Biopsy Procedural Differences in the States

[lenihant]

In reading you blog, I see you are in favor of preforming an MRI on the prostate pior to the biopsy to isolate areas of potential concern. You are also in favor of performing a Transperineal Biopsy versus the Transrectal Biopsy using the MRI data to target the area of interest and allowing access to all areas of the prostate.

I am living in the States and the standard procedure is to go right to a Transrectal Biopsy (which can be done in the Doctor’s office.) when there are elevated PSA values. Having an MRI of the prostate or getting a 4K Score are not standard pre-biopsy requirements. I doubt anyone would have any other type of cancer checked via biopsy or surgery without knowing the exact area of interest.

With some difficulty, I did manage to get the MRI and 4K Score ahead of scheduling a biopsy. There is a Fusion (or Targeted) Biopsy in the States where the MRI data and the Ultrasound data are overlaid to increase the probability of getting a sample in the area of interest. This Fusion Biopsy is still done Transrectal.

One item I would like to add is that Fusion Biopsies are still considered “leading edge procedures” here and are generally performed at a research university. One issue I came up against is the MRI data format doesn’t always work with the MRI data system at the university. In such cases, the university wants to have the MRI performed again which the insurance companies here don’t really want to pay for.

I just wanted to pass on some experiences to your other readers so they avoid the same problems. The more a patient knows, the better they can be part of their care.

It seems obvious to me that the probability of finding a problem increases greatly if you can sample in the area of interest. This saves time and money as the procedure may not have to be performed again in 6 months or a year later if the PSA scores continue to rise.

Based on your experience, could you highlight the benefits of the 4K Score and Transperineal biopsy so other patients can discuss these options with their Urologist?

[professoreden]

PSA is an imperfect tumour marker but it is still an excellent tool for identifying men in whom more interest needs to be taken to either exclude or confirm the presence of prostate cancer. We know this because the largest screening study for prostate cancer (the European Randomised Screening study for Prostate Cancer or ERSPC) ever done showed up to a 44% reduction in prostate cancer deaths in men who were screened compared to those who were not http://www.erspc.org/.

However, because PSA is not wholly sensitive (picks up all cases) or specific (only picks up men with cancer) for prostate cancer the urological community is, and has been for many years, looking hard for other tests or markers to use in conjunction with PSA to determine more accurately an individual patient's risk of having prostate cancer and therefore how intensively to investigate them. These other tests include free PSA, PCA3, EN2, the 4K score and STHLM 3 but there are many others and the list is being added to on a yearly and sometimes on a monthly basis.

However, before their widespread use these new markers need to be validated to determine their true usefulness and this process takes many years. The other issue with their development and release is one of cost, as new tests tend to be more expensive as they are done in smaller numbers. In future, it is very likely that a panel of several (5-10) tests will be done in men to determine which of them is recommended to have which investigations. This is a few years away though but using a single test in conjunction with PSA, such as 4K or free PSA, to increase its accuracy is becoming increasingly common.

The second part of your question relates to the advantages of transperineal versus transrectal biopsy. These are safety (a lower risk of infection when not biopsying the prostate through the rectum), comfort (a general anaesthetic is used for the transperineal route), access (you can reach all parts of the prostate equally well from the perineum, whereas tumours in the front of the prostate are difficult to reach transrectally) and precision (a grid is used for transperineal biopsies, through which the biopsy needle is inserted to allow for great accuracy in knowing precisely what part of the prostate is being sampled).

We rarely now do any transrectal biopsies. The great majority are now done via a perineal approach and are MRI-targeted.