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Color Doppler Transrectal Ultrasound

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Posted 9/2/2010 3:32 AM (GMT 0)
Thanks to members of this and other forums and a special thanks to Lucky Penny for enlightening me that there was another way to go looking at things after a high PSA. The UDocs that I have consulted all quickly recommended biopsy. I just couldn't get comfortable with the carpet bombing approach to look for PCa. Color Doppler is not the cheap, one size fits all scan that every UDoc does, and I might add at great profit for themselves and the hospital they are affiliated with, but rather a specialized, high resolution version that has the ability to measure blood flow. The procedure is just like the TRUS but with incredible detail. Now then, I will tell all of you, everyone recommends what ever procedure they choose but I hope I can objective in why I choose this procedure rather than TRUS.

I will tell you that my Doppler scan revealed two areas of concern, one showing increased blood flow and thus of greater concern. I choose Dr Bahn in Ventura Ca....he is one of the innovators of the procedure and is internationally recognized....I tried to go the best, not the cheapest (for the record, I paid the bill entirely....we will see if the insurance covers it.) Both areas were Biopsied and as it turns our, both were Negative!.....thankfully! But here is another benefit....because the Dr. can actuall see areas of concern and those of no concern, the biopsy is very specific.....if there is cancer, it will be found....the first time. That along is reason enough IMO to get one but, in the event it is negative, you can be quite sure it really is negative and not "we missed it" negative. As JohnT pointed out and confirmed by Dr. Bahn, we now have a baseline. That baseline will prove invaluable should further scans be required due to changes in PSA or DRE.

Just because I am negative now doesn't mean I am leaving the forum, I want to offer support to those with different outcomes, offer help in research for those who need it and to answer questions for those who are just beginning. This and other forums have been far greater help than anything else.
Posted 9/2/2010 4:12 AM (GMT 0)
Just some thoughts...

It certainly is a good idea to follow the size and location of tumor regions within the prostate, if possible. If someone has a tumor in the brain, neurosurgeons sometimes follow it with MRIs to see if it is growing. My understanding that this is a lot more difficult with the prostate because the cancer often doesn't look very different from normal prostate tissue on the scan, and because the cancer isn't always localized to masses, but can be more diffuse. This method is an attempt to better distinguish the cancer areas. It'd be easier to do this and get fewer biopsies, but I've had two biopsies, and they aren't all that bad. Also, if there is a tumor mass near to the outside of the prostate ready to escape, that'd be a good thing to know, so maybe these scans can do that.


Is this perfect? Unlikely. If there were a few high grade tumor cells that were diffusely spread in the prostate and not in a mass, I bet this method might not see them. I think any method misses something.

Also, I'm not sure that I could agree with the comments about money. You mention that the method you don't like is profitable for the doctors and hospitals that perform it, but then tell us that the doctor you like requires you to pay cash up front for the test that you do like. This seems inconsistent. It's better not to guess about the these guy's motives, but to try to read the studies and talk to people to figure out the strength and weakness of the evidence that a particular approach is the best one.
Posted 9/2/2010 4:19 AM (GMT 0)
Windquest.....Lucky Penny here aka cooper360 [don't know why 2 names I guess when I started posting I freaked out LOL lucky if I knew my real name!!!] Hopefully the people that are familiar with color doppler can let some know the advantages of this scan,especially when just starting out w/elevated psa. Through our experience maybe some will benefit! So glad for your results, my husband and I know the feeling!
Posted 9/2/2010 4:22 AM (GMT 0)
Four Genes Signature Urine Test, developed by Health Discovery Corp.

Windquest, THIS is what you have been looking for..During its clinical trials, it spotted 93% of ALL PC, many of them in younger men with very low PSA scores...

When used in conjunction with a PSA test, it can eliminate most unnecessary biopsies..

http://www.healthdiscoverycorp.com/pr/aug7_08.htm

Post Edited (Fairwind) : 9/1/2010 10:32:40 PM (GMT-6)

Posted 9/2/2010 4:22 AM (GMT 0)
I've just recently hear of color dopplar study. I'm confused, why did you have to pay cash and hope insurance reimburses you? Is it experimental? What a shame that insurance won't help us poor guys if that is the case. Nobody ever mentioned it to me when it was my turn to face prostate ca.....
Posted 9/2/2010 4:22 AM (GMT 0)
signature i hope
Posted 9/2/2010 4:30 AM (GMT 0)
As a comment about the money....the Dr. takes insurance like all the rest BUT here is the kicker.....the billed amount vs the cash amount was unbelievable. There was a possibility that my insurance company might refuse one part of the exam (billed at a ridicules rate) and I had not met my deductible. If my insurance paid for everything @ 80%, my out of pocket would have been greater than the cash price. My comments about the profitable business is that Drs order about 800,000 biopsies a year...that's big business in anyone's book. Worse, the carpet bombing method that comes back negative gives the patient zero confidence that there is no cancer....only none was found, and almost every post I have read notes another carpet bombing biopsy in 6 months or a year. Now then, I agree that cancer cells are pesky things and avoid detection, however i truly believe that with Color Doppler, anything concerning is detected. Those areas are biopsied. The scan reveals increased blood flow which seems to be an indicator of Cancer activity. And I agree that no test is perfect. Dr Bahn recommended continued checking but only recommended another scan / biopsy if something changed and was also revealed against the baseline. My common sense tells me that is is at least a better approach than the traditional "shot in the dark" and repeat and repeat and repeat. I also am not very trusting....and that means I am sending my "negative" slides out for a second opinion!
Posted 9/2/2010 4:35 AM (GMT 0)
My husband had color doppler w/ Dr Fred Lee [Dr Bahns mentor] & Blue Cross covered it [even as second opinion] I guess the best route is to check w/insurance first. Cost for scan $350.00 ,diagnostic fee $350.00!
Posted 9/2/2010 4:39 AM (GMT 0)
Fairwind......quite true. I will avail my self to this test as soon as I can. I think we all just want to know for sure (if that is possible). With a positive you ARE sure but a negative is anything but sure. I think that Dr. Bahn may have greater confidence is the procedure than is realistic, but until the urine test you mention, this is IMO the best that was available.. For those of us that are negative now, must never become complacent.....in fact, we should be all the more watchful and demanding. As I stated before, I am sending the negative slides out for a second opinion and will be visiting the Doc in three months. And the best to you on Friday!!!!
Posted 9/2/2010 10:47 PM (GMT 0)
Color Doppler is a very useful tool. When used in conjunction with psa kinetics and PCA3 it can result in a highly reliable diagonosis without very invasive biopsies. With a CDU there is a maximum of 6 cores taken, many times much less or none at all.
With a regular TRUS you can be sure that the doctor will take a biopsy every time, even if he see nothing. From experience I can state that a 6 core biopsy is much less painful and has less effects than a 12 or 16 core one.
I think I paid about $1700 for a CDU biopsy, which insurance covered 100%. I've paid anywhere between $900 and $1200 for a regular biopsy.
JT
Posted 9/2/2010 11:38 PM (GMT 0)
My urological oncologist surgeon used the color doppler after my 14 core biopsy to plan the robotic surgery. He wanted to check whether the cancer was capsule-contained and whether bilateral nerve sparing surgery was possible. It was, and the path report confirmed what the doppler showed. He said the doppler was accurate enough to make this decision most of the time before even starting the surgery, and he thought the doppler was more accurate then an endoscopic coil MRI.

Interestingly enough, my uro, when doing my ultrasound-guided biopsy, said that the gland looked entirely normal on the conventional ultrasound he was using; in other words regular ultrasound didn't show the tumor at all but doppler allowed the doc to not only see the tumor but also to assess where it was relative to the capsule wall.

Post Edited (proscapt) : 9/2/2010 5:43:39 PM (GMT-6)

Posted 9/2/2010 11:44 PM (GMT 0)
Do doctors who do a color doppler typically do a biopsy along with it, or do they just do the color doppler? Or do they do the color doppler and then decide whether to do the biospy depending on what they see on the color doppler?
Posted 9/3/2010 12:07 AM (GMT 0)
What proscapt had, a doppler followed by surgery, is the real way to prove the reliability of this method. Are their any published series that compare the doppler results to the pathology for a large group of patients that received surgery? The doppler could be used to predict where the cancer is, and where it is not. It's been said that this method can predict the grade of the tumor. You could predict that too. Then you could actually test these predictions and see how often they are right. That's the scientific method--make a prediction, and then test whether it is correct.
Posted 9/3/2010 12:51 AM (GMT 0)
medved....When my husband saw Dr Lee, he did color doppler and would biopsy if anything suspicious was seen. Since he didn't see anything except some calcification and patchy prostititis he did not do biopsy. After antibiotic treatment,[psa went down a couple pts]he did another CDU and noticed great improvement of prostatitis, again no biopsy.
Posted 9/3/2010 1:02 AM (GMT 0)
Postop..... below is an excerpt of the beginnings of Dr Lee's work on color doppler, he is the real expert on this technology. I think through the years he has perfected his readings of CDU by doing thousands of them!! While not 100% [nothing is] I have great confidence in his ability of spotting PCa!!!

"I began performing ultrasound on radical prostatectomy specimens that were placed in a water bath. I then mapped out where the tumor was on ultrasound and compared it to the pathologists findings. We studied about 10 radical prostatectomy specimens and were right on every one of them. We made glass slides of whole mounts (the entire prostate gland) and slides of corresponding ultrasound images. We took these to the conference and changed the minds of the so called experts. When I gave my talk I told the audience that prostate cancer on ultrasound was not a white lesion like most people believed but a dark lesion. The very next doctor had a presentation intended to demonstrate that transrectal ultrasound did not work. He would show a transrectal ultrasound slide and ask me to point out the cancer. Here is the cancer in this dark area, I would say. Sure enough when he showed the next slide which was the pathology slide, I had correctly identified the tumor. That speaker was Dr. Tom Stamey, Chairman of Urology at Stanford University, who shortly thereafter visited me to learn how to read transrectal ultrasound images. "
Posted 9/3/2010 1:51 AM (GMT 0)
Yes, but this is just an interview from the website of a urology practice group in Michigan:

http://www.rochesterurology.urologydomain.com/images/uploaded/rochesterurology/drleestory.cfm

Web site are not peer reviewed, and are really just advertising. What about doing a formal study and publishing it in a medical journal? If this a so good, would they want to do this so that they could convince the world of its value? Not just talk about what you've done, but proving it by showing the facts in press. Has this been done?
Posted 9/3/2010 2:03 AM (GMT 0)
JohnT......Help me out here LOL!! Your much better at explaining CDU and the value of having Dr Lee do it!!
Posted 9/3/2010 2:16 AM (GMT 0)

proscapt said...
My urological oncologist surgeon used the color doppler after my 14 core biopsy to plan the robotic surgery. He wanted to check whether the cancer was capsule-contained and whether bilateral nerve sparing surgery was possible. It was, and the path report confirmed what the doppler showed. He said the doppler was accurate enough to make this decision most of the time before even starting the surgery, and he thought the doppler was more accurate then an endoscopic coil MRI.

I can only talk about our experience with MRIS. With a small cancer like my husbands I agree that it would have been hard for any existing screening technology to pick up the cancer. But what was interesting was the false positive. The MRIS found cancer in a region of the prostate which was found to have no cancer in the post surgery report.

Although anecdotally Color Doppler has great results, what proves a technology is a proven very low rate of false positives and negatives. And once a technology is proven it should be possible to train other technicians and doctors to do it so that its widely available. I suspect that the reason that its not widely available is either because it has not been scientifically proven or the rate of false positives or false negatives is high.

Everyone benefits from a better screening technology, patients, surgeons, oncologists and I cannot see any reason for any sort of conspiracy to limit the availability of a techology if it works as well as many say here.

An

Post Edited (An38) : 9/2/2010 8:26:08 PM (GMT-6)

Posted 9/3/2010 2:58 AM (GMT 0)
I don't think there's a conspiracy!!!! A few of us [that have experienced it] are just trying to get the word out that if CDU is done by one of the few experts, it can be an invaluable test to have done. It can possibly save a few of these guys from several biopsies or in my husbands case no biopsy. I think the only conspiracy is the U-docs convincing everyone biopsy is the only way! It's not and if a biopsy is necessary only a few cores are taken usually less than 6! cooper

JohnT's explanation........

"The reason that color doppler is not more widely used is that the equipment costs about $140k and is not justified with the amount of biopsies done by a regular urologist. Also it is old technology and universities are more enthusiastic about the newer MRIS and DEC imaging. It is also very skill and experience related and it takes a long time to be effective in using it and most doctors just don't have the volume or time. Drs Bahn and Lee have each done over 20,000 biopsies and have fine tuned their skills."
Posted 9/3/2010 3:24 AM (GMT 0)
$140K is not a lot of money for a piece of medical equipment that could be shared by several urologists. And I would have thought that medicine is evidence based so that the technology that had been proven to work best would be used - MRIS, although very far from perfect has some false positive and false negative numbers to back it up.

There are many medical procedures that need a lot of skill and or experience - nerve sparing RP is one of them. If the CDU was proven and effective wouldn't the thousands of urologists who have raced out to learn the skills of a nerve sparing RP also have learnt how to do biopsies with a color doppler?

There is no doubt that CDU sounds like a good test. Dr Bahn and Lee are no doubt impressive. But the question is has it proven to be a good test through published data on its accuracy and low false positive and false negative results.

An

An
Posted 9/3/2010 3:47 AM (GMT 0)
Postop,
I have read about 4 or 5 studies on CDU that were published. about 50% show a significant advantage over a standard 12 core biopsies and others show a minor or no advantage.
I believe that skill and experience are probably just as important as technology. You can look them up on Pubmed.
I'm an avid fisherman and compare a color doppler to a fish finding sonar. I can identify the bottom or a fish, but a charter captain who uses it every day and depends on it for a living can identify exactly what type of bottom he's over and exactly what species of fish he is metering. Same equipment, just a different level of skill and experience.
I absolutely believe that Drs Bahn and Lee have developed a skill level with the technology that few others will achieve. Dr Scholz has a CDU and when he sees something he always refers his patients to Dr Bahn. He says, he's just so much better than I am in looking at the scans, and Scholz probably does 10-15 color dopplers a week.
I know that some will only take randomized controlled studies as evidence in any treatment or diagonostics, but I believe that skill is left out of these studies. We accept in sports and business that some individuals consistantly produce superior results that can't be duplicated by others, but when it comes to PC we will only accept controlled studies that are usually done by average or below average doctors and researchers, and can't accept that there a few exceptional doctors than can get results that can't be duplicated by most other doctors.
JT
Posted 9/3/2010 4:01 AM (GMT 0)
I just did a quick check of pubmed seaching on the two words "doppler" and "prostate".

Most of the articles are generally positive on the color doppler, but not conclusive. They say it is a "promising" technology. One that goes further is pasted below:

BJU Int. 2010 Mar 25.
Contrast-enhanced colour Doppler-targeted prostate biopsy: correlation of a subjective blood-flow rating scale with the histopathological outcome of the biopsy.
Mitterberger M, Aigner F, Pinggera GM, Steiner E, Rehder P, Ulmer H, Halpern EJ, Horninger W, Frauscher F.
Department of Urology, Medical University Innsbruck, Innsbruck, Austria.


Study Type - Diagnosis (exploratory cohort) Level of Evidence 2b

OBJECTIVE To correlate a subjective blood-flow rating scale from contrast-enhanced colour Doppler (CECD) transrectal ultrasonography-targeted prostate biopsy with the histopathological outcome of the biopsy.

PATIENTS AND METHODS In all, 760 men with a serum total prostate-specific antigen (PSA) level of >/=1.25 ng/mL and a free-to-total PSA ratio of <18% were included. CECD-targeted biopsies with five cores were taken only in hypervascular areas of the peripheral zone using a second-generation ultrasonography contrast agent, followed by a 10-core systematic biopsy. Prostate blood flow was scored using a subjective 5-point scale in which 1 indicated 'benign', 2 'probably benign', 3 'indeterminate', 4 'probably malignant' and 5 'malignant'.

RESULTS Overall 37% (283 of 760) patients had prostate cancer in the biopsy. All 100 patients with a score of 5 had cancer; 153 had a score of 4, of whom 130 (85%) had cancer and 23 had benign histology (15%); 131 had a score of 3, of whom 34 (26%) had cancer and 97 (74%) had benign histology; 284 had a score of 2, of whom 17 (6%) had cancer and 267 (94%) had benign histology; 92 had a score of 1, of whom two (2%) had cancer and 90 (98%) had benign tissue. Statistical evaluation showed that the subjective blood-flow rating scale correlated strongly and significantly (r= 0.75, P < 0.01) with the histopathological outcome of the biopsy.

CONCLUSION The present study shows that a subjective CECD blood-flow rating scale is a reliable tool to predict the pathological outcome of biopsy cores.
Posted 9/3/2010 4:02 AM (GMT 0)
With all respect, John, I'm not going to put my life on the line based on someone's belief. If this guy is so good at this, he can do the study by himself. It doesn't have to be randomized or blinded, just prospective. Just have him do these scans on a group of patients who are going to have a prostatectomy. He can predict the tumor locations and grade. Then these patients get their prostate out. His scan interpretation, put down in writing before the procedure, will be taken out of a sealed envelope by an independent observer, and compared to the pathology. Do this on 20 or 30 patients, write the article and submit to medical journal. Done.

No matter how likable, earnest and sincere a member of this board might be, I'm not putting my money or my hiney on the line without some kinded of evidence that's been vetted by peer review.
Posted 9/3/2010 4:05 AM (GMT 0)
I just saw proscapt's post. Sounds promising, but hardly infallible.
Posted 9/3/2010 5:34 AM (GMT 0)
Its one thing to use a color doppler to guide the doctor as to where a needle should by placed for biopsy - I imagine this technique can only be better that the woeful standard transrectal ultrasound. The thing I am objecting to here is that in many threads relating to AS people cite the accuracy of the Color Doppler as one of the reasons why people can confidently believe that the cancer is small/not growing.

If there are no basic checks and balances to make sure that CDU does what people believe it does (and I agree with postop that very basic peer reviewed studies by these experienced individuals on their results is the absolute minimum you would expect) then I don't think it is possible to make any claims about the colour doppler apart from the fact that many people have faith in Dr Lees and Bahns skills, methods and their own results.

An

Post Edited (An38) : 9/3/2010 12:28:23 AM (GMT-6)

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