Sunday, 16 December 2018

To biopsy or not?

Quick drawing made on a train; inspired pic on Prostate Cancer UK
When I had my biopsy last year there was little talk of any side-effects or possible impacts other than the standard list I consider below. Would I have the biopsy with what I know now? I’m not sure, but hey this is all so individual that we all have to come to our own conclusions for what is right at that time. I’m also aware that a little knowledge can be dangerous so treat carefully blog readers!

What is it?

Well a 'TRUS prostate biopsy' is basically 10-12 thin needles that are guided by ultrasound and used to take small samples of tissue from the prostate; these are then studied and give us a Gleason score. Some people - hopefully all now - will also have had a special type of magnetic resonance imaging (MRI) scan, before having a biopsy; this can help see if there is any cancer inside your prostate and also help with guiding the needles (although after news this month I would be wary of MRI’s using contrast dyes) (i). I have to say it is not so great to have a probe up the back passage and what feels like a gun being ‘fired’ 12 times into the prostate - but also not terrible! However, it is possibly better than the other type of biopsy, a template (transperineal) biopsy, where the needle goes through the skin between the testicles and the back passage?


What is Gleason?

The score is named after Donald Gleason, a pathologist at the Minneapolis Veterans Affairs Hospital, who developed it with colleagues in the 1960s. Our prostate cells are looked at under a microscope for the different patterns and speed that they are likely to grow. I think prostate cancer is the only cancer measured looking at the ‘architectural’ patterns. Anyhow these patterns are graded from 1 to 5 with only 3, 4 and 5 being cancer; the higher the grade, the more likely the cancer will spread beyond the prostate. The samples from the biopsy may vary so an overall score is calculated by taking the most common grade in all the samples and then the highest grade of what’s left. These two grades are then added together to give the Gleason score. In my case that was 3+4 totally 7; this is better than a 4+3. Yes a weird way of measuring that is not so clear to many of us! 


Why do it?

Well, a biopsy is the only way to find out for certain if you have prostate cancer. It may also be able to give some indication of how aggressive the cancer is and likely to spread; this can lead to earlier treatment and potentially stopping the cancer spread.


What are the possible problems with it?

1. Accuracy? The biopsy can only show whether there was cancer in the samples taken, so it’s possible that cancer might be missed. It is hard to assess from the research online how accurate biopsy results are today…certainly lots saying how inaccurate, but more recently by combining with MRI the results are improved very significantly.

Professor Emberton talking on the BBC’s Inside Health (ii) a year ago says of the 2015 PROMIS trial (iii) that it showed; "that our standard of care is really very poor so that our standard biopsy, which we’d been relying on for about 40 years, misses over half of all the clinically important cancers. So half the men who were told they were all clear were indeed harbouring clinically significant disease. MRI was about twice as good, it had a sensitivity so its ability to detect clinically significant disease is present in excess of 90%.  And so the majority of patients that had clinically significant disease were successfully detected”.

Local artist Russ cartoon
The MRI will also hopefully put an end to as many as 25% of biopsies and some over diagnosis of prostate cancer. This can only be good news as most of us have some negative reactions to a cancer diagnosis! In the book, with a rather scary title, “Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency“ by Dr Mark Scholz and Ralph Blum they note that during the first two weeks after diagnosis the risk of suicide goes up twenty-two fold and heart attacks are ten times more likely (iv).


2. Side effects? I guess if finding more out about your cancer saves your life, these are a minor consideration. However, it is worth noting them as some of us have not had such an easy time! See Prostate Cancer UK’s website for more on side effects and of course talk with your doctors about any/all of this as some symptoms require a quick trip to A&E (v):

Pain or discomfort - Some men will feel pain or discomfort in their back passage (rectum) for a few days or weeks afterwards. Each man is different and while some find the biopsy painful, others have only slight discomfort. My discomfort sadly went on for over three months including making it difficult to sit in the first couple of weeks.

Short-term bleeding - It’s normal to see a small amount of blood in your urine or bowel movements for about two weeks and in the semen for a couple of months. That probably looked more scary than it actually was! A small number of men (less than 1 in 100) may have more serious bleeding in their urine or from their back passage (rectum). 

Infection - Some men get an infection after their biopsy and antibiotics are given prescribed, I think to all, to try to prevent this. 

Acute urine retention - a guy I spoke to had this - it is not at all common but I understand the biopsy causes the prostate to swell making urination difficult.

Sexual problems - some guys have difficulties for example with erections for a couple of months after the biopsy.

3. Spreads cancer? Well, Dr Larry Bans, MD at the Cancer Treatment Centres of America unequivocally writes: “The risk of ’seeding’, or ’tracking’, or ’spreading’ cancer with prostate needle biopsies, if there is a risk at all, has to be exceedingly rare and low.”

There are various analysies supporting this view. For example in 2014 in a paper published by Volanis et al, they showed that the number of prostate biopsies conducted each year has continued to increase, yet there is no apparent proportionate increase in the rate of track seeding resulting from prostate biopsies. They also found that most of the described cases of seeding involve neuroendocrine tumors of the prostate, which are <1% of prostate tumors. This is reassuring to those of us with an adenocarcinoma. Seeding is said to occur more often in some other cancers like pancreatic cancers (vi).

However, while the majority of medics believe there is no or very little evidence for seeding, concerns still persist. The worry is that cancer cells are pulled along the track formed by the needle or worse, spill directly into the lymphatic system or bloodstream. This is more likely when the biopsy punctures the tumour a number of separate times in order to obtain adequate tissue for diagnostic purposes.

The BMJ in July 2018 published G. David Stainsby and Susan Bewley, who write (and I quote nearly in full as it covers some important ground) (vii): "Men should be warned about uncertain safety of multi-needle prostate biopsy. Godlee et al. stress that researchers must accept patients as full partners included in design, conduct and reporting of clinical research, along with presenting and disseminating results to participants and relevant communities. However, patient/research subjects must also take centre stage regarding safety. Population screening for prostate cancer with PSA has failed to improve men’s survival. Treatment outcomes remain disappointing, especially following radical surgery for ‘early intra-capsular disease’. Five recent studies report underestimation of tumour extent on histology of excised prostate glands: in a third of men malignant tissue was outside the capsule; in a quarter tumour tissue was incompletely removed in the unsuccessful operation. Nevertheless, urologists press on, using ever-increasing numbers of biopsy cores in men with only slight elevation of PSA, seemingly indifferent to the possibility of local extension and needle track spread. Thus, this potential adverse event has not been routinely sought. Suggestions that MRI scan post-positive biopsy might accurately assess the extent of malignant tissue before treatment decision-making have been disregarded. Men managed by 'watchful waiting or ‘active surveillance’ may receive repeat interval biopsies with additional risks of local tumour extension each time. Without adequate investigation of potential local effects of multi-needle prostate biopsy, there is uncertainty about harm. Not looking leads to ‘lack of evidence' which should not be accepted as ‘evidence of no harm’."

There is also evidence that inflammation can cause prostate cancer metastasis (viii). Certainly if my biopsy took over three months to feel comfortable I’m guessing there was inflammation a fair bit of that time?

It is also interesting that three different doctors in two Hospitals in Germany also warned against biopsies. My own German doctor said before I had the transurethral hyperthermia that it would be less successful due to me having a biopsy. This was a view shared by a number of doctors I heard speak at Trew Fields and an integrative doctor who I have just seen locally. 

It seems to me that there is enough doubt to conclude "Men should be warned that multi-needle prostate biopsy has the potential to cause extra-capsular tumour spread.” 
So where does that leave us? 

I don’t know! I’ve already written about how inaccurate the PSA test is and now here I am finding biopsies may not be so good? This is perhaps a blog for the future but one possible thought for now came after reading a paper from 2017 (ix) that puts forward the idea of measuring PSA and serum ferritin together. They write: "In conclusion, serum ferritin is significantly associated with prostate cancer and may serve as a non-invasive biomarker to complement the PSA test in the diagnosis and prognostic evaluation of prostate cancer.” Could this, even with a PSA that is not so accurate, help diagnose prostate cancer instead of the invasive biopsy? Update Dec 18: I suspect not great as I have now read that further tests re Serum ferritin have been inconclusive re diagnosis (x). :(

As always, thoughts welcomed.

Notes:

(i)  See more: https://www.radiologybusiness.com/topics/care-delivery/gadolinium-actual-offender-or-unwitting-pretender and https://medshadow.org/features/mri-gadolinium-contrast-agent/
(ii) BBC’s excellent Inside Health from a year ago: https://www.bbc.co.uk/programmes/b086s7jr
(iii) See more re PROMIS trial: https://www.ncbi.nlm.nih.gov/pubmed/25749312   
(iv) See: 'Completed Suicides among newly diagnosed prostate cancer patients' (2008) by Inner Valdimarsdottir and 'Cardiovascular events among newly diagnosed prostate patients' (2008) by Fang Fang
(v) See: https://prostatecanceruk.org/prostate-information/prostate-tests/prostate-biopsy
(vi) See: https://sperlingprostatecenter.com/truth-biopsy-track-seeding/
(vii) https://www.bmj.com/content/362/bmj.k3193/rr-10 
(viii) March 19, 2007 in the journal Nature described the findings of University of California San Diego: https://www.ncbi.nlm.nih.gov/pubmed/17377533  

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