Over-biopsying

One step along the path towards curbing over-treatment is curbing over-biopsying. I'd like to see the AUA and NCCN come out with revised guidelines for a first biopsy, which might include:

• unless very high, an established pattern of PSA progression (not just a single reading)
  
• if very high, rule out prostatitis
  
• % free PSA (and PHI when it's available)
  
• other biomarkers when they are proven (e.g., AMACR, 4KScore, other gene tests)
  
• transabdominal ultrasound - prostate size (PSA density), abnormalities, bladder emptying
  
• if Dx of BPH, consider a 5ARi
  
• if possible prostatitis, consider antibiotic
  
• only consider biopsy if PSA progression after 5ARi and antibiotic
  
• sharing of information and decision-making, using patient-decision-aids

Out of those nine talking points you listed, my urologist did 6 of those.
I have had two biopsies almost two years apart. First was negative (false negative btw) and the second was positive. I was never good at gambling.

And don't get me started on DREs! I'm not sure whether family doctors are badly trained in how to do them, or are embarrassed and just want to get it over with as quickly as possible. Mine just stuck a finger in for about a second and declared my prostate fine. The urologist spent more time poking around and found a small lump.

Because staging is reliant on the DRE, which is imprecise, and on any imaging that may be done -- most of which are not very good at finding cancer either, PC clinical staging leaves a lot to be desired. TRUS, CTs and 1.5T MRIs only detect very large, dense tumors. Sophisticated US and MRIs are expensive.

There have been some attempts to take out the human factor in DREs. Engineers in Korea developed a robotic palpation device:

Robotic palpation-based mechanical property mapping for diagnosis of prostate cancer.

And some engineers in Greece are working on an optical probe:

Development of a new optical device and its feasibility in prostate cancer detection.

Maybe a mechanical finger is the way to go (ouch!)

TA, a good list as I said on the other thread.  Additionaly, however, might I suggest that we need some guidelines on how many samples to take on the first biopsy.  There are still men showing up on this forum whose first biopsy was six samples -- talk about shooting in the dark...

Jim

My doctor used an ultrasound probe to do the biopsy and he hit 4 out of 8 cores positive. He said he could see the tumors with the ultrasound so not sure why an MRI targeted biopsy would be needed and I didn't even know anyone took biopsies blind. He said he could have taken a 12 or 16 core sample but he was pretty confident he got/hit what he needed with 8.

My family doctor never performed a DRE prior to my Dx.
It was at my yearly physical before my surgery, she decided to check. It was a 2, maybe 4 second DRE and I never felt anything, you can tell btw, when you've had a proper DRE.
I should add, my family doctor doesn't do PSA or DRE's on a man younger than 50. :-\

JNF,
The real stats on biopsies in the US are 1,000,000 annually and 750,000 are negative.
Following Allen's guidelines we should be able to reduce unnecessary biopsies significantly.
Having had 13 biopsies I was amazed at the lack of knowledge that most doctors have; it seems they have only one tool in their bag, a biopsy.
I went to UCLA for a 2nd opinion for my rising PSA after several negative biopsies. The urologist said I had BPH and if I really wanted to monitor it I should use a Hopkins nomogram. I asked him to run the nomogram while I was there, and he ran it and said it indicated a very high probability that I had cancer, but said you have BPH and not cancer so don't worry.
When I saw Dr's Scholz and Bahn for 2nd opinions years later the first thing they both did was run a calculator for expected PSA and it came out at 7.2 max given my prostate size and what was found on my biopsy. Since my PSA was 40 at the time I had 33 points of PSA that could not be explained. They actually worked backwards from that point, eliminating all causes for high PSA like infection, transition zone tumors and lymph node cancer. None of my previous 5 doctors approached my case like this; they either recommended a biopsy and when it came up negative it was obviously BPH. More knowledge would eliminate unnecessary biopsies and at the same time detect cancers that biopsies miss. The one take away I got from my experience is that all causes of abnormal PSA must be explained and can easily be done with tools that are available.
JT

nobody enjoys having a biopsy. I'd imagine everyone looks for a way out.

My urologist wasn't sure I needed one. We did a course of antibiotics first followed by a second PSA. I then waited another 3 weeks and did a third PSA.

Even then he said he thought a biopsy might be wise but that i could delay it if I wanted.

I wanted to have one.

In fairness, let's forget about prostate biopsies specifically. I wonder what the percentage of positive findings in medical biopsies in general. There are all kinds of biopsies performed for all kinds of reasons, and I would imagine a lot of them come up negative too (good for the patient). Biopsies are just another diagnostic tool used in the medical world.

david in sc

Only 25% of biopsy reveals cancer in PSA screened cases. So on the surface it would seem prudent to curb biopsy to reduce the morbidities of it. But first let's take a look at where we are:

1> Screening only after certain criteria meets a scientific standard that best targets those who need it most.

2> Follow a criteria, for the sake of this discussion, as outlined by Allen. Using logic but lacking enough science.

3> The select AS versus active therapies using some science and hoping for patient and doctor restraint. Where we have no checksum on practice and still imperfect science on whom to treat.

A complicated matter on screening gets more complicated.

Since this is the "biopsy thread" I'll comment on Allen's points on biopsy. There are nine bullet points.

1> Most men are screened by their PCP or family practitioner, or a screening event. Once a detection of suspicion is made, it's now time for the specialist where most, if not all men face a second PSA. Patients will be again screened and most assigned to an antibiotic to eliminate UTI or prostatitis. After a month or so they will be retested. This is a common practice. (the is likely at minimum a third doctors appointment)

2>If the PSA is "very high" then the step above has already been completed this is now a redundant step.

3> I see no reason why step one does not include the Free test along with the PCA urine test. Again we're redundant here and just setting up more clinical visits.

4> Other biomarkers when they are proven ~ well they are not so time to move to step 5.

5> An external US looking in to establish size and other variables. I believe that urologists would be asking on day one about the typical symptoms of BPH. If present then this 4th visit could have also been covered in the previous initial visit. An external ultrasound is cheap and easy, why not make this on day one in the urologists office? (Still a results day and at minimum visit 4)

6>A 5ARI is a good call for BPH, but the science of it's use of still open to the many debates about 5ARI and the risk of reducing PSA is likely and also controversial. (repeat visits to monitor the 5ARI progress)

7>If possible prostatitis then an antibiotic was covered on day one. Many men receive a prescription of Cipro or other antibiotics so this step is again redundant. (Repeat visits for monitoring)

8> Consider the biopsy (Another visit with another antibiotic for the biopsy)

9> Talk, talk, talk. (A visit to get the news and start the finger nail chewing)
(visits for continued monitoring or treatment planning)

As you can see I'm no fan of repeat visits to any doctors appointments at age 51 and was less so when I was 44. I suppose as I get older I'll be more interested in the fun in the examination room.

Forgotten in this was the secret handshake with the index fingers. If a nodule is felt a biopsy will follow and the rest was just for fun.

All this for a guys with a PSA at 2.5 is an awful lot. If negative please return to step one...

Just my observations...

Tony

anyone ever hear of a false positive with a biopsy?

What Tony said!
I was pretty darned sure they had my biopsy samples mixed up with someone else's! However, I was wrong. :-(

Thank you Casey...

Shocking news! There's another blow to screening coming soon.

We save 1 in 1000 men screened. Don't forget that.

Tony