PSA Screening?

BY MARK SCHOLZ

The recent task force’s recommendation* to discontinue PSA screening has shocked the prostate cancer community.  Yet with radical prostatectomy rates up 50% over the last five years their desire to apply the brakes is understandable. 

No one disputes that PSA testing leads to earlier detection of prostate cancer. In fact, one could argue that the problem with PSA is that it works too well, diagnosing the disease years before we even need to know about it. Attention, therefore, needs to be refocused on how doctors respond to an elevated PSA rather than recommending the end of PSA testing altogether.

Presently, at the first sign of PSA elevation doctors urge immediate prostate biopsy, taking a dozen needle samples of the gland through the rectum. More than a million men undergo this unpleasant procedure annually, risking the possibility of serious infections, bleeding and temporary impotence.

Rather than triggering an immediate biopsy, an elevated PSA should prompt additional testing with urine tests and scans along with thorough patient education about the risks of biopsy. 

Moreover, this would be a good time to educate the medical community about how to judiciously use the information PSA provides. We can’t forget the fact that 30,000 men die annually from advanced prostate cancer, and that twice that many are living and suffering from advanced disease including metastatic disease in their bones. We also need to remain mindful that studies clearly show that early diagnosis leading to the selective use of appropriate treatment reduces mortality rates.

*The public may submit comments to the task force through November 8.