Prostate Biopsy and Alternatives

It seems we have a national passion for prostate biopsies. A million men are biopsied every year. Two hundred thousand of them will be diagnosed with prostate cancer and about half of these with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, more than half of these men with Low-Risk will undergo prompt, radical treatment.  Sadly, irrational fears rooted in the electrifying word “cancer” drive most men into taking immediate action.

Since a diagnosis of “cancer” overwhelmingly portends overtreatment, some experts have suggested that we simply stop PSA testing altogether. That way, if men are not diagnosed they will be spared from the ravenous medical system that funnels everyone into immediate radical treatment.  Practically speaking, however, backtracking on the use of PSA for screening is never going to happen. Patients and doctors alike are unwilling to forgo the information that PSA testing provides, imperfect as it may be.

Realistically speaking, intelligent people are starting to realize that PSA testing per se is not the real problem.  The problem is that doctors and patients are overreacting to the information PSA provides. PSA is a totally nonspecific indicator that can be elevated for many noncancerous reasons such as prostate enlargement, recent sexual activity or inflammation (prostatitis). 

The solution to an overenthusiastic medical industry is, therefore, not less frequent PSA testing, but rather convincing physicians to slow down the rush to immediately random biopsy at the first sign of slight increases in PSA.

We now know that there is no value in diagnosing every single case of prostate cancer as so many of them are totally harmless. It is actually advantageous to spare men the unnecessary knowledge that they have a non-threatening Low-Risk prostate cancer. 

So where is the middle ground between immediate biopsy of every PSA elevation and forgoing PSA testing and biopsy altogether?  Before deciding to do a biopsy, the prostate gland should be measured with an ultrasound scan to determine whether it is abnormally enlarged.  If the amount of PSA elevation is proportionate to the degree of prostate enlargement, then the PSA elevation can be attributed to a benign cause. Rather than proceeding with an immediate biopsy, additional PSA testing with OPKO 4Kscore may be indicated. The advantage of the OPKO 4Kscore over standard PSA is that it provides an indication of the risk of having High-Risk prostate cancer, a much more clinically relevant endpoint.  

If the OPKO 4Kscore test and PSA density are favorable, then further monitoring with some form of imaging offers additional insurance against missing the diagnosis of aggressive cancer.  Modern 3-Tesla Multiparametric MRI (MP-MRI) and high-resolution color Doppler ultrasound, while not perfect, are reasonably accurate methods for detecting aggressive cancers.  

So in summary, random biopsy should be an absolute last step for men with modestly elevated PSA levels that can’t be explained by a prostate infection, laboratory error or recent sexual activity. Here are some signs that a biopsy may be needed:

1.                  A PSA elevation out of proportion to the size of their gland
2.                 An OPKO 4Kscore indicating a high likelihood for High-Risk prostate cancer
3.                 An abnormality felt on digital rectal examination
4.                 Imaging studies suggestive of underlying aggressive cancer

PSA is a remarkable tool that we have depended on to diagnose prostate cancer since the early 1990s.  It certainly has transformed the management of prostate cancer over the last 20 years. However, the cost has been the rampant overtreatment of approximately to 100,000 men annually.  A high PSA, rather than triggering an immediate biopsy, should lead to further investigation as outlined above.  Rushing to a biopsy simply because the PSA is elevated frequently leads to unnecessary radical treatment with detrimental lifelong consequences. 

Article originally posted August 11, 2015, on about.com, by Mark Scholz, MD


More about Dr. Scholz: 

A board-certified medical oncologist, Mark C. Scholz, MD, serves as medical director of Prostate Oncology Specialists Inc. in Marina del Rey, CA, a medical practice exclusively focused on prostate cancer. He is also the Executive Director of the Prostate Cancer Research Institute. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is the co-author of the book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Potency.  He is a strong advocate for patient empowerment.