By Dr. Sperling
As a new year begins, many people are surprised at how time seems to fly by. “Where did last year go?” they wonder. Yet when it comes to changes in medical practice, I am astonished at how often the medical world seems to drag its feet in adopting a true breakthrough. A perfect example is the snail’s pace at which news about positive change in prostate cancer diagnosis travels. This is sad enough within the patient community, but it borders on tragic within the professional community, which is responsible for staying abreast of and implementing changes that can significantly improve patient care. At the very least, patients have a right to know about all their options, yet many doctors continue to offer patients only conventional biopsies and whole-gland therapies. Let’s review the past decade to underscore how technological advances in imaging and detection have literally changed our “view” of prostate tumors. Ten years ago, prostate cancer was suspected based on of three factors: a rising PSA, an abnormal digital rectal exam, or a combination. By my standards, the problem with these methods is that the information is insufficient, and often misleading. Almost 7 ½ years ago, respected urologist Thomas Stamey, M.D. (Stanford University School of Medicine) and colleagues published research demonstrating that an elevated PSA more often correlated with the prostate enlargement common to aging men (benign prostatic hyperplasia) than with prostate cancer: “We emphasize that the most, and almost only, significant variable related to serum PSA in the radical prostatectomy specimens of the last 5 years (January 1999 to July 2003) is prostate weight… ie benign prostatic hyperplasia.” Nonetheless, many men with elevated PSA are still literally rushed off for a transrectal ultrasound-guided biopsy (TRUS biopsy). This approach carries the risk of a “false negative.” This means that taking 10-14 tiny tissue samples via transrectal ultrasound (TRUS) guidance is like putting a drinking straw in a loaf of rye bread and hoping to pull out one of the scattered seeds. If you don’t find a seed, that doesn’t mean there are NO seeds in the loaf. It means you have a false negative. The same is true of hoping to find a very small, early stage tumor. TRUS has insufficient fidelity to identify small tumors by imaging-so the doctor doing the needle biopsy is basically making an educated guess about where to find cancer. Now, ten years later, we have a whole new world when it comes to diagnosis. With today’s multiparametric MRI capability, we can literally see very small areas of suspicion. This results in the ability to guide a minimum number of biopsy needles directly into the suspected tumor, meaning far less trauma for the patient and far greater accuracy in diagnosis. Again, going back to the turn of the millennium, a positive biopsy meant that depending on the stage and grade, a patient would be offered options from the following menu: A. Active Surveillance (or Watchful Waiting) B. Radical Prostatectomy C. Beam Radiation D. Radioactive Seed Implants E. Cryotherapy (freezing) Patients who opted for (A) had to be psychologically motivated to live with uncertainty from blood test to blood test. And, without today’s sophisticated cell analysis, wondering whether or not they were living with an indolent or aggressive cell line-were they truly appropriate for delaying treatment? On the other hand, patients who opted for B, C, D or E generally had their whole glands treated, with varying risk of incontinence and sexual dysfunction. As the decade moved forward, a relative handful of urologists and radiologists began offering targeted (focal) therapies using tissue ablation within the body, either with cryotherapy or HIFU. This shift in thinking, still not widely accepted, was made possible by fairly recent laboratory evidence that not all prostate cancer is necessarily multifocal (present throughout the gland), and not all microscopic prostate cancer will necessarily become lethal. Thus, today’s laboratory analysis can better filter who is a candidate for which menu options. Now let’s put 1 + 1 together to equal 2: New diagnostic imaging + new targeted treatment strategy = Whole New Prostate Cancer Worldview. Today, in 2012, patients have a right to know about precise, minimal biopsy methods guided by superior imaging advances. Today, in 2012, patients have a right to know about targeted treatment options if, as is the case in roughly 1/3 of patients, they have a small focus of disease that could be treated by the latest thermal ablations using extreme cold (focal cryotherapy) or heat (focal HIFU, laser ablation). Yes, it’s a New Year, and a new day in the world of prostate cancer biopsy and treatment. This is why we at the Sperling Prostate Center are doing our best to speed up time, and quickly get the word out about the significant change in the prostate cancer worldview.
- Stamey TA, Caldwell M et al. The prostate specific antigen era in the United States is over for prostate cancer:. J Urol 172 . 1297-1301. Oct. 04.