Alternatives to Random Biopsy for Prostate Cancer

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 - who wants to miss cancer? But what about alternatives?  Is 12 stabs in the rectum our only option?

A million men undergo biopsy annually. At an average cost of two thousand dollars, that makes prostate biopsy business a 2-billion-a-year enterprise.

 But it’s not merely the high cost that gives pause.  Three percent of the time, after a prostate biopsy, men are hospitalized with infections.  In addition, another 100,000 receive the disheartening message, “You have cancer” albeit a Grade 6 type that is totally harmless and never spreads.  But a diagnoses of “CANCER” sets of fireworks.  Fear ends up driving men into undergoing mutilating surgery, “just to be safe.”

Obviously, biopsy is a risky and unpleasant proposition.  However, ignoring a high PSA would be irresponsible.  No one wants to miss detecting a high grade prostate cancer at a time when it can be cured.  As things stand now with the present system of doing a million biopsies annually, about one hundred thousand men are detected with higher grade cancers that can benefit from timely treatment

So the question is, how can we continue to detect the 100,000 men with higher-grade cancers that need to be detected, without over-diagnosing and over-treating the 100,000 men with harmless Grade 6?

 In addition, is there any way to avoid doing 800,000 biopsies every year that show no cancer whatsoever?  The answer to this question continues to evolve as technology marches forward. 

The latest thinking, assuming the PSA is not wildly elevated, say over 20, is to first simply repeat the PSA to confirm it is 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.  If the PSA remains elevated with repeat testing, the next consideration would be to do a new blood test called OPKO 4K Score. The 4K Score test gives 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 patient receives a 4K Score 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 odds.  Further reassurance can be achieved if the doctor who did the digital rectal exam reports that the prostate is somewhat enlarged.  In such a scenario BPH is the most likely explanation for a modest PSA elevation.  If with continued PSA testing over time the mildly elevated PSA remains relatively stable, further studies to detect prostate cancer may be unnecessary.

 

When the OPKO 4K Score test indicates that the risk of high-grade disease is above 15%, the next step to consider is performing a prostate scan with high-resolution color Doppler ultrasound, a 3-Tesla multi-parametric MRI or both.  Prostate scanning can detect clinically-significant, high-grade disease with 80-90% accuracy.  When scanning identifies a potentially high-grade lesion, the scan can be used to guide a targeted biopsy with only 2 or 3 cores rather than the traditional 12 core approach.

The government clearly recognizes that the prostate biopsy business has gotten totally out of control.  So much that the US Preventative Services Task Force (USPSTF) strongly advocates against PSA testing altogether because it leads to too many unnecessary biopsies followed by the rampant overtreatment of grade 6 prostate cancer.  The Task Force has marshalled strong, scientifically-based arguments showing that PSA testing is causing far more harm than good. They argue that the reduction in prostate cancer mortality is way too small to offset the harm of more than 100,000 men getting unnecessary surgery and radiation every year.

However, it should be noted that in 2011, when the USPSTF published their recommendations neither the OPKO 4K Score test or the 3-Tesla multi-parametric prostate MRI were available.  Now with better technology, the significant dangers created by the rampant overuse of random biopsy can be circumvented.  With more OPKO 4K Score testing and modern imaging, PSA screening can once again be considered as a reasonable method for detecting higher grade prostate cancers at the earliest possible stage, at a time when they can still be cured.  

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