“Getting off biopsy train in prostate cancer”

“Getting off biopsy train in prostate cancer” is the title of the latest article by Howard Wolinsky (a long-time active active surveillance patient) on the MedPage Today web site. We recommend it to your attention.

In this article Wolinsky writes about the oft-raised possibility that men with low- and very-low risk forms of prostate cancer will or should, in the near future, be told that they have something other than “cancer” (although quite what that should be is still to be defined). And of course if they don’t have “cancer” than they don’t need to have a biopsy to diagnose it.

Now there are distinct upsides to this possibility — and it is far from being a bad idea. But it does come with some very real risks, of which the following is a critical one.

Some men with relatively low PSA levels, and no evident symptoms suggestive of prostate cancer, are in fact found to have aggressive types of prostate cancer. If we start to tell all men with the apparent indicators of low- and very low-risk prostate cancer that they don’t have cancer, then what is going to happen to this subset of — often relatively young — men? Are we going to increase their risk for metastatic disease because we fail to diagnose them early enough to treat them with curative intent? Such a failure to diagnose early could leave physicians and insurance companies in the United States open to all sort of potential legal and ethical problems — some of which could prove to be very expensive.

In Howard Wolinksy’s article, he talks very specifically about a conversation he had with Dr. Freddie Hamdy — a well-known and highly respected urologist in the UK. Their conversation related to the content of the patient-coordinated meeting on active surveillance to be held in Iceland in October 2019. Your sitmaster is in complete agreement with Dr. Hamdy, who Wolinsky quotes as stating the following:

To be honest, if you’re going to have a conference which is only going to discuss what do you do with a low-volume, low-risk and very low-risk Gleason 6, you don’t need to have a conference because there is pretty much a consensus that these patients should be first on active surveillance. But I think if you’re going to expand into whether we can stretch the indication for active surveillance and can [help] patients make informed choices, I think you really are going to do a lot of good to at least have people start to think that there are options beyond jumping straight into radical treatments.

And this again raises the whole issue of “proactive” surveillance. What can a man who starts on active surveillance actually do to minimize his risk for progression and the need for treatment over time? For a 65-year-old man diagnosed, for example, with a PSA of 5, a clinical stage of T1c, and a single 3-mm-long focus of Gleason 3 + 4 = 7 prostate cancer, he starts out with a low probability of  risk for metastasis within the next 10 years … but what if we could lower his risk for metastatic to having a very low probability over 20 or 25 years? Can we do this by helping him to adjust his lifestyle (diet and exercise) and may be take a cholesterol-lowering agent and a baby aspirin? We don’t know the answer to a question like that yet, but if we could then we massively decrease the risk that such a patient (who 10 years ago would be given a radical prostatectomy without a thought) would ever need invasive treatment at all.

This … at least in your sitmaster’s mind … is one of the great new frontiers of prostate cancer research. Right along with the development of drugs that can be used to extend the lives of men with advanced and metastatic prostate cancer but without all the quality of life problems that currently affect the management of such patients.

We’d like to be able to “cure” as many cases of prostate cancer as we can, but if we can turn prostate cancer into a long-term chronic condition (as we have been able to do for many types of cardiovascular disease) that people can basically live with without serious complications or side effects of their treatment wouldn’t that be great!

13 Responses

  1. As one on active surveillance since 2012, I am extremely thankful for these articles and information provided at PCIL. Thank you, very much.

  2. A 12 or 18 core blind biopsy, holey prostate! One million dangerous prostate blind biopsies are performed in the USA each year and they should be banned. Men with a high PSA tests result are often sent to an urologist for a blind biopsy. Men should be told about other options; Percent free PSA test, 4Kscore test, PCA3 test or a MRI, 3D color-Doppler test before receiving any biopsy. These tests can often eliminate the need for a risky and invasive blind biopsy. Insertion of 12 or 18 large hollow needles through the rectum into a gland the size of a walnut, a blind Biopsy can result in pain, infections. A high risk of temporary or permanent erectile dysfunction, 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. Biopsies can cause urinary problems, 6.9% hospitalization within 30 days from a complication, sometimes even death from sepsis (About 1.3 to 3.5 deaths per 1,000). There is also debate that a biopsy may spread cancer because of needle tracking. A blind biopsy can also increase PSA reading for several weeks or months, further frightening men into unnecessary treatment. Blind biopsies are almost never performed on other organs. One prestigious hospital biopsy information states “Notice that your semen has a red or rust-colored tint caused by a small amount of blood in your semen”. Another well-known hospital states “Blood, either red or reddish brown, may also be in your ejaculate.” These statements are frequently an extreme exaggeration (mostly lies). Very often after a biopsy a man’s semen will turn into jet black goo. This could be an unpleasant surprise for a man and especially for his unsuspecting partner. However if a biopsy is performed before Halloween or April Fools’ day this may be of benefit to a few men. If some prestigious hospitals are not factual about the color of semen, what other facts are being misrepresented?

  3. Yes; completely agree with you and Hamdy. I am sure you know this but it would be good to get someone from the METAL trial to Iceland. (Conflict notification: I am shadowing the treatment arm with 2000mg/365 metformin)

  4. While we are happy to post commentary from readers on this web site, we would also note that this commentary is not always entirely accurate, and may be highly colored by the opinions of the author of the comment.

  5. Dear SUM:

    There is a host of issues that are relevant to all of this. The possible role of metformin is just one of these. I have little doubt that this will be discussed at the meeting.

  6. I agree with your hopefullness and your warning — I am 58 and was not biopsied after an increase from 2.4 to 4 and was finally diagnosed a year later with Stage IV, Gleason 10 cancer after PSA went to 5.6. I had surgery, radiation, and chemo and am on Crestor and metformin.

  7. Yes but when I see Howard saying he is amending his plans in light of Hamdy’s feedback you can perhaps see I wanted to make sure we are out of the comfort zone.

  8. Dear Dr. Bergs:

    Thank you for providing a near to perfect example of my concerns … although I am sorry to hear that this happened to you.

  9. This is the problem with individual patients applying their personal experience as exempletive of what may be appropriate for everyone else.

    The issue is that there is no real “comfort zone” at present because we don’t yet have all the relevant data. You are a good example of what can be accomplished by a man even with Gleason 4 + 3 (but I couldn’t tell any other man that they could necessarily replicate your experience. Howard is the perfect example of how men with very low-risk prostate cancer may never again have a second positive biopsy (but I couldn’t tell any other man like Howard that they are going to replicate his experience).

  10. Thanks for your concern. Fortunately I’ve had excellent care at Fradert Memorial in Milwaukee. I’ve received their first Axumin scan, which identified peri-aortic lymph nodes which we were able to treat with radiation. At my last follow-up visit on March 7 I got to undetectable. Certainly not out of the woods yet but very grateful to have gotten the results that we have had so far.

  11. @Joseph: Good luck and God bless.

    @Sitemaster: What “accomplishment”? I have no “accomplishment”.

    One of my greatest and oldest friends starts salvage radiation after RP this week. The only difference between us is a different fear of different outcomes. Fear is no accomplishment. The only “accomplishment” I can aspire to is to die of something else before metastatic pain and other complications become meaningful. (To be clear there is no sign of either yet.) And if I fail I will of course blame myself.

    Meanwhile I know many men who know themselves to be much sicker than I hope myself not to be read this site. I weep and pray for those who travel the road “voluntarily” or involuntary. Good luck, fellas. It is not a “failure” and you are entitled to travel it in any way you like.

  12. JJ, some of your statistics and interpretations are substantially more on the dark side of side effects than what I have seen published. The statement that especially caught my attention was: “Very often after a biopsy a man’s semen will turn into jet black goo.” Without a credible source, that seems a most misleading statement. Your source?

  13. Jimwaldenfels,

    Go to http://www.yananow.org/display_story.php?id=1659 for a full version of my article with references.

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