Healthcast 647 - Just for Men: Prostate Cancer Can Be Diagnosed Without Blind Biopsies

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This subject is for men who have had a high PSA and who have been advised that they need a prostate biopsy to determine if they have cancer. Many men go into the doctor for the biopsy necessary for diagnosis without expecting the “blind biopsy” procedure that is done through the rectum and is extremely painful when the doctor blindly takes pieces of the prostate…over and over again.   Blindly, means he is randomly picking a place to biopsy without a real target….with the urologist biopsying everywhere in the prostate 10 or more times. Finding a small cancer with this random or “blind” biopsy method is a less than effective way to find a small area of prostate cancer. Men who have had this procedure done rarely agree to a second round, under any circumstances and I agree with them.

I always do a PSA test before I treat a man with testosterone so I often am faced with the question of what advice I should give him in this situation before I feel it is safe to give him testosterone. Of course, if he has prostate cancer, even a high PSA, I will not give a man testosterone until his urologist says he is safe to receive it.

 Until recently there was no radiologic way to screen a for prostate cancer. Now urologists use Ultrasound or MRIs to find an abnormality in the prostate that they can biopsy.  This makes the procedure both more accurate and less painful.

The way this procedure was done in the past, and is still done throughout the US, always caused me to wonder why urologists hadn’t figured out a way to do it in a way that accurately biopsied a high risk area of the prostate, with one or two biopsies.  Now Urologists use rectal ultrasound or MRI, like Gynecologists use vaginal ultrasounds to find and drain or biopsy ovarian masses, or to harvest eggs in IVF. The urologists have even borrowed the idea to use numbing medicine as well to make it comfortable.  In the last 2 years I have found a few Urologists who have embraced the new, accurate biopsy procedure that used the MRI to find high risk areas and ultrasound to locate suspicious areas for biopsy, then used the same radiologic method to locate and  treat discrete focal areas of abnormality with cryotherapy (freezing) or focused ultrasound. 

Finally in August of 2023,  a research article titled, “Focal Therapy for Localized Prostate Cancer in Older Men”, was published in the Journal of Urology.

This article describes a much more accurate method of treating prostate cancer that resulted in the diagnosis and treatment of  low grade prostate cancer without recurrence and without complications, allowing men to have a conservative treatment for low grade prostate cancer, following a less painful and invasive diagnostic procedure. Compassion has finally come to diagnosis and  treatment of prostate cancer. We applaud the authors.

August 22, 2023

Focal Therapy for Localized Prostate Cancer in Older Men

Allan S. Brett, MD, reviewing Habashy D et al. J Urol 2023 Jul Lomas DJ and Frendl DM. J Urol 2023 Jul

In an observational study, focal therapy was compared with radical treatment.

At some centers, focal ablative therapy (generally with high-intensity focused ultrasound or cryotherapy) is a treatment option for selected patients with localized prostate cancer. This option could be attractive for some older patients with comorbidities who might be candidates for radical prostatectomy or radiotherapy (according to tumor grade) but who wish to avoid complications from radical intervention.

Using data from national registries, U.K. researchers compared 262 patients (age, ≥70; median age, 74) who underwent focal ablative therapy with 262 propensity-score–matched patients who underwent radical treatment (mostly radiotherapy with androgen-deprivation therapy). At baseline, nearly all patients had intermediate- or high-risk disease. Estimated 5-year failure-free survival (the composite primary outcome, which included absence of salvage radical treatment, systemic treatment, distant metastases, or prostate cancer–specific death) was significantly higher in the radically treated group than in the focal-therapy group (96% vs. 82%). Estimated 5-year overall survival with focal therapy was 96%.

COMMENT

The better failure-free survival with radical treatment than with focal therapy (a 14 percentage-point difference) is not surprising. The challenge for individual decision making is to balance that difference against the higher rate of complications with radical treatment in older men — especially men with substantial comorbidities. We don't have long-term data from randomized trials to compare focal therapy versus radical treatment, active surveillance, or watchful waiting. But in the meantime, editorialists from Mayo Clinic conclude that focal therapy is “a reasonable strategy in older patients.”

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They insert a needle through the wall of your rectum and into the prostate to extract the cells for testing. This is a “transrectal biopsy.” Doctors usually take a dozen samples from various parts of the prostate. In some cases, they do the biopsy by inserting a needle through the skin between the scrotum and the anus.May 29, 2023