Biopsy, Not PSA, Leads to Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer is way over treated, and the problem starts with over diagnosis.  Once men are diagnosed, the fear of cancer naturally drives them toward radical treatment. In 2011 the US Preventive Services Task Force intervened, trying to stop overtreatment, argued that PSA testing causes more harm than good.

Some have questioned the expertise of the panel because of the lack of representation by urologists, radiation therapists or medical oncologists --the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel constituents appear entirely appropriate to comment on screening, because this is an area of medicine usually handled by primary care doctors.  The panel members consisted of twelve MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force agrees that PSA screening may save lives. Their judgment, however, was that too few lives are saved to justify thousands of men getting unnecessary radical treatment. One statistic indicates that a thousand men must be screened to save one life within the next 12 years.

Personally, I agree with the panel in regards to over diagnosis is a root cause of over treatment. However, simply discarding PSA is an oversimplification. PSA can detect a variety of problems infection and benign prostate enlargement. Actually, the majority of men with elevated PSA, don’t have prostate cancer.

No, the real problem is after a PSA test rises. Every year, a million men are advised to have a dozen, large-bore needles jabbed into their rectums “Just to be sure there is no cancer.”  Such behavior sounds ridiculous, but really, it is just the survival instinct in action. People will do practically anything when they fear for their lives.

So if not a biopsy to evaluate an elevated PSA, what’s next?

First, the fear must be faced. Ralph Waldo Emerson says “Knowledge is the antidote to fear.” So let’s look at some basic facts:

• One out of 38 men die of prostate cancer
• One out of seven men are diagnosed with prostate cancer
• In men who are “diagnosed”
  • Five-year survival is 100%
  • Ten-year survival is 99%
  • Fifteen-year survival is 94%
    

Considering it is cancer, survival rates are great! At least these numbers should overcome any urge to rush. Clearly there is plenty of time is to study and learn more. Confusion arises because a minority of prostate cancers can indeed be dangerous. Not as dangerous as lung or pancreas cancer which kill within months. However, demise from prostate cancer certainly qualifies as “dangerous,” even if it is rather infrequent and much postponed.

These statistics reveal something else that is quite useful. Prostate management issues are of long-range nature, like saving for college or for retirement. Just as expert financial planners are limited in the ability to make predictions about economic activity ten years in the future, doctors should be equally humble in their pronouncements about the future of prostate cancer. We don’t know for sure, but we strongly suspect there will be substantial breakthroughs in the diagnosis and treatment of prostate cancer in the next ten years.

For the short term, I think the best way to proceed is with imaging the prostate with a 3Tmulti-parametric MRI or color Doppler ultrasound. Scans are about as accurate as a random biopsy for detecting aggressive cancers and they usually fail to detect the harmless low grade types, which is a good thing. However, if there is a worrisome abnormality, a targeted biopsy with just a couple cores is needed.

Over-diagnosis and over-treatment is not due to PSA. It’s the misguided policy of rushing into an immediate random biopsy whenever there is a slight elevation.  .The random biopsy procedure should be abandoned.  PSA abnormalities should be evaluated with prostate imaging A targeted biopsy can be considered in men who have a distinct abnormality detected by imaging.    

Taking Charge of Your Prostate Cancer Recovery:Fast Forward From the Old Model

RALPH BLUM

In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

 There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.
*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 3% will eventually die from it, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

 
Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.

Making Friends with Your PSA

BY RALPH BLUM

It’s a simple enough blood test. So who’s afraid of a PSA? The straight answer? Every guy who’s ever been told his PSA was elevated for his age, and that he needs to have a biopsy. Because from that point on, things can happen fast. It’s the prostate cancer version of the old Tinker-to-Evers-to-Chance double play: PSA Test to Biopsy to Surgery.

PSA is an acronym for prostate-specific antigen, a protein produced by normal prostate cells. Cancer cells, however, produce more PSA per unit volume than benign cells. Since 1986, PSA testing, although not perfect, has served as the gold standard for early diagnosis and—the area of most controversy—screening for prostate cancer.

While with the majority of younger men, early diagnosis far too often leads to unnecessary treatment and anxiety, urologists are justifiably concerned that, without PSA testing, they will miss diagnosing the less-common high-grade form. So, when in doubt, test.

So, I’m talking primarily to those of you with low-grade tumors, conditions that qualify as “chronic” and might better not even be called “cancer.” That doesn’t mean that being newly diagnosed with prostate cancer is any less of a shock. But there are things you can do to reduce the anxiety.

Bottom line, after all the millions spent and all the years of research, we still don’t have a foolproof diagnostic test for prostate cancer. So don’t panic if you get a high PSA reading. Here are some factors that can distort PSA test results in ways that don’t necessarily indicate cancer:

BPH: Benign prostatic hyperplasia, prostate enlargement caused by age or infection, can produce elevations in PSA not indicative of cancer. Check it out.

Infection: Consider the possibility of infection. When my PSA spiked unaccountably from 5 to 17, my wife, Jeanne, who practices Traditional Oriental Medicine, put me on a course of Cipro, and my PSA plummeted back to 6.5 within two weeks.

The 48 Hour Rule: Strenuous exercise, heavy lifting, sexual activity, even bicycle riding before a PSA test are all considered to negatively effect the result. So don’t do any of it before your PSA test.

Inconsistent Lab Work: Standardization between assays and labs is still lacking, making comparisons between PSA tests from different labs are unreliable. Make certain your urologist uses the same lab every time.

Then, there are those of you for whom PSA testing is a higher priority:

Family history: If you have a family history of prostate cancer, it’s advisable to begin PSA testing at 40 and repeat the test at six-month intervals.

African Americans: All African-Americans are advised to begin tests by age 40 regardless. The death rate from undiagnosed prostate cancer for African-Americans is currently twice that of Caucasian men. Partly for genetic reasons, partly from refusal to submit to the DRE, the finger-up-the-butt trick the rest of us, so to speak, take in our stride. Trust me, it’s over before you know it. 

Men Over 75: Nowadays, men over 75 are apt to be spared testing entirely. So avoid the anxiety, and have a good time? On the other hand, you might just go for the PSA test, and take the prostate cancer alert as a wake up call to get yourself a checkup.How long since your last physical, dude?

Finally, remember that the big decisions are all yours to make. So never hesitate to go for a second opinion—or a third. And if you don’t like the test results, get another PSA test done by a different lab. Or find a different urologist.

The best clinicians do not mindlessly screen all of their male patients. They decide which men should be tested based on age, symptoms, family history, expected longevity, general medical condition, physical examination findings, and—a significant factor—the patient's own request for the test. The goal of early detection remains to identify patients who have clinically significant cancers at a time when treatment is most likely to be effective.  

And here’s the really good news: 28 out of 30 men reading this blog, who do have prostate cancer, will die with it, not of it.  Regardless of its shortcomings, the PSA is still the most useful test that is widely available.

So if you’ve been avoiding it, have a PSA test done this week. And while you wait for results, instead of fretting, call the golf pro and get yourself a tee time for Saturday.

Risk

BY RALPH BLUM

Prostate cancer is the most common non-skin cancer in the U.S. affecting one in seven men. It is estimated that there are nearly 3 million American men currently living with prostate cancer and it is still not known what causes the disease. However, here are the main factors that might affect your risk level of risk.

Age
Age is the most significant risk factor. Your risk increases exponentially as you get older. In old age, up to 8 out of 10 men harbor microscopic amounts of the disease in their prostate, live with it, and die of something else. In the opinion of one well-known urologist, “If you are over seventy and you don’t have prostate cancer, chances are you’re a woman.”

A Family History of Cancer
Generally speaking if you have a father or brother who was diagnosed with prostate cancer you are twice as likely to develop the disease compared to the average man, while men with two or more relatives with the disease are nearly four times as likely to be diagnosed. If your relatives were diagnosed before the age of 60, this increases the risk slightly. And the younger the age at diagnosis, the more likely it is you have a faulty gene called BRCA2 in the family. Cutting edge research is ongoing to read and interpret the genetic code of prostate cancer.

Race & Ethnicity
Prostate cancer is more common in black Caribbean and black African men than in white or Asian men. The difference seems to be a mixture of inherited genes and environmental factors. African American men are 56% more likely to develop prostate cancer than Caucasian men, and nearly 2.5 times more likely to die from the disease.

Height & Body Weight
Research has shown that taller men have a higher risk of getting aggressive prostate cancer, or prostate cancer that has spread. And there are a number of studies confirming that men who overeat and who are overweight display increased incidence and aggressiveness of the disease.

IGF-1
Insulin growth factor is involved in the regulation of normal cell growth and death. Some studies have shown that men with a higher level of IGF-1 in the blood have a higher risk of developing prostate cancer. So it is not high blood sugar, but rather the high level of insulin triggered by high blood sugar that stimulates rapid cancer growth.

So what can you do to inhibit prostate cancer growth?  Unfortunately, the days of eating everything you want are over. There has never been a more important time in your life to eat sensibly.  Your diet can no longer be rich in animal fat, processed and fast food and low in fruit and vegetables. We did not evolve and develop to eat this way.  This doesn’t mean you can never have another piece of pizza.  But it does mean that having less than 10% of calories from animal protein can result in a dramatic reduction in cancer risk.

Bottom line, you are not without power in influencing your level prostate cancer risk.

A Closer Look into the Book

MARK SCHOLZ, MD, prostate expert and medical oncologist and Ralph Blum, living with prostate cancer for over 20 years, co-authored "Invasion of the Prostate Snatchers:  Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency."  Written for newly diagnosed men - do research before you take the next step, rather than rushing forward.  They present a closer look into the book with these three videos CLICK HERE

KNOW YOUR OPTIONS

RALPH'S JOURNEY

DOCTOR MEETS PATIENT

The Power of a Word

BY MARK SCHOLZ, MD

At an Active Surveillance Consensus Conference in 2007, it was openly bemoaned that the word “cancer” profoundly overstates the significance of low risk prostate cancer.  The pathology experts who were present, however, shot down the idea of a name change saying, “Under the microscope it looks like a cancer, so it’s cancer.” At that time no one had a rebuttal, so the subject was dropped. Now studies confirm that Gleason grade six prostate cancer never metastasizes.

In retrospect, I wish the conference attendees had been able to rise up to the name-change challenge. Back when the makers of 7-Up wanted to emphasize the distinctness of their product compared to other soft drinks, they came up with the name “Un-Cola,” a stroke of marketing genius. Since the pathology experts insist that low-risk disease is a cancer—we should undo the negativity of this word by renaming it: “The Un-Cancer.” Alternatively, the SHADES of Blue classification system calls this harmless type of prostate cancer SKY BLUE.

Misinterpreting the significance of the word cancer leads everyone to think, “I had better be safe and remove the gland.”  The biggest challenge of educating people about prostate cancer is overcoming their preconceived notions, what they already think they know about cancer.  Random biopsies are detecting cancers that are so small that even if they grow while under observation, they will still be curable.  And for the minority of men on active surveillance who develop progressive disease, at least they have real proof that their cancer truly needs intervention, for this minority, it’s not a paper tiger and undergoing treatment is justified.

Defining the Un-Cancer—The Basic Components of SKY

	Favorable	Ambiguous Zone	Unfavorable
Color Doppler or Multiparametric-MRI	< 10 mm  in maximum tumor dimension	11-17 mm  maximum tumor dimension	> 18 mm max tumor dimension
Highest Gleason Grade	Grade 3 + 3 = 6	3 + 4 = 7	4 + 3 = 7 or higher
PSA Density	Under 0.13	0.14 to 0.17	Over 0.18

Further In-depth Testing for SKY
New technology is also providing new insight into how favorable cancer can be distinguished from unfavorable cancer. The biggest advance is better imaging of the prostate. Other new blood and genetic tests such as Prolaris, Oncotype, MDx, OPKO 4K and Mitomics, can also ferret out the cancers that are prone to behave more aggressively or have been missed on the initial random biopsy.

The Drawbacks for Active Surveillance
The main concern is that the initial random biopsy missed a higher grade tumor somewhere else in the prostate. Most centers address this problem by doing random biopsies over and over. Repeated random biopsies are unpleasant and they can cause serious infections.  Multiple biopsies have also been associated with higher impotence rates and worse urinary symptoms. A better way is to rely on modern imaging with color Doppler ultrasound or multiparametric MRI (MP-MRI). Also, because with active surveillance prostate gland is left intact, there is the possibility of a new, higher grade cancer developing. The privilege of keeping the prostate intact entails the responsibility of close monitoring. Then, if a new higher grade cancer subsequently develops, it can be detected and treated at an early stage.

Anxiety and uncertainty about living with untreated cancer is also a problem, one that is often magnified by the treating physicians, surgeons or radiation doctors who often send an ambivalent and lukewarm message about active surveillance to their patients.  This half-hearted attitude is probably rooted in the doctor’s own uncertainties about untreated cancer. Despite all these very real issues, however, studies show that men on an active surveillance program are no more anxious than men who have had surgery or radiation and are being monitored after therapy to make sure their cancer stays in remission.

It’s Hard to Teach an Old Dog New Tricks
It’s easier to teach a proper golf swing to a true beginner than to someone who has previously developed bad habits.  The mind of a child learns a new language much more easily than the cluttered mind of the adult.  Good first impressions are valued so highly because we all know how hard it is to undo a bad first impression.  Changing the mindset of doctors and patients about how to treat something called CANCER is going to be a slow process.

Men need to realize that survival rates with low-risk prostate cancer managed with observation are extremely favorable.  Studies show that survival with active surveillance matches the survival of men getting immediate surgery. Men need to guard themselves from being rushed into unnecessary treatments that have irreversible side effects.

Multiparametric MRI Prostate Imaging

BY MARK SCHOLZ, MD

Historically, prostate imaging with CT, ultrasound or MRI has been too inaccurate for diagnosing prostate cancer.   Random needle biopsy has been the mainstay of accurate diagnosis. However, after a number of false starts, advances have brought multiparametric MRI (MP-MRI) into the winner’s circle, even surpassing the accuracy of random biopsy.

Prostate Imaging Presents a Special Challenge
Success with prostate imaging has been a long time coming. While mammography for breast imaging and CAT scans for lung cancer have enjoyed mainstream use for decades, the technology to differentiate the high-grade prostate cancers from harmless, low-grade prostate cancers—those that experts believe are better off being left undiagnosed—has only been developed recently.

New Technology Brings Growing Pains
You might think that new technological advances would immediately revolutionize prostate cancer management. Not necessarily. Many doctors simply don’t know what’s now available. Those that are aware are often unacquainted with the full extent of its capabilities. And finally, even the fully informed doctors may be reluctant to venture outside their comfort zone and embrace MP-MRI as a substitute for doing a random biopsy.

Barriers to Change—The Status Quo has Deep Roots
Random biopsy has been the de facto standard for 25 years.  Prior to MP-MRI, biopsy was the ONLY way to confirm the diagnosis of prostate cancer and obtain accurate information about its extent. Additionally, periodic random biopsy has been fundamental to the monitoring process in men with low-grade prostate cancer on Active Surveillance. Biopsy has grown to become a very big business, performed in more than a million men annually.  It is financially lucrative, paying thousands of dollars to providers for each procedure.

Ending the Twenty-five Year Reign of Random Biopsy
Random biopsy has major drawbacks. It misses high-grade cancer 15% of the time and 3% of men end up in the hospital with uncontrolled infections.  Repeat biopsies, such as those done to men on active surveillance are uncomfortable, affect erectile function and incur an even higher risk of infection. Most importantly, random biopsy over-diagnoses 100,000 men annually, leading to rampant and excessive use of surgery or radiation.

Imaging with Multiparametric MRI 
MP-MRI detects high-grade disease accurately and, thankfully, overlooks low grade disease, thus sparing the shock of an unnecessary cancer diagnosis and, in many cases, unwarranted treatment. Any suspicious lesions that are detected can be further investigated with a targeted biopsy, a more accurate way to find high-grade disease that requires far fewer biopsy cores. Men with a clear scan can usually forgo biopsy altogether. The word “Multi-parametric” means the performance of three scans sequentially during a single visit to the imaging center: 

1)    T2-weighted imaging allows for the best assessment of the prostate morphology, size, margins and internal structures with easy differentiation between the central and peripheral zones.

2)     Diffusion-weighted imaging details the tissue microstructure and generates an “apparent diffusion coefficient” (ADC) which helps to determine the aggressiveness of a lesion if one is seen.

3)    Dynamic contrast-enhanced imaging detects areas of increased vascularity to better detail any suspect lesions.

The radiologist who reads the scans unifies the information from all three modalities to compile a report. Findings are then summarized in an overall impression which falls into one of three categories:

First: No evidence for high grade disease, no need for biopsy

Second: A suspicious lesion is detected, a targeted biopsy is probably necessary

Third: An ambiguous area is detected. Either a targeted biopsy can be considered or alternatively, ongoing monitoring with another scan in 6-12 months can be considered

Scanning in the Context of Prostate Size, PSA and Age
Men’s prostates come in many sizes and shapes.  MP-MRI accurately measures prostate size, which is essential to interpreting PSA because an enlarged prostate produces higher PSA levels. An oversized gland, therefore, provides a reassuringly benign explanation for a modestly elevated PSA. Since many forms of prostate cancer take decades to grow large enough to present a problem, a man’s age is also relevant to the interpretation process. For example, elderly men with rather small ambiguous lesions (Third) might be advised to follow up with further scans to determine if it grows rather than going to a biopsy right away.   

Scanning at a Center of Excellence
Very few imaging centers can do prostate imaging at the level of quality we are discussing. There are essentially three components required to achieve reliable results: State-of-the-art, three-Tesla hardware; technicians who are precisely trained in how to perform prostate imaging; and physicians carefully trained specifically in the interpretation of prostate imaging. Imaging technology is developing so rapidly that even some board-certified radiologists remain unaware of what the latest technology can achieve.   

Don’t Be Cheated Out of the Best Technology
Today’s MP-MRI scans, when performed at centers of excellence, generate prostate images of stunning clarity. Every effort must be made to raise general awareness among patients and doctors alike about the advantages of MP-MRI over random biopsy in men with high PSA levels and in men who have been diagnosed with low-grade cancer that are pursuing Active Surveillance.   

PSA Screening for Prostate Cancer

BY MARK SCHOLZ, MD

Most elderly men already have prostate cancer—they just don’t know they have it.  And they might be better off remaining ignorant. Newly-diagnosed men are thrown into an eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that a New England Journal of Medicine study estimates that forty-eight men are getting unnecessary surgery or radiation for each individual who truly benefits from them.

Random Biopsy, Not PSA is the Real Problem
When PSA is elevated, primary care physicians usually refer to a urologist for an immediate 12-core random prostate biopsy. One million men are biopsied annually in the United States. Few people realize that even when the PSA is normal, the biopsy will be positive 20% of the time. The problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads to surgery or radiation.

Biopsies Are Not Benign
Over-diagnosing Low-Risk prostate cancer, and the attendant risk of over-treatment, is not the only problem caused by random biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men are literally frightened to death by the discovery of prostate cancer: The first week after diagnosis, the risk of suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced infections resulting in hospitalization. Fatal infections are estimated to occur in approximately one-thousand men undergoing random biopsy per year.

Stop PSA Screening?
Due to all these mounting negatives, the US Preventative Services Task Force now recommends that routine PSA testing cease altogether. The Task Force’s conclusion was that unnecessary treatment to over a hundred thousand men annually is too big a price to pay even though PSA screening saves lives. The Task Force fails to understand that overtreatment isn’t caused by PSA, it’s what physicians do with the information PSA provides—they automatically refer every patient for immediate random biopsy.

PSA Is Heavily Influenced by Prostate Size
Most PSA originates from the prostate gland, not from cancer. Therefore, when the cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA normally averages one-tenth of the prostate volume. For example, the average PSA for a 30cc prostate is 3; five for a 50cc prostate and 10 for a 100cc prostate with size determined by ultrasound or MRI.

Therefore, PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a 50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such as low-grade infections, lab variations and recent sexual activity can also cause PSA to vary.  Repeat testing helps average out these variations so the “real” PSA can be determined.

Primary Care Doctors Are the Source for Balanced Counsel
Only the primary care physicians can stop the mindless rush to random biopsy. Instead of referring for random biopsy they can send their patients with elevated PSA for prostate imaging with multiparametric MRI or Color Doppler Ultrasound. Imaging can put the PSA elevation into context by determining the prostate size. Also, in the hands of an experienced radiologist, using state-of-the-art, three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.

If imaging detects a high-grade lesion, primary physicians can then counsel their patients about whether a targeted biopsy directed at the abnormal lesion should be performed. Alternatively they can recommend simple monitoring with a repeat imaging study six to twelve months down the road to determine if the lesion is growing. Lastly, if a targeted biopsy shows cancer, rather than being guided by a urologist, who is, after all, a surgeon, patients can obtain counsel from their primary physician, a non-surgeon who can provide unbiased assistance in selecting the best treatment.

Estimating Cancer Risk
If men are concerned about the risk of forgoing an immediate random biopsy they can estimate the percentage likelihood of harboring low-grade or high-grade disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”

Imaging Rather than Biopsy
Prior to PSA screening men should be informed that if PSA is high, the first step should be imaging rather than random biopsy. Random biopsy can cause serious infections. It also diagnoses Low-Risk prostate cancer, a harmless condition that nevertheless, often leads to unnecessary treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled improperly, lead to unnecessary treatment with many lifelong side effects.   

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

Stress: Romancing the Immune System (Part 2)

BY RALPH BLUM

Thanks to having to find a way to co-exist with prostate cancer for nearly a quarter of a century, I found myself enrolled in “Stress 101.”  And as I don’t have Mark’s scientific background, my take on how to alleviate the inevitable stress of dealing with this disease revolves mainly around mind-body interaction; in particular, the ways in which our chronic fears and concerns inhibit immune function and thus jeopardize our recovery.

Around three thousand years ago, King Solomon declared that, “A joyful heart is good medicine, but a broken spirit dries up the bones.” And I learned from Mark that the “wet” part of the bones—otherwise known as the bone marrow—is where the immune system is located.

In Invasion of the Prostate Snatchers I reported that, due to my refusal to redo a botched biopsy, there was no “proof positive” that I had prostate cancer. So, despite a urologist’s report evaluating the lump in my prostate as “suspicious for well-differentiated adenocarcinoma,” I returned to my home on Maui where I spent nine peaceful years enjoying my life. I had no idea at the time that those worry-free years in upcountry Maui supported and even strengthened my immune system. I am now convinced that they helped to keep the cancer dormant, on hold.

But then a series of life circumstances left me chronically stressed and depressed. I began to worry that perhaps I had been a fool not committing to treatment. And sure enough, that was when my PSA began to climb and the tumor began to grow.

My ignorance about the immune system at that time was monumental, but when I started to find out what makes it tick, I realized that my brain was constantly sending my immune system chemical messages which, for better or worse, influenced its ability to function. There is no doubt that good nutrition and staying physically active play a role in supporting a healthy immune system. My problem was I have never been big on raw foods, low carbs or a high intake of leafy greens. And I have an aversion to most forms of exercise. So I decided to focus on “romancing” my immune system by sending it benign signals.

In my next blog I will go further into what I have termed positive emotional-chemical text messages.

A Prostate Biopsy Can be Dangerous

BY MARK SCHOLZ, MD

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

What is a Mindless Biopsy?

MARK SCHOLZ, MD

The recent recommendations by the U.S Preventative Services Task Force to stop PSA screening are articulated as follows:

1.  The magnitude of harms from screening (e.g., falsely high PSA, psychological effects, unnecessary biopsies, over diagnosis of indolent tumors) is “at least small.”

2.  The magnitude of treatment-associated harms (i.e., adverse effects of surgery, radiation and hormonal therapy) is “at least moderate”—particularly because of over treatment among men with low-grade disease.

3.  The 10-year mortality benefit of PSA-based screening is “small to none.”

4.       The overall balance of benefits and harms results in “moderate certainty that PSA-based screening … has no net benefit.”

In the United States a diagnosis of prostate cancer leads to radical treatment 90% of the time, even when men are diagnosed with the Low-Risk form, the type that experts agree can be safely monitored. In fact, since the definitive consensus conference of 2007 in San Francisco stipulated that active surveillance is a reasonable treatment methodology, the use of surgery has increased.  In 2005 approximately 56,000 men had radical prostate surgery.  This number ballooned to 88,000 in 2008.

Surgery is overused because of ignorance about the innocuous nature of Low-Risk prostate cancer and ignorance about the devastating consequences of surgery, which include impotence, incontinence, Peyronie’s disease (crooked penis disease), climactauria (ejaculating urine), urethral scaring and penile shrinkage.

Superstar surgeons are only successful in making 50% of 58-year-old men and 25% of 65 year old men “happy” when happy is defined as staying cured, not leaking urine and having a modicum of erectile function.

A prostate cancer diagnosis is dangerous, even if the terrible risks of over treatment are ignored.  This year the New England Journal of Medicine reported that in first 3 months after a diagnosis of prostate cancer, the rate of heart attack and suicides both increase by about 200%.

Even though the Task Force is entirely correct about the dangers of over treatment, PSA is an inexpensive test that’s proven to saves lives; it is here to stay. In reality, the essence of the problem is not PSA.  The problem resides in the mindsets of the doctors and patients. The doctors doing the biopsies, the urologists who are surgeons, are intensively trained to be action oriented.

The general populace is just as much to blame because the average person knows next to nothing about prostate cancer. When confronted with the shock of a cancer diagnosis, patients naturally assume prostate cancer just as deadly as other cancers.  Surgical removal seems like the most logical way to proceed.

No one has any idea what they are getting into before they are diagnosed. Yet more than a million men rush into a prostate biopsy every year wondering, “Do I have prostate cancer?”  But what are they wondering about?  It is a medical fact that more than half of elderly men harbor some form of prostate cancer. Even men with normal PSA levels will have a positive prostate biopsy 20% of the time.

If you are going to have a biopsy, prepare yourself to have prostate cancer.

So if PSA is abnormal, say between 2 and 10, what should a man do?  First, an individual’s risk of having cancer can accurately be estimated prior to biopsy using a calculator which is available on the web.  The calculator can be accessed by googling “PCPT Risk Calculator.” The real value in this calculator is its capacity to predict the risk of having high-grade prostate cancer, the type of prostate cancer that does require treatment.

In addition, men should consider measuring the size of their prostate gland with MRI or ultrasound. Men with a prostate gland that is in the 30-60 cc range are only one-fourth as likely to have prostate cancer as a man with a prostate that is less than 30 cc. Men with a prostate volume more than 60 cc are only one-tenth as likely to have prostate cancer as a man with a prostate less than 30 cc. High quality imaging with color Doppler ultrasound or 3T MRI can also “see” cancers, especially the larger more malignant types that need treatment.

It’s understandable that people are uninterested in these mundane issues prior to a diagnosis. They think they don’t have it.  The sad fact is that the majority of elderly men do have it.  All it takes is a biopsy to open Pandora’s Box.