Latest / Intellectual Medicine / Prostate Biopsy: Why You Might Regret Getting One—and What to Do If You Already Did

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Prostate Biopsy: Why You Might Regret Getting One—and What to Do If You Already Did · Intellectual Medicine

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  I could spend this podcast explaining to you how to
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  interpret your prostate biopsy, but that would mean you have not
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  been paying attention and you got the biopsy that I told you
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  not to get. All right, all right, I get it.
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  Some of you already had the biopsy, and some of you may
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  choose to get one. I support your prerogative,
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  although I have my opinion. And my opinion, well, it's based
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  in a lot of research and experience, but it also has an
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  overlay of philosophy. But it's more important what you
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  derive from it. So what about that biopsy?
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  How do you interpret it? Why do I say you ought not to
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  get one? Well, here are the reasons.
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  First, spread. I know, I know.
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  The urologist tells you that the biopsy does not really spread
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  cancer. Logic dictates otherwise.
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  If you stick a needle into cancer and it bleeds, it can
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  spread. If I am taking off a skin
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  cancer, Melanoma in particular, and I've done this in my
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  practice, remove melanomas, you have to be very careful to cut
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  the perimeter. You do not want to cut into the
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  Melanoma because you can spread it.
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  If I purposefully cut into a Melanoma, that's malpractice.
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  Think about removing, oh say a breast cancer.
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  The surgeons are very astute in carefully cutting it out, making
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  sure the borders are clean. No surgeon would just recklessly
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  hack into the middle of it. Why then do we suspend our
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  concern when it comes to the prostate biopsy?
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  I maintain it's out of convenience more than reality.
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  Not only do I maintain it, but a study out of Sweden 2014, they
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  looked at men who had prostate cancer biopsies, then they took
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  blood out of their arm, peripheral venous blood.
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  And you know what they found? In many cases they found debris,
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  cellular material from the prostate biopsy in the blood,
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  and in some cases it occurred 30 minutes afterward.
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  That means it wasn't immediately eliminated.
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  So that's a huge reason to be very contemplative about the
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  biopsy. But wait, how will I know if I
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  have cancer or not? Folks, it's a new era.
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  The biopsies have been around since 1980.
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  We now have an MRI. We can see your gland, we can
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  see the nodules. We have diagnostic testing.
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  PSA is just one of them. Or others.
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  Do they prove you have cancer? No.
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  But then again, does a biopsy prove you have cancer?
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  No. When you get a biopsy, I don't
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  care how precise, how targeted, I don't care how careful.
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  It only samples less than 1% of the total volume of the prostate
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  tissue, So the odds that you'll actually get the material, it's
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  not 100%. You can remember the game
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  Battleship. You'd have to go blindly try to
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  sync your neighbor's battleship. I don't know, it's kind of a fun
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  game. Maybe not, I guess nowadays,
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  right? If if you're listening to this,
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  you probably remember it. Kids nowadays are all like video
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  games. Anyhow, back to the biopsy.
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  They are sticking needles into the prostate gland.
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  Prostate cancer is not organizing itself into a neat
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  little nodule. It is speckled and disseminated
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  at its origin. So the idea of targeting it,
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  they may say, well, we can target it with an MRI guided
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  biopsy. Maybe so.
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  But the Gleason score, this is what we're talking about now.
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  And Doctor Donald Gleason arrived at his interpretive
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  judgement, subjective judgement about what these cells look like
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  back in the 1970s. And you know, I suppose he did
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  us a service. He did his best pathologist,
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  right? He wanted to categorize those
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  cells, what do they look like? And he did do that.
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  But over the years, the categories have shifted a bit
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  and the way they're reported is different in America, say versus
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  in Europe. Imagine they're looking at 20
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  different biopsy specimens. Well, how do you report that?
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  The most aggressive looking one, the most pathologic looking one
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  or the average amount In the US, they go for typically the most
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  pathologic looking one versus in Europe where they tend to
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  aggregate them. But does this all really matter?
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  Does it make a difference? And it may not.
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  So now we can get to a reasonable degree of certainty.
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  That's what we're after, folks. If you want guarantees, ain't
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  going to happen in medicine, and it will not happen regarding
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  your prostate health. You must live with uncertainty.
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  Just a matter of what type, but I want reassurance.
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  I want a biopsy. OK, so they do the biopsy.
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  Suppose it comes back and shows no cancer.
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  I already told you they've only sampled maybe 1% of the
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  material. Is there really no cancer there,
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  or did they just miss it? You don't know uncertainty will
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  persist, and furthermore, what happens next?
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  I had a biopsy done in June. How about a year from now?
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  Should I get another one? See the dilemma that you're
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  painted into and suppose it does show cancer.
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  Does that make a difference regarding your decision about
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  treatment? I mean, I suppose it might, I
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  suppose psychologically, right? If you have biopsy proven cancer
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  in your prostate gland, you might opt for surgery.
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  Take it out. It's comforting.
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  Psychologically, it seems to make sense.
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  It just doesn't seem to make a big difference regarding your
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  survival. This is a real dilemma.
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  I mean, traditionally, not traditionally.
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  Intuitively, if you cut a cancer out, you shouldn't then die from
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  it. That's the objective.
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  That's the gold standard. Cut it out.
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  I don't die from it. The PIVOT trial, published in
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  the New England Journal of Medicine, looked at men who had
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  the prostate gland removed versus those who did not, and
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  they followed them for 20 years, and they found no significant
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  difference in death from prostate cancer in either group.
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  I know that's disturbing that men who left the gland in place
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  had the same, statistically the same risk of dying from prostate
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  cancer as men who had it removed.
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  That's not what you bargained for, is it?
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  You take the gland out, you do not expect the cancer to then
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  take your life. I wouldn't mind so much the
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  aggressiveness of treatment if it weren't for the devastating
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  consequence. Leaking urine, sexual
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  dysfunction, it is heartbreaking.
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  We need to push forward. We need better techniques of
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  intervening. How do you manage the
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  uncertainty? Doing nothing is uncomfortable,
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  but does it matter? Suppose you do a bopsy.
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  And by the way, in the PIVOT study, they did categorize the
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  disease based upon the magnitude of pathology.
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  That is the Gleason score. So let me talk about that.
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  For those of you that have had a biopsy or are curious thinking
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  about it. The Gleason score is a numeric
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  categorization about how funny the cells look.
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  If they look not bad, they are given a score of 6.
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  Now the score goes up to 10, but it really starts at 6.
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  So if you get a Gleason score of 6, it doesn't imply that you're
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  past the halfway mark. In fact, a Gleason score of 6
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  has the same risk of dying from prostate cancer as somebody was
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  never diagnosed with it. So it's been argued that there
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  should be another label applied to a Gleason score of 6.
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  Not cancer, but something else I maintain that consideration
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  should be should be applied to prostate cancer in general.
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  Atypical dormant cells is the is a nomenclature that I add that I
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  advocate for these the cells that are in the gland and aren't
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  going to do much, They just stay there.
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  But how do you know the Gleason score 678910?
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  It is true that the higher the Gleason score, the worse the
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  prognosis. You're more likely to die from
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  prostate cancer with a Gleason score of 8 or 9 versus 6.
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  That's true. What is not true is that you can
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  use that score to make definitive judgments about your
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  best path of treatment because in the trials it doesn't appear
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  to have a huge difference regarding the outcome.
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  It is understandable that if you had a high Gleason score, you
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  might be inclined to want to do something more aggressive, and I
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  can't blame you if you did. Does appeal to logic.
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  After all, nobody wants to die. But worse than dying is
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  suffering, withering consequence, losing your manhood
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  and then dying. So the Gleason score, it's the
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  way it's reported. Sometimes they'll call it a more
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  aggressive cancer. Suppose you get a Gleason score
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  of eight or nine. Well #1 you did the biopsy, told
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  you not to do that, but that's OK.
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  It's OK, it's your prerogative. So Gleason score of eight or
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  nine, they'll call that aggressive.
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  How can you tell? It is a statistical reality that
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  if you have one point on a curve, you can make no judgement
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  about what comes next until you get another point, right?
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  You got to see progression. Aggression is not defined by the
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  stagnant nature of any entity, but rather what it does over
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  time. A tank can be considered
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  aggressive, but if it's in park and it's sitting there, not
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  much, it's when it's moving. So let's translate that into the
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  prostate. One of the reasons that I like
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  non biopsy assessments because you can sequentially monitor
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  them without causing harm without risking disseminating
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  cancer. So you can do a prostate MRI.
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  Let's follow the bread crumbs. PSA is elevated and staggering
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  an interval. You do it three months later and
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  it's starting to creep up. The next step in my view should
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  be an MRI of the prostate and the MRI of the prostate.
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  If your PSA is above 5, let's say if it's above 10, you may
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  find some nodules in there. That does not mean you go biopsy
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  them. It just means you have nodules
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  in your prostate. But are they cancer or not?
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  You don't know there are features that can help guide
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  that thought, and you can make a reasonable judgment about what's
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  there. Then you can do things to make
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  your body more resilient against cancer.
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  Now, we've talked about some of those things, and we'll continue
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  to do that, but they're not surgery, they're not radiation.
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  We're not talking chemotherapy. We're talking stuff you can live
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  with. Then you can repeat the study
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  three months later if you have in the M, the MRI is gauged on
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  what's called a Π rods, zero to five.
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  You go from a three to a four or five.
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  That's evidence of progression. That means whatever it is you're
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  doing at the time, it's not quite enough.
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  Maybe you got to do a little bit more.
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  So interpreting the biopsy implies you did the biopsy.
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  Interpreting the biopsy implies that it has tangible merit,
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  concrete evidence of a path forward.
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  It does not. It's not to say that the
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  treatment approaches are irrational, It's just to say
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  they're unproven. Do not let any surgeon tell you
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  they're going to cure your cancer with surgery.
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  They can't do that. They shouldn't say that the
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  support, the research does not support that.
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  They should be saying we're going to attempt to prevent
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  cancer progression. We hope that this is a curative
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  procedure, but for the rest of your life we'll have no way to
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  know. The literature and clinical
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  experience is replete with men who had the prostate removed
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  only to have the cancer come back.
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  So uncertainty will be with you forever.
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  My goal for you is to have vitality always.
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  Death comes, but it ought not to be preceded by a withering phase
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  of life. Vertical life.
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  We call it vertical living, right?
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  Stay vital, stay vital, and then boom, quick death at the end,
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  hopefully at an advanced stage, hopefully not from prostate
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  cancer. But no matter the path you pick,
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  you don't get the guarantee in the biopsy does not help with
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  the outcome decision decision making.
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  It's difficult. The reason I I don't like
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  biopsies, dissemination, lack of correlation to help guide
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  definitive treatment options and the the need to do them again to
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  see what goes on. I, you know, I hear a lot of
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  stories, not stories, histories of men who suffered from the
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  biopsy itself, lingering pain, sexual dysfunction from the
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  biopsy. And it can happen.
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  If you're inclined to get the biopsy, be advised that the,
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  that the Gleason score will come to you.
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  But the Gleason score is just the pathologist.
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  Best guess you could look at two different pathologist and they
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  can come up with two different Gleason scores of the same
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  biopsy. So perhaps that's a tip I can
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  give you. Have that biopsy specimen
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  interpreted by an independent pathologist.
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  Would they agree that the Gleason score is the same?
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  But does it even matter? It comes down to how do you want
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  to manage your prostate? What are you willing to risk and
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  what are you hoping to gain? I maintain that if you can take
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  a deep breath. That's the biggest advice.
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  Go slowly, you have time, no matter the status of your
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  prostate or the cancer. There's never a rush, so do not
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  jump at the first recommendation of treatment.
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  Give yourself reflection, even if it's only a few weeks, and
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  then decide how you want to live your life.
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  Would you accept a compromise in your vitality through the
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  surgery of removing the gland or through the radiation?
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  Would you accept that? Would that be a fair trade in
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  your mind? Very individual.
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  It's a very individual decision. A lot of it has to do with what
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  you value. For some men, the notion of
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  leaking urine or losing erectile and a sexual function is not a
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  big inhibitor. I respect that.
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  It's your life, it's your prerogative.
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  That's how you're going to roll. But the biopsy itself, the
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  Gleason score, how to interpret it?
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  Perhaps this has helped a little bit.
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  That it is. I like it.
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  That old cliche. When you can't measure what's
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  important, you give importance to what you can measure.
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  We like numbers, we like scores, we like protocols.
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  Prostate cancer treatment based on a Gleason score has been an
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  empirically derived treatment pathway without proven benefit
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  and outcomes. Not to say it's wrong, it's just
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  not as concrete as we wish it were.
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  So with that mire of uncertainty, we move forward,
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  man. Not a guarantee.
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  Here's what I hope for you. Here's what I hope for me.
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  I want to die with prostate cancer cells in my gland because
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  it means I lived long enough to get them.
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  Because if you live long enough, it is almost inevitable that
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  they'll be cancer cells within the gland and that they will in
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  all likelihood stay there. This could be considered a
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  normal progression. These atypical dormant cells can
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  be considered normal for an aging homo sapien male, and as
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  such should be intervening aggressively.
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  Food for thought. You know how I feel.
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  Keep your prostate, keep your manhood, don't let them
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  irradiate you. Accept the journey forward,
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  accept the uncertainty. The thing you can be certain of
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  is treatment will cause harm. That's about the only guarantee
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  when it comes to conventional pathways.
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  Where you can be certain of is no matter whether you follow my
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  recommendations or surgical irradiation, the outcome will
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  remain uncertain, but we can always move forward.
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  That is, you can go from a non surgical, non radiation pathway
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  toward that if you choose to. But when the prostate's taken
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  out, you can't put it back. Same thing with radiation.
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  You can't put that toothpaste back in the tube.
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  So folks, the biopsy should be predicated based upon what would
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  you do with that result. Don't do the biopsy before you
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  contemplate how you want to manage your prostate health.
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  If it shows cancer, what would you then likely do?
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  If it doesn't show cancer, you're still on a conundrum.
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  The reason they did the biopsy is because they thought you had
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  cancer. Comes back negative, May not be
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  convincing enough to make them not want to do another one in
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  the future. Conversely, if you have a MRI
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  that shows up pyrides of five very likely to be cancer and you
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  have nodules in the prostate. Worse yet, suppose there's
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  evidence of dissemination. Do you even need a biopsy when
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  all the hours of pointing toward certainty of diagnosis, so I
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  maintain my position. A biopsy is not terribly
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  helpful. Not always necessary that we now
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  have a non invasive means of assessing between the prostate
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  MRI and if needed a prostate specific membrane antigen PET
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  scan. These are non surgical pathways
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  that surgeons are not likely to embrace anytime real soon.
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  It's incumbent upon you to do your own homework and direct
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  your care. Even if that direction is not
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  aligned with what's given, the advice it's given to you.
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  All right team, Well, that's all I got for today.
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  Thanks for spending time with me and continue your reflections.
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  Remember, you have time. Consider multiple sources, but
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  don't go it alone. Don't go down the rabbit hole of
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  Internet based arbitrary treatments.
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  You need to have a partner. You need to have your family
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  doc. You need to have somebody who
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  can look at the whole picture. And yeah, oftentimes you need a
• 18:47
  urologist, maybe even an oncologist part of the team.
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  All right, gang, until next time, look forward to the
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  conversation.