New Technology Revolutionizes Prostate Cancer Diagnosis

New Technology Revolutionizes Prostate Cancer Diagnosis

Written by Dr. Geovanni Espinosa
Posted November 4, 2014

No one wakes up in the morning and says, ”I can’t wait to get a prostate biopsy!”

And let’s be real here — why would you?? Having a needle pushed through your rectum (or your penis, or your perineum) into your prostate gland isn’t exactly a walk in the park. It’s straight up nightmare material.

And that’s just the procedure itself. Like all invasive medical procedures, biopsies come with side effects, too.

Erectile dysfunction occurs in about 20% of patients. And blood in the semen and urine occurs in virtually everyone who undergoes this procedure.

Then there’s the risk of cancer cells spreading — a process called “seeding” — after a biopsy. (This is not a universally acknowledged danger, but as a theory, I think it’s worth investigating. And it’s reason enough to warrant caution, if nothing else.)

But the bottom line is that, at this point in time, agreeing to a biopsy is the only way you’re getting a definitive prostate cancer diagnosis. It’s the gold standard for disease identification. And if you have a reason to suspect prostate cancer, you really have no other choice...

Or is there?

Imaging is improving, genetic tests are developing — but I don’t suspect any of these will replace screening with a prostate biopsy anytime soon. So at-risk men would be wise to suck it up and get one, assuming they’re interested in staying alive.

Unfortunately, though, that’s about as black and white as this issue gets. The real challenge here seems to be knowing whether you actually fall into this category or not.

As I mentioned last week, I only recommend a biopsy when it’s absolutely necessary. And I urge all men to get second and third opinions before they go down that road. So today, I want to talk to you a little more about how you know if your risk profile fits the bill.

First things first: One PSA value shouldn’t determine your need for a biopsy, no matter what. As I explained last week, a single high PSA score is pretty much worthless as a diagnostic tool. PSA results that rapidly rise over the course of months are a different story.

But they’re still not a green light for a biopsy.

Before you make any big decisions, your doctor should also give you a urine test called the prostate cancer antigen 3 (PCA3) test. Unlike PSA — which can be elevated for a number of reasons — PCA3 is specific to prostate cancer.

The magic number here is 35. If your PCA3 results are higher than that, then you’re essentially testing positive for prostate cancer. And yes, you want to get a biopsy to find out what you’re dealing with.

Here’s the thing, though: You don’t want the biopsy most doctors are currently offering.

Why? Because most doctors perform what’s called a “blind” biopsy — which is pretty much exactly what it sounds like. A very literal stab in the dark. Your doctor will go in and take random samples from different areas of your prostate. And you might come out of the whole ordeal with some useful information...keyword, might.

A lot of times, you come back with nothing. Which is why repeat biopsies are common...

But they’re not any easier on you the second, third, or fourth time. And given that every time you get a biopsy, you run the risk of losing your ability to get an erection and peeing blood for several weeks, I think it’s pretty obvious why this isn’t the best way to get answers.

So it’s a good thing that it’s not the only option you have. And it’s definitely not the way that I do things.

Biopsies are never going to be as effective or accurate as they can be until doctors start using the technology available to them. And in this case, that means imaging.

Since the ‘80s, doctors have relied on transrectal ultrasound to guide their biopsies — an antiquated approach that uses sound waves that register as black and white images on a monitor. Abnormal tissue does appear different on an ultrasound. But more than half of these suspicious areas actually turn out not to be cancerous. (Hence the practice of random sampling.)

Because of this imprecision, a lot of nasty cancers end up flying under the radar.

That’s why every man who comes to me with a rising PSA and positive PCA3 gets a multi-parametric MRI before we do anything else. Because MRIs are more sensitive than ultrasound — and they happen to be particularly good at revealing cancerous lesions.

An MRI essentially gives your urologist an illustrated map leading straight to your prostate cancer. And the technology is moving so fast, that it can even tip you off to more aggressive forms of the disease — a critical slice of information that will steer pretty much all of your future treatment decisions. (Or at least, it should. But more on that next week.)

If there’s nothing to see, then you just saved yourself a whole lot of pain and trouble. And if there is something there, then your doctor can fuse that imaging with ultrasound to get in and out of your prostate with the finesse of a professional marksman. No mess. No mistakes.

This is called a fusion biopsy. This combination of MRI and ultrasound better ensures that the biopsy needle goes directly to cancerous lesions. And it also delivers dramatic improvements in the accuracy of high-risk prostate cancer diagnoses.

The technology is pretty brand spanking new. So it may be a challenge to find a doctor performing these targeted biopsies. Community physicians are particularly unlikely to use this newer technique for collecting prostate tissue, since there is a relatively steep learning curve and higher cost associated with fusion biopsies. (They require a team effort between your urologist, a specialized radiologist, and a pathologist — and obviously, that’s going to demand more resources than a one-man operation.)

But there are doctors out there using fusion biopsy with incredible success. (Academic hospitals tend to stay particularly ahead of the curve — we’ve been performing them at NYU for four years now.) And as far as I’m concerned, tracking one down is a no-brainer.

Fusion biopsy is the only kind of biopsy worth doing. Because anything worth doing is worth doing right. Especially when it comes to your prostate health.

Stay tuned and stay well,

Dr. Geo

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Source: Wysock JS, et al. A Prospective, Blinded Comparison of Magnetic Resonance (MR) Imaging-Ultrasound Fusion and Visual Estimation in the Performance of MR-targeted Prostate Biopsy: The PROFUS Trial. Eur Urol. 2013 Nov 8.


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