Articles tagged with: PSA testing

14
October
2013

Biopsy Techniques for Prostate Cancer

Biopsy Techniques for Prostate Cancer

This week’s Guest Post is by highly regarded expert in the early detection of prostate cancer, Dr. Stacy Loeb. Stacy takes questions on prostate biopsy, and discusses its use, potential problems, and some developments in the field.

Dr Stacy Loeb is an Assistant Professor of Urology and Population Health at New York University (NYU) and the Manhattan Veterans Affairs Medical Center, specializing in prostate cancer. Dr. Loeb has published over 170 peer-reviewed articles and 8 book chapters, primarily on prostate cancer. She is on the Editorial Board for the British Journal of Urology International and Reviews in Urology, and authored the chapter on “Early Detection, Diagnosis, and Staging of Prostate Cancer” for Campbell-Walsh Urology, the primary textbook for the field. Stacy also frequently gives international lectures and courses on prostate cancer for other urologists, and hosts the Men’s Health Show on Sirius XM 81 satellite radio.


Stacy, TRUS biopsy is the most common technique for the diagnosis of prostate cancer. Can you give us an idea of the potential complications and the rates at which they occur?

The most common complication of prostate biopsy is bleeding, which can be in the urine, stool or ejaculate. Fortunately in most cases it is mild and self-limiting. Less common but often more serious is the potential for infection after biopsy. Indeed, the frequency of serious infections requiring hospitalization after prostate biopsy has increased in recent years. Other potential complications of prostate biopsy include pain and urinary difficulties, which are usually transient.


Is it a painful procedure to have done, and what techniques are used to reduce pain?

Prostate biopsy can cause both discomfort and anxiety, although there are many ways to mitigate these problems. Optimising patient positioning and simple relaxation techniques (such as deep breathing, listening to music, or even medication) may be useful to reduce anxiety. For pain, many different anesthetic options are available. For transrectal biopsy, several studies have shown that lidocaine jelly can ease insertion of the ultrasound probe, which is among the more uncomfortable parts of the procedure. Periprostatic nerve block is also commonly employed to successfully reduce pain during outpatient transrectal prostate biopsies. Other forms of biopsy such as the transperineal approach are frequently performed under sedation/general anesthesia, also effective forms of pain control. Overall, there are very few high-quality studies comparing the different methods for pain reduction during prostate biopsy, so the choice may be governed by patient-specific and procedural factors.


Some men require more than one biopsy to diagnose prostate cancer. There has been concern that repeat biopsies can predispose men to erectile dysfunction; can you comment on this?

There is conflicting evidence on the link between repeat prostate biopsies and the risk of erectile dysfunction. A study from the Johns Hopkins active surveillance program suggested that greater biopsy number was associated with erectile dysfunction after adjusting age, prostate volume and PSA, but a similar study from UCSF failed to confirm these results. Possible mechanisms for a link between repeated biopsies and erectile dysfunction include psychological factors as well as potential inflammation in the area around that prostate that houses the nerves involved in erections. Although this issue remains unresolved at this time, each procedure has potential risks making careful patient selection of critical importance. Hopefully, ongoing improvements in markers and imaging will reduce the need for repeat biopsies in the future.


You mentioned infection rates above. Are we seeing a rise in infection following TRUS biopsy of the prostate, and if so, why?

In the United States Medicare population, our research group reported a recent increase in hospitalisations for infection after prostate biopsy. Similar results have been confirmed in other populations, including Canada and Europe. The most likely explanation for these findings is increasing antimicrobial resistance in the community. Traditionally, the majority of patients were given fluoroquinolones as prophylaxis for prostate biopsy, but fluoroquinolone resistance has been on the rise. As a result, recent studies have explored other options for prostate biopsy prophylaxis, One option is to use more broad-spectrum antibiotics, although this may ultimately lead to greater antibiotic resistance in the future. An alternative option is to tailor the antimicrobial regimen based upon the local hospital antibiogram or individual rectal swab cultures performed at the visit prior to prostate biopsy. Other key recommendations are to assess the patient for risk factors for a prostate biopsy infection (such as diabetes, recent antibiotic use and foreign travel) and to counsel patients to seek immediate medical attention at the first sign of an infection.


Transperineal biopsy is another way to biopsy the prostate. Can you outline the advantages and disadvantages of this technique?

In the United States, most prostate biopsies are performed in the outpatient clinic through the rectum (transrectal) using ultrasound guidance. An alternate way to access the prostate for tissue sampling is through the skin of the perineum. Recent studies have suggested that the transperineal approach may reduce the risk of infectious complications. However, unlike transrectal biopsy, it is typically performed in the operating theatre with general anesthesia, thus involving greater time and expense. Transperineal prostate biopsies may also involve a greater risk of urinary retention, a situation where the patient is temporarily unable to urinate.


There has been a lot of interest in the use of MRI as a way of reducing 'unnecessary' biopsies. What are your views on this?

MRI technology has advanced substantially in recent years. At New York University, we have a well-established prostate imaging program using a 3 Tesla multiparametric MRI without an endorectal coil. Most patients tolerate the procedure well and it provides a very detailed anatomic view of the entire prostate, including regions that are poorly sampled during a traditional prostate biopsy. Suspicious lesions found on MRI can then be targeted during the prostate biopsy as a way to increase diagnostic yield. MRI may be particularly useful for men with a persistently elevated PSA and previous negative prostate biopsies, as well as for monitoring patients during active surveillance.


You can read more about Stacy by following the link to NYU Langone Medical Centre and you can follow her @loebstacy on Twitter.


Categories: Prostate Cancer

01
October
2013

Melbourne Consensus Statement on Prostate Cancer Testing

Melbourne Consensus Statement on Prostate Cancer Testing

This is the fourth in a series of posts by highly respected guest authors in Urology. Drs. Matt Cooperberg and Declan Murphy answer questions on the recently released Melbourne Consensus Statement on Prostate Cancer Testing


Matthew Cooperberg is Associate Professor of Urology and Epidemiology & Biostatistics at the UCSF Helen Diller Family Comprehensive Cancer Center. He is a urologic oncologist specialising in prostate cancer management. Matt is a highly published academic surgeon, having written/co-authored 130 peer-reviewed journal articles and 12 book chapters. He is Associate Editor for European Urology and sits on multiple other editorial boards.

Declan Murphy is Uro-Oncologist and Associate Professor of Surgery at the University of Melbourne, Peter MacCallum Cancer Centre. He is an Associate Editor at the BJUI and holds other senior editorial positions at European Urology and Nature Reviews Urology.


Declan, what was the rationale behind writing the Melbourne PSA Consensus Statement?

“The Melbourne Statement was a response to the very confused landscape we found ourselves in after the release of the USPSTF Recommendation last year and to a lesser extent, the AUA PSA Guideline a few months ago. While the USPSTF recommendation was frankly ridiculous and unworkable (PSA is not going to go away), the AUA Guideline did have some merit. However we felt that it did not adequately address some areas, e.g. how should we approach the average man in his 40’s who does not want to die of prostate cancer? Knowing that we would have a gathering of highly respected experts in prostate cancer in Melbourne in August 2013 we decided to release a simple document, which would provide straightforward guidance for GPs and others.”


Matt, has the statement been well received by Urologists, Patients and GPs/Family Doctors in the US?

“I was quite impressed with the press coverage in Australia and even in the U.S. when it was presented at the PCWC conference in Melbourne. We’ll see how much more discussion it generates when the final document is published in British Journal of Urology International. Ultimately, though, at least in the U.S., urologists’ recommendations don’t carry much weight with the primary care providers who are really making PSA testing decisions. They give far more credence to the USPSTF, unfortunately. Likewise in Australia, the RCGP Red Book is the bible for many GPs and it is very anti-PSA testing. Nevertheless we have had much positive feedback from GPs already.”


Matt, the USPSTF position statement essentially came out against PSA testing. Has this had a measurable impact on PSA testing in the US?

“This is hard to say so far. In 2009 the USPSTF came out against testing among older men, and multiple papers have shown that the recommendation had virtually no impact on PSA testing rates in the older population. However, this time it seems to be different. While there are no published data yet, multiple anecdotes seem to suggest that many primary care providers are simply abandoning PSA testing—equally for younger men in good health as for older ones with significant comorbidity. It is very much a case of throwing the baby out with the bath water.”


Matt, if the reductions in metastasis and prostate cancer mortality with PSA testing are so large, why does the consensus not support a population-wide screening programme?

“That term (population-wide screening) tends to imply reflexive PSA testing without any a priori discussion with the individual man. Enough controversy and confusion exists regarding both screening and prostate cancer treatment—and overtreatment is still enough of a problem in the U.S. and elsewhere—that we should not be screening men without warning them of the possible outcomes of testing. The relative cancer-specific mortality reductions are large, but the absolute reductions are not with 10-15 year follow-up, thus leading to calculations of relatively high numbers needed to screen and diagnose to prevent one cancer death. Though these numbers fall substantially with longer follow-up (a horizon of 30 years or more is entirely appropriate for a 50 year old man facing a screening decision), most men with prostate cancer die of cardiac disease, just like those without prostate cancer.”


Declan, are there any improvements or changes to the document planned?

“The document is set to evolve. One of the benefits of publishing it as a blog at bjui.org was to get it into circulation very quickly and also to allow others to comment. Within 72 hours the Melbourne Statement had become the most-read and most-commented blog at BJUI. The print version will appear in the BJUI in coming months.”


Matt, what is the future for PSA testing in your view?

“It’s very hard to say. I think many of us know the way PSA screening should evolve: men should be offered testing at a relatively young age—with the express understanding that testing is intended to detect high-risk prostate cancer, and that if a low-risk tumour is identified, it does not need immediate treatment. Those with low baseline PSAs can be re-screened less frequently than they are now. Evolving biomarkers will help determine who needs a biopsy and who needs treatment, but PSA is not going anywhere as a first screen. From what I understand, most national policies are evolving toward some variation on a “smarter screening” approach. Unfortunately, in the U.S. it will likely require a legislative remedy to force the USPSTF to accept actual expert opinion before the policy is corrected. There is a bill working its way through Congress to do just this, but it is not a quick process.

"In the meantime, the best we as urologists can do is to implement smarter screening in practice, to strive to reduce overtreatment and to improve quality of treatment when it is needed, to continue to advocate for USPSTF reform, and to reach out to local groups of primary care providers to educate them that the truth about PSA—which, as is usually the case in medicine, is neither black nor white. Only through understanding the truth in the shades of grey can we at once maximise the benefits of screening and minimize its harms.”


You can follow both Declan Murphy @declangmurphy and Matt Cooperberg @dr_coops on Twitter.


Categories: Prostate Cancer

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