Needle tracking of prostate cancer cells during prostate biopsy: a review


A new review article in BJU International has addressed the perennial question of whether prostate biopsy is associated with a risk for spreading of the cancer (“seeding”) as a consequence of so-called “needle tracking” of prostate cancer cells.

Volanis et al. conducted a thorough search for published papers that addressed such issues as incidence of seeding, clinical presentation, and associated risk factors (e.g.,  type of biopsy needle used, transrectal vs. transperineal approach, tumor grade and stage). Here is the quick summary of their findings:

  • A total of 26 published papers were identified that report needle tracking and “seeding” of prostate cancer post-biopsy.
  • These 26 papers reported that seeding occurred in just 42 patients.
    • 9 such cases occurred after transrectal biopsy.
    • 33 such cased occurred after transperineal biopsy.
  • The incidence of seeding after biopsy “appears [to be] much less than 1 percent”.

In other words, while it is certainly possible for a biopsy to cause “seeding” of prostate cancer along the track of a biopsy needle under rare circumstances, there is almost no evidence at all to suggest that such seeding has ever led to the true “spread” of prostate cancer.

Furthermore, as the authors also note, even though — over the past 20+ years — there has been a massive increase in the number of prostate biopsies carried out each year, and a similarly massive increase in the number of biopsy cores taken, there is no evidence whatsoever to suggest that this is associated with any increase in reports of “seeding”.

Patients regularly express great concern about the risk that a prostate biopsy will increase the risk that their cancer will be spread as a consequence of needle tracking. And there is no doubt that such “seeding” can occur. However, it is also extremely clear that the clinical risk associated with such needle tracking and seeding is so small as to be trivial.

There were probably well in excess of 2 million prostate biopsies conducted in America last year. Even if as many as half of the 42 identified cases of seeding had occurred last year in America (which they most certainly did not), this means that the individual risk for seeding at the time of a specific biopsy is certainly no higher than 21 × 100 ÷ 2,000,000 or 0.001 percent (i.e., 1 in 1,000), and it may be a lot lower than that.

Furthermore, even when such seeding does occur, there is no evidence to suggest that such seeding is associated with any increase in risk for clinically significant prostate cancer.

31 Responses

  1. Sitemaster:

    Since I am not a clinician, I advise all to do your research and review all remarks with a trusted doctor.

    Thank you for this update on needle tracking. Yes, studies show the overall risk of needles spreading prostate cancer during a blind biopsy is very low.

    However, this does not mean that blind biopsies and saturation, or mapping, biopsies are low risk. For example, what is the risk of infection? It is not insignificant. Moreover, the problems with treating these infections are growing rapidly as bacteria rapidly morph into resistant strains, some of which have no effective antibiotics to treat them.

    If you are concerned about this, I would encourage you to minimize the number of biopsies using a 3 T multiparametric MRI to find the clinically significant lesions and to biopsy those areas of suspicion with an MRI-guided biopsy. With any biopsy, you should discuss ways to minimize risk including enemas, antibiotics, rectal swabs and post-biopsy monitoring. Be aware that many patients, particularly those with a military background or who have used antibiotics quite a bit, may have serious problems with ciprofloxacin and other drugs in its class.

    Also regarding risk, biopsies can cause pain, edema, hemmorrhaging, elevated PSA, urethral damage, inflammation and/or cloud future MRIs. Repeat biopsies and saturation biopsies can even jeopardize the use of certain treatments since the prostate is damaged.

    So, while needle tracking is in the very low risk category, these other risks are significant.

    And blind biopsies do not always find all of the clinically significant lesions. You might say they prove nothing. If a blind biopsy finds nothing, tumors may still exist. You could have another blind biopsy, but what does this prove? If a Gleason 6 lesion is found, there could still be a Gleason 7 or higher. Last, a biopsy does nothing to identify spread outside the capsule.

    Yes, needle tracking risk is very low. But, is a blind biopsy, including a saturation biopsy, safe and effective? Again, I would strongly encourage everyone to research these issues and discuss a multiparametric MRI alternative with a qualified interventional radiologist who has this capability.

    Be well :-)

    John

  2. With no denominator value given, and no denominator identified, the number “42” is not useful as a numerator.

    You took a look at the following ratio, and quite properly characterized at as de minimis:

    ½ × (42 tracks reported) / (2,000,000 American biopsies in 2014)

    But why that denominator and not a different candidate?

    I am not seriously suggesting the following, but from what I read in the abstract and in this summary, the following candidate is just as possible (although obviously even more implausible):

    (42 tracks reported) / (42 cases investigated)

    I wonder, therefore, if the sitemaster could provide more context. The abstract of the Volanis paper cited does not do so.

  3. Good to have this study information available to pass on when we receive those queries as to biopsy tissue extraction possibly causing spread of cancer cells. As with so many issues regarding prostate cancer, this is another with a extremely near insignificant likelihood to occur and certainly not of sufficient significance to argue against biopsies.

  4. The question about “seeding” during biopsies is very important. Each time I ask a urologist about the risk of cancer cell dissemination during a biopsy, the answer comes unambiguously: there is no risk! Of course, questioning biopsies for (prostate) cancers is like touching the cornerstone of the diagnosis. Because indeed, there is no alternative today to securely determine the nature of dubious cells on a image.

    However, even ignoring medical things, it is very hard to believe that extracting/snatching cells out of a tumor while inevitably opening the blood (capillary or bigger) vessels around does not provoke some dissemination. Of course these few (tens, hundreds?) snatched cells are undetectable by any means, making studies practically impossible. But 3, 5, or more years later, who can tell whether one or more metastases came from the regular cancer process or from these few escaped cells ? Which study will ever be able to make the difference?

    Concerning prostate cancer, we know that aggressive forms are naturally disseminated at an early stage. Do biopsies worsen the spread? And for low/middle risk cancers, if biopsies promote seeding while they would not happen naturally, aren’t consequences significant?

    I understand that there is no choice today. Biopsy or ignorance. This is why it is so important that chemical markers are invented to make the diagnosis much safer.

  5. Paul:

    With respect to the number 42, it is the only actual number I know of … i.e., the total number reported in the published literature over the past 30 or so years.

  6. Jean-Paul:

    If your concerns were justified, then there would have been a significant increase in the numbers of men progressing to metastatic disease since the widespread introduction of the PSA test in the early 1990s, and the associated massive increase in the annual numbers of prostate biopsies. However, there is absolutely no evidence of such an effect at all.

    Finding something “hard to believe” doesn’t mean it isn’t true.

  7. So 7.5 years ago I had transrectal biopsies done and had Gleason scores of 10 for half of the 6 biopsies done on one side of the prostate. The other side was normal. All scans showed the cancer confined to the prostate gland and a RP was done 3 weeks after the biopsy. 6 weeks following surgery my PSA went from a pre-op 17.9 to 25. Thinking this was a lab error, it went to 30 one week later. For the last 7 years we have been fighting this microscopic disease in my body until I got an actual metastatic growth in my C2 spinal canal. I have to believe this was caused by seeding from the biopsy.

    So yes the numbers look good until it actually pertains to you. I would rather have won a lottery ticket.

  8. Dear Albert:

    You are of course completely entitled to your opinion … and I certainly understand that you “would rather have won a lottery ticket”. However, I feel that — in the spirit of transparency for others — I should point out that anyone who is initially diagnosed with three biopsy cores that show Gleason 10 disease has an extremely high probability of pre-existing micrometastatic disease at the time of diagnosis, and there is no good reason that I am aware of to think that “seeding” associated with a biopsy would be the cause of that micrometastatic disease.

  9. Albert:

    Given the fact that it took 7 years for bone metastasis to become apparent, it does not sound like your disease is that fast moving.

    What was your PSA right before the biopsy? This would be a good indicator as to the extent of the disease before surgery, since sadly your disease appears to have already been metastatic.

    While I am not a doctor, I would suggest you do not beat yourself up as to your biopsy being the cause of your metastatic disease.

  10. My original PSA was 17.9. The previous test was 2 years before and was normal. Six weeks after surgery my PSA jumped to 25 and the doctor, thinking a lab error, repeated it and it was up to 30. The highest the PSA ever was was 35 ng/ml about 6 weeks following radiation, and twice it has gotten down to 0.4 (at the end of 18 rounds of chemo and once while on oral medications). Throughout all of the treatment all my scans were negative and this tumor metastasis was actually in the spinal canal, extending out the space of the nerves and was found on a scan in March of this year.

  11. Albert:

    17.9 is high enough to raise suspicion before you even had a biopsy. You do not mention your Gleason, but no doubt there was at least one 4 in there somewhere!

    If you would like to discuss further, consider joining us tomorrow, 8/4, on our locally advanced/advanced telephone support call — check http://www.thereluctantbrotherhood.org for more information.

  12. I’m increasingly troubled by this. I agree with PaulC that 42 reports in the literature does not mean this has happened only 42 times. It only means that some doctor took the trouble to write it up.

    There was a recent study in Sweden that found that prostate cells are extensively set loose into venous blood following biopsy. This is not particularly troubling if all the cores were Gleason 3 + 3. The most recent study from the Netherlands affirms previous studies that show that true Gleason 3 + 3 never metastasizes. Most men who go in for a biopsy, and are positive for prostate cancer, will have Gleason 3 + 3, so the risk of needle tracking across the population is low.

    But what of men with higher Gleason scores? Gleason pattern 4 and 5 have been found outside of the prostatic environment. Perhaps some of the recurrences found after RP on men diagnosed with stage cT2 are due to needle tracking — how would we know unless the needle path is charted and correlated with a biopsy of recurrence sites (a procedure that is never done, to my knowledge)?

    The implications of this are staggering if we consider the possibility of RP to set loose huge amounts of Gleason pattern 4 and 5 cells.

    As to the Sitemaster’s response to Jean-Paul’s concern, I would suggest that stage migration since the inception of widespread PSA testing plays a major role. It has resulted in a decidedly lower percentage of diagnoses of metastatic disease, which may mask any effect of seeding of higher grade cancers.

  13. Again … If needle tracking of Gleason 4 and Gleason 5 prostate cancer was leading to actual seeding of cancer outside the prostate, then there would have to have been a massive increase in the occurrence of metastatic disease over the past 30 years. Prior to about 1989, nearly all initial prostate biopsies were being done in men who already had intermediate- or high-risk, extracapsular prostate cancer of some type. Today, nearly all initial prostate biopsies are done in men who have low-risk, organ-confined prostate cancer. And yet the numbers of men who die of metastatic prostate cancer has fallen by some 40% on a population basis (i.e., numbers of deaths per 100,000 persons in the USA). In fact, therefore, stage migration — made possible by the massive increase in the number of prostate biopsies over the past 30 years — has led, at least in part — to a major reduction in risk for prostate cancer death, which makes no sense if prostate biopsies increase the risk for seeding of Gleason 4 and 5 prostate cancer cells.

    One needs to appreciate that it is actually very, very difficult for a prostate cancer cell that leaves the prostate to become established at a secondary site (“seeding”) within or outside the prostate. Men with prostate cancer shed prostate cancer cells into their blood stream on a frequent basis. This is a part of the normal cell cycle. However, most of those cells never become established elsewhere because they are destroyed by the patient’s normal immune system. The process by which a cell travels through the body and can become established at any new site is, in fact, extraordinarily complex, and the vast majority of cells that are “shed” from one site are completely unable to survive at any new sites they reach because the appropriate microenvironment is not available. Prostate cancer cells are highly selective about where they can grow once they leave the prostate.

    Please understand that I am not saying that either “only” 42 cases of such seeding have ever occurred or that there has “never” been a single case in which a prostate biopsy has led to metastasis. What I am saying (and what the authors of the paper on which this discussion is based are saying) is that the clinically significant occurrence of such events has to be so low as to near to a non-existent risk for any individual patient. Could it happen? Of course it could. And, like Isadora Duncan, one could be killed by one’s own scarf becoming entangled in the spokes of the wheel of an open-top sports car. (This is the only such death of this type that I have ever heard of happening. And no one ever banned either the wearing of scarves or spokes on the wheels of open-top sports cars as a consequence.)

  14. Actually the initial biopsies on 1/2 of the prostate were either 9 or 10 for the 6-core biopsies and after surgery were confirmed as 10 (5 + 5)

  15. I think most prostate cancer doctors would tell you that your metastatic disease was present well before the biopsy! If you run the MSKCC nomogram for surgery, it will indicate the likelihood your disease had spread before your prostatectomy.

  16. I should also add that the other factor mitigating the spread of cancer through surgical incision is that surgeons, with time and experience, are getting better at avoiding that. The positive surgical margin rate has come down a lot, with the best approaching about 10% now (at Johns Hopkins). Of course the bigger effect, as I said, is stage migration — due to widespread PSA testing, most tumors now are Gleason 6, so it doesn’t matter if it is inoculated — it won’t grow outside of the prostate environment. Before PSA testing, most tumors were higher grade, and since Gleason pattern 4 + 5 can live and circulate in the bloodstream until they find fertile ground in which to grow, there was probably a lot more inoculating of tumors in the past. So even though there are many more biopsies and prostatectomies now, the percentage that result in metastatic inoculation are far fewer.

    There are many cancers where radiation is given before surgical excision to avoid spreading the cancer. I wonder how much this contributes to the current 30% recurrence rate following radical prostatectomy for prostate cancer.

  17. Dear Allen:

    Your statement that “Before PSA testing, most tumors were higher grade” is simply not true. We simply weren’t usually finding the patients with low-grade tumors, but their presence was well known from pathological data on autopsy specimens. However, before PSA testing, many patients were quite certainly never good candidates for surgery in the first place because they weren’t being diagnosed with localized disease. In the 1970s radiation therapy was actually the most common first-line treatment for prostate cancer that was thought to be localized. Surgery was widely considered to be too difficult and even in the late 1980s surgery would commonly be aborted during the procedure when evidence of positive lymph nodes was discovered during the procedure.

    There is no known evidence of radical surgery leading to the spread of prostate cancer and positive surgical margins have nothing to do with the tracking or seeding of prostate cancer and everything to do with the fact that a radical prostatectomy is an extremely difficult surgical procedure. Positive surgical margins are known to occur after many types of surgical treatment for a variety of solid tumors. This risk for such positive surgical margins depends to a large extent on the location of the organ in question, the anatomy of the patient, the difficulty of the procedure, and the skill of the surgeon. However, they are known to occur even in the surgical treatment of evident, superficial cases of melanoma.

    Giving radiation therapy to a man with prostate cancer deliberately, prior to radical surgery, would, at best, be naive, since surgical removal of an irradiated prostate is widely recognized to be an extremely difficult operation with a very high risk for complications and side effects — even in the hands of highly skilled surgeons. There are, as far as I am aware, very few forms of cancer for which radiation therapy is given as a first-line treatment with the deliberate intention of the patient having later surgery. There may be, however, some solid tumors (not many that I am aware of) for which radiation therapy is considered to be the preferred first-line treatment and salvage surgery is the standard second-line treatment if radiation therapy fails. There is also the very controversial use of radiation therapy during surgery. However, I do not believe that such perioperative radiation therapy is endorsed by guidelines issued by any major medical association at this time.

  18. I wasn’t at all suggestion that radiation be given before prostate cancer surgery. I just mentioned that in other cancers that is sometimes done. My mother had uterine cancer of a very undifferentiated type, and her surgeon at NYU decided to radiate it first to prevent seeding the cancer during surgery. I’m suggesting that if seeding can occur with one undifferentiated cancer, it can possibly occur with another (e.g. Gleason pattern 5).

    I raise the point about positive surgical margins because incision into the tumor may possibly spread it. That is exactly what happened in the following cases (http://www.canjurol.com/abstract.php?ArticleID=&version=1.0&PMID=22704320 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175179/)

    How can there be any question that biopsies and radical prostatectomies in the present day are done on men with lower Gleason scores now than they were in, say, 1990? In 1990, men were only biopsied and treated when symptoms occurred, which is at a much later stage. My point is that there is less spreading of tumors due to needles and knives now because Gleason 6 cannot be spread that way. So your statement “If needle tracking of Gleason 4 and Gleason 5 prostate cancer was leading to actual seeding of cancer outside the prostate, then there would have to have been a massive increase in the occurrence of metastatic disease over the past 30 years” is not true, because of the massive relative DECREASE in Gleason 4s and 5s found at biopsy and at surgery now vs then. It would mask any seeding effect.

    To be honest, I have no idea if seeding is occurring to any extent through biopsies or surgeries for prostate cancer. But the citation you gave does not begin to resolve the question. We can’t assume it’s not true just because it rarely gets reported. The only way we ever get to an answer is if we do the research that would demonstrate or refute it.

  19. Dear Allen:

    No one is suggesting that seeding never happens. All anyone is saying is that on the basis of all of the available information it is extremely rare — largely because, on a biological and biochemical basis it is extremely improbable. The case you refer to only confirms this further.

    The large “decrease” in numbers of Gleason 4 and Gleason 5 prostate cancers you are suggesting is actually not true. There has been a considerable relative decrease but the absolute decrease in the numbers of high-grade cancers getting diagnosed on an annual basis was only about 9% from 1988 to 2005 and has risen by about 1% per annum since 2005 according to published data based on the SEER databases.

    There have, in fact, been several attempts over the years to identify through research whether seeding of prostate cancer might lead to true metastatic disease … but none of that research has even provided any indication of a significant probability of this occurring on anything but the very rarest of occasions. You could never “refute” that it happens, in any case (because it is impossible to prove a negative like this, and it is evident that it does occur very rarely). Seeding of some other forms of cancer can occur more frequently because the biological nature of the cell types facilitates spread to a wider range of potential metastatic sites. This is one of the reasons why the FDA just banned power morcellation as a method for surgical treatment of uterine fibroid tumors — because of risk for seeding unidentified uterine cancers associated with the fibroids (which is also rare, but distinctly more common than any known occurrence of the seeding of prostate cancers).

  20. Albert,

    Were you experiencing pain, urination, etc., … problems prior to your first biopsy?

  21. No. I had no pain or symptoms prior to the biopsy. Two weeks later though, the night before my surgery, I still had a very bloody ejaculate.

  22. I am not a clinician, but here’s what my nurse said.

    Blood in ejaculate is very common after biopsy. Often, it doesn’t show up for a few days or so. It may be a muddy reddish color. Generally not a problem. Can last for 6 weeks or even a little longer.

    If you have pain or a high temperature or any sign of infection following biopsy, call your doctor immediately — even if it’s after hours.

  23. A recent prostate biopsy revealed 5% cancer cells at one of 14 sites biopsied. Gleason score is 6. I’m not sure what to do. I have an appointment with a urologist surgeon and a radiologist. Any suggestions?

  24. Dear REyeton1:

    I suggest that you join our social network where we can discuss your case in more detail. It sounds as though you have a low- or very low-risk forms of prostate cancer, which means you probably have lots of time to come a good decisions about what you want to do. It would not be wise to let anyone rush you into a decision you might come to regret.

  25. As a latecomer to this interesting discussion I have to say that — unless my maths or interpretation of the meaning are incorrect — that the individual risk of seeding of 0.001 percent mentioned in the article is 1 in 100,000, not 1 in 1,000. If the odds were a thousand to one I would be quite worried.

  26. I write from Italy, after the biopsy the cancer has gone to my bones. Sure.

  27. I had a prostate biopsy about 7 years ago that was entirely negative. I bled for 3.5 months with black ejaculate and other evidence of bleeding throughout that time. I thought at the time that there was no way such a massive release of cancerous prostate cells into the blood circulation could be without consequences if I had actually had prostate cancer. The scarring and the toxic reaction to blood in the tissue would be an irritant that could even cause cancer by itself with no seeding, only irritation.

    I just had a spectral MRI and they found a small area that they grade as probably cancer and they want to do a biopsy. I am conflicted. Yet I am greatly helped by this discussion that the needle is smaller with more precautions to not spread cancer. I have not yet made up my mind but it seems crazy that no other methods are available to go forward. I tried for all those 7 years to have something done about my huge prostate and my urinary incontinence but all the urologists and other doctors (five urologists and countless other doctors) wanted to do was to look for cancer or do a procedure that would leave me impotent. It looks suspiciously like they make their real money doing biopsies and cancer treatments.

    Now I have no way to go but to get another needle biopsy. I really do feel trapped. If I had any faith in standard medicine I might be able to make a decision more easily but cancer treatments are a farce and a legally protected malpractice from all that I can see. Chemotherapy has at best about a 2% improvement in outcome. Curing cancer is living for 5 years. That is ridiculous. Surgery spreads cancer (I have lost both a father and a wife to surgery-spread cancer.) We have to make these decisions without competent non-money-motivated advice. I also instantly saw that 0.001% is 1 in 100,000 not 1 in 1,000. I also believe that the statistics presented are assuming that you have reasonable numbers of those who have actually experienced track seeding, and I see no assurance that this is the case. How could you ever figure out which ones did and which didn’t?

  28. Dear Bill:

    We would all like better answers to a whole bunch of questions that you raise either explicitly or implicitly. Many of us would also like a healthcare system that was designed to provide reasonable health care for all as opposed to poor health care for the poor and sophisticated (but not necessarily excellent) health care for those with good insurance or sufficient financial resources.

    Our currently effective forms of treatment for cancer are getting better … but it is a very slow process.

    We are probably capable, today, of actually determining what percentage of men who have a prostate biopsy (a) have cancer actually spread by that biopsy and (b) have consequent progression of their cancer. However, the cost of the trial that would be necessary to make those two determinations would be huge, and the national cancer research budget keeps getting cut, so I don’t see it happening within the next 10 years.

    On the “up side”, we are getting a lot better at not giving biopsies to men who really don’t need them … but it is not a perfect world.

  29. A very informative and well-documented article on a very sensitive and most confusing issue.

    I was about to subject myself to a second biopsy, after being diagnosed with prostate cancer back in 2015, after a comprehensive battery of diagnostic tests, along with a needle biopsy, with a Gleason score of 6 and a T1c, a stint with Watchful Waiting, as they’ve coined the phrase, to hold off on any sudden need for prostate removal, having seen Dr. B. Carter and Dr. Welsh, at the Brady Urological Center at Johns Hopkins University Medical Center, in 2016.

    A recent MRI has now shown the cancer has decided to become more aggressive and as such my urologist, who has been seeing me for over 10 years now, sent me to see Dr. V. Patel, in Orlando, FL, who is world famous for having performed over 12,000 and counting, robotic prostatectomies. After his review of my MRI and PSA records, it was Dr. Patel’s opinion, before he agreed to operate on me, that he wanted me to have a PET scan, and, depending on the results, possibly a guided biopsy with an MRI to determine how aggressive the cancer has become.

    After I returned from my visit with Dr. Patel, I spoke with my urologist, who was not in favor of my having another biopsy, since he was now recommending that I have my prostate removed ASAP and not waste any more time with a biopsy or even a PET scan. I tended to agree with him. Why put my body through all these modalities, when the prostate must be removed based on the MRI findings.

    PS: My urologist had me seek a third opinion from a well-known robotic surgeon in south Florida, closer to my home. After seeing him 2 weeks ago, he disagreed with Dr. Patel, and suggested I have a whole body scan, a free and total PSA, and a needle biopsy. When I questioned him about why the needle biopsy, his reply was because he wants to learn first-hand where the cancer is now and compare the results of this new biopsy to the one from 2015. I argued with him that I felt that was risky due to my belief that microscopic capsule penetration, and/or needle tracking was very possible and I didn’t want to take that risk. I wanted the prostate out and done with. He stood his ground and told me to have the biopsy done before he would consider operating on me. I read the article above, twice, and have since concluded that I am not going to subject myself to another needle biopsy under any circumstances.

    Dr. Patel, in Orlando, after his review of my medical records and recent MRI, is of the opinion that my cancer may have already pierced the prostate capsule and if the PET scan and Whole Body Bone Scan depict his suspicions, most likely surgery will be ruled out for the time being and chemotherapy and radiation therapy will be the choice of treatment he will recommend for me. So, I’m more confused now than I’ve ever been. Scared and full of apprehension. This is my second bout with cancer. I had kidney cancer 14 years ago. Knock on wood, I’m still around to talk about it. I need to drop back and punt on this latest prostate cancer situation and determine my course of action, as I may only have one shot at doing so. I’d like to be around for my grandchildren’s weddings, within the next say 10 to 15 years. I’m a young 71 years old and look much younger than I am. ANY SUGGESTIONS? I’d welcome them all. Thanks for reading this lengthy response!

    Best to ALL.

    Steven (West Palm Beach, FL).

  30. Dear Steven:

    (1) I entirely understand why you want to avoid another biopsy, but I actually believe — very sincerely — that you would be wise to have one if the need for such a biopsy is confirmed by either a Prostate Health Index (phi) test or a 4KScore test. Either of these tests should be able to give you a much clearer idea of the need for a biopsy than a %free PSA test

    (2) If I was in your situation, and one or other of the above two tests indicated the need for a biopsy, I would want to have it done under MRI/TRUS fusion guidance as a combination of a 12-core systematic biopsy with extra cores taken of any areas that looked suspicious on the MRI scan. Depending on the results of that biopsy, I might also want to have the index biopsy lesion sent for genomic analysis using a test like the Decipher test or the Oncotype DX test (especially if the highest Gleason score on the rebiopsied tissue was still 3 + 3 = 6 or 3 + 4 = 7. (If the new biopsy showed a Gleason score of 4 + 3 = 7 or higher, then I would want to discuss treatment without the need for the genomic analysis.)

    I am telling you all this for the following reasons:

    (3) There is considerable evidence that data from MRI scans can sometimes be innaccurate and thus highly misleading. Specifically, there are multiple cases of areas of the prostate that were clearly PI-RADs 4 or 5 on MRI scans turning out not to show any signs of cancer on biopsy or even on post-surgical pathology. MRI scans of the prostate are not perfect by any manner iof means, and so you have to treat your own MRI result with a degree of caution. The evidence supporting that and presented at this year’s annual meeting of the American Urological Association in Chicago earlier this month was very clear. (There is also clear evidence of cases when MRI scans were negative and the patient was found to have a high-risk form of prostate cancer.)

    (4) The chances that you would have any significant increase in risk for progressive prostate cancer from needle tracking or any other reason associated with that biopsy are minimal. Almost all the concerns about prostate cancer progression as a consequence of prior biopsy are speculative rather than “real.” It is actually extremely difficult for a prostate cancer cell that gets physically moved by something like a biopsy to start to grow in a new microenvironment (even within the prostate). It just isn’t the way that cancer is able to spread in 99.99% of circumstances.

    Now Dr. Patel may be right about you needing the Axumin PET scan, and so if your insurance will cover this, you may want to do it, but again, I certainly wouldn’t even consider this until I had had either a phi test or a 4KScore test. In any case, it seems unlikely to me that Medicare or any other insurance provider would cover the costs of a PET scan unless there was clear evidence that you had high-risk prostate cancer (and a single positive MRI of the prostate doesn’t meet that criterion).

    Now let me be very clear. You have every right to do exactly whatever you want to do. I am not going to be critical if you decide to do something else. THis is your body and your decision. However, I have given you the most honest opinion I can of what I would do in your situation — and I have absolutely no self-interest in whether you do or don’t go on to have treatment (by any of the three physicians you have seen or anyone else either). I do, however, worry a lot that many men like you get over-treated far to early because of their misunderstandings about the level of risk they may be at. And then they end up with the side effects and complications of treatment that may not have been necessary. Bluntly, I think you need to take one careful step at a time as opposed to making a decision solely on the basis of the MRI scan — but in the end it’s entirely up to you.

  31. I agree completely with the Sitemaster’s comments. I would only add that you obviously did not follow the Johns Hopkins protocol for active surveillance, which always includes a confirmatory biopsy within a year of the first one, and periodic biopsies afterwards.I don’t say this to chide you for past errors, but to motivate you to take corrective action.

    If you have an mpMRI/US fusion biopsy, it is sometimes a good idea to take cores that penetrate through the prostate capsule at the site of the suspected extraprostatic extension to verify that tumor tissue has infiltrated.

    The Sitemaster makes a good point about insurance coverage for PET scans in a pre-treatment situation. Be sure to get pre-authorization — they are very costly.

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