Examining The Basis For New Prostate Cancer Screening Recommendations

Image from a 3D staged biopsy - the only type that can eliminate false positives.


Many men are confused after the latest shift in advice from the U.S. Preventive Services Task Force's  2012 recommendations against prostate cancer screening.  At that time the advice was less screening, specifically via the PSA test, for men even past the age of 55, noting that the "possibility of the PSA lowering deaths from prostate cancer was very small." .  The reasons were not hard to grasp, mainly that one can get false positives which put the tested person on a track for even more invasive tests including unnecessary biopsies.  These can carry their own risks, including sepsis, impotence.

For example, the standard prostate biopsy consists of an extraction of from 10 to 20 cores of tissue.. Thus, a needle device is inserted into the rectum and each time extracts tissue from the gland after puncturing the rectal wall. The primary risk is for sepsis, which is why antibiotics like ciproflaxin must be administered in advance.

The procedure is usually done in the urologist's office without even a sedative and takes from 20 minutes to 45 minutes, depending on the number of sample cores taken. The chief side effects include: swelling and pain in prostate, possible problem urinating, and blood in urine, stools and semen. In the former two body fluids it can remain 1-2 days and in the last up to 3 months.

Even given all this, the biopsy is basically "random" and can miss up to 30 percent of cancerous lesions.  By contrast, the 3D staging biopsy entails up to 100 needle sampling insertions through the perineum to extract prostate tissue. The locations are again confirmed via trans rectal ultrasound for later mapping of all the samples to a 3D grid. The meticulous and exhaustive sampling ensures nothing is missed, hence represents the "gold standard" for prostate biopsies with up to 99 percent confidence of identifying all carcinomas.

The downside is, while vastly more accurate, it entails a far greater medical burden. Thus one must undergo a full surgery prep for general anesthesia, including being asked if you're an organ donor, and to leave an advanced medical directive .  The main risk is for hemorrhage, given the dozens of extractions.

A confirmation of lesion, however, then also is more accurately graded (by Gleason score) and can allow more choices in terms of treatment which one may not have with the standard biopsy. (For example if the standard biopsy reveals a higher Gleason score than the lesion actually merits, as I learned in my own case - after getting the 3D staging biopsy)

Now, in the new advice from the U.S. Preventive Services Task Force for men aged 55- 69, the conclusion is that the benefits of getting the test are marginally enhanced over the risks. This has been ascribed to "additional medical evidence from some clinical studies increasing the certainty about the PSA test reducing the risk of dying from prostate cancer.".   Even so, the panel's qualifying remarks noted the balance between pluses and minuses "was very close", and advised men aged 55-69 to consult their doctors in deciding whether to get the PSA.

Let's note that the statistics show that for every 1,000 men who get screened, an estimated 240 will test positive on the PSA. Some share of these - maybe 10 percent - will show false positives meaning those men will be faced with unnecessary biopsies. Those who decide to get treatment run the risk of developing impotence and incontinence as a result of surgery or radiation.

Owing to these facts,  the Task Force recommendation for those 70 and older stands by its 2012 position that "the benefits of screening do not outweigh the risks". .  The reasoning, again, is that because most prostate cancers are slowly growing, by the time one is diagnosed - say at 70 or 71 - he is still more likely to die from any other cause than cancer. (Up to 50 percent have a form of prostate cancer that doesn't spread or grow rapidly.)

In addition, an older guy getting screened sets him up for even more nasty complications, as well as costly treatments that may not be needed, and in fact are unwarranted. This is assuming such a test is positive with "high PSA" say 5.0 or 6.0.  One is then liable to be trapped in the "rabbit hole" of cancer quandaries summarized by the aspects below:

1) Cancer experts themselves can't agree on which primary treatment is best.

2) The same experts (oncologists) can't agree on which ("salvage") treatment for recurrent disease is best, or when to start it.

3) Most agree that if a guy has recurrent disease and a biopsy shows it has spread to the bones ("bone mets"), his days are basically numbered - though certain treatments (e.g. hormone) will allow some limited life extension.

Now also, once driven into the treatment domain one will have to decide how far to go, i.e. how many and what type of treatments are you willing to get in order to grab maybe ten years of life? Are you even willing to go the medical castration route?

Recall I earlier cited the Prolaris genetic test for the aggressiveness of a prostate cancer tumor,e.g.


I cited my own score of 6.6, corresponding with a 12.5 % specific risk of mortality at ten years. That translated to a 1 in 8  probability of croaking from it if I decided to do nothing.  As my oncologist (Dr. Crawford) pointed out, most guys at age 70 would make that bet.  I'm not doing it because he insists I have a better chance getting rid of the tumor completely using focal cryotherapy. But the point is for many "watchful waiting" might be an equally ok strategy.

Watchful waiting, especially if a guy is younger (say than 55)  - becomes a dicier proposition especially if the Gleason score is 6. By now most everyone has also seen or read of actor Ben Stiller's bout with prostate cancer, e.g.
http://www.cnn.com/2016/10/04/health/ben-stiller-prostate-cancer/

But what they may have ignored is how the treatments and testing can often be worse than anything else - especially if one has a slow growing cancer. The risks of further treatments include sexual impotence and incontinence  The latter means wearing diapers - as in Depends - permanently. This is also why Otis Brawley of the American Cancer Society, has warned that most men need to be very careful before stepping through that testing and treatment door. Nine times out of ten the cancer will be so slowly growing that you can do 'watchful waiting' - especially for Gleason scores of 6 or less.

But ....also nine times out of ten a guy's significant other will insist the cancer come out as in out, out, out. The idea of living with a tumor that can grow - no matter how slowly - is a non-starter.  This is why it's a good idea for men and their spouses to have "the talk" ahead of time, say before the next PSA test. Decide in advance what PSA test value or threshold sets in motion further tests, including the "free PSA" test, MRIs and prostate biopsies (including MRI fusion biopsy.)

3D Staging Prostate Biopsy Unlikely To Come Into General Use - My Account

Image of a 3D reconstruction- with grids superimposed-- after 3D Staging Biopsy. Note the prostate (in red), urethra (in green) and the exact location of areas of cancer (in mud yellow). 


The advantages of the 3D staging biopsy for prostate cancer which I just had two days ago, are well known and explicated wonderfully on Dr. E. David Crawford's University of Colorado site. We are informed, for example, that with this 3D rendition many more lesions, prostate cancer tumors can now be identified because the technique is much more thorough. As Dr. Crawford has noted, from 10-30 percent of prostate cancers are missed even in the MRI fusion biopsy.

In other words, given the much higher accuracy the 3D Prostate biopsy is now the "gold standard" for PCa diagnosis. But that standard doesn't mean many more men will choose it.  We need to look at why this is so.

The standard prostate biopsy is more or less an "in and out" procedure, done rectally with the accompaniment of an ultrasound to provide location data for the prostate sampling. This may be from 10 to 20 cores. Thus, a needle sample device is inserted into the rectum and each time extracts tissue from the gland after puncturing the rectal wall. Primary risk is for sepsis, which is why antibiotics like ciproflaxin must be administered in advance.

The procedure is usually done in the urologist's office without even a sedative and takes from 20 minutes to 45 minutes, depending on the number of sample cores taken. The chief side effects include: swelling and pain in prostate, possible problem urinating, and blood in urine, stools and semen. In the former two body fluids it can remain 1-2 days and in the last up to 3 months.

The 3D staging biopsy by contrast is an entirely different animal. While described as an "outpatient" procedure, you are actually administered general anesthesia because the technique is much more invasive and entails up to 100 needle sampling insertions through the perineum to extract prostate tissue. The locations are again confirmed via trans rectal ultrasound for later mapping of all the samples to a 3D grid. The samplings are taken approximately 5mm apart. In my case a total of 45 were taken, fewer than originally projected (60).

Of course, before getting it done you are undergoing a full surgery prep, including being asked if you're an organ donor, and to leave an advanced medical directive (or living will) in case the surgery or anesthesia goes awry - or you hemorrhage. Also Janice had to be there to provide durable power of attorney and medical power of attorney in the event I was left unable to render decisions, directions for my own care.

In the pre-op setting you also discuss with the anesthesiologist any allergies, and note if you are sensitive to meds (as I am.) By the time you are being wheeled into the OR you are already half out of it from the mix of sedatives, painkillers including fentanyl.

Once in the OR you must move yourself from the gurney to the operating table where the sampling is done. I don't believe I'd completed the transition more than a minute before I was knocked out.   (Just before I was asked by a urology resident if I wanted a transfusion in case of hemorrhage, and I gave my blood type).

I awakened in the PACU or Post-Anesthesia Care Unit, to the soft voice of a beautiful nursing grad student, "Rachel", who asked the usual questions: Where are you? What is your name? What is your date of birth? What year is it? Etc. All this is done to ensure you are all there.

She then questioned me about the pain, where it hurt and the nature. I told her the worst aspect was a burning sensation all through the urethra, from the catheter. (I ended up opting for a Foley catheter, as opposed to supra-pubic on the advice of a urology resident, "Tim".).

She immediately brought me three meds to take with water, one of which was specifically to reduce the burning sensation that had become almost unbearable.

After giving me the meds, she brought me a few light Jello snacks. This time (unlike my gall bladder removal in May) there was no nausea at all so the anesthesiologist hit just the right mix.

Janice by now had also come up, after tracking my various locations using a "patient tracker" - coded by color to follow my progress. Once she arrived, Rachel and another student RN ("Callie")  showed her how to change the catheter bags, and also go from the usual (day time) leg bag to the much larger night bag.

Let me say right off the bat that having a Foley catheter in place is no ball of fun, and ranks maybe up there with a root canal - or two.  I had to wear the damned thing for two days before Dr. Crawford's RN gave the ok to take it out.   She emphasized it was foolhardy to do so too early because then "you could be in a real world of hurt". That refers to all the ancillary tissues swelling up preventing urination, which earns you a trip to the ER. 

So now, with it out I am still recovering and will get the results of the biopsy in 5 days or so.

Having had the normal biopsies and this one I can agree right now with what a paper dealing with it noted, that in general most men would not opt for it given the greater "medical burden" - that entails more invasive procedure - as I described - as well as more side effects, bleeding from rectum, penis, etc. and pain as well as having to wear a urinary catheter.

Most men, despite the touted accuracy of results (which isn't in dispute),  will simply not opt for this advanced biopsy unless they are looking for a specific treatment option (e.g. focal cryo-ablation) for which it is required.

Anyway, recovering now, and thankfully with no catheter. I am just waiting for further word on whether I am a candidate for the focal cryo. I will have to meet with Dr. Crawford again in 2 weeks.

See also:


http://www.edavidcrawford.com/video-gallery

Update:

Yesterday (1/24) I received word from UC Health that the biopsy came results came out favorably for further treatment. 5 of 45 cores showed cancer but no scores higher than Gleason 3 + 3. So I am cleared to schedule treatment in about two months.

So I have "Aggressive Prostate Cancer" -- What Exactly Does That Mean?

Sample report for the Prolaris genetic test .

First, let's clear the air.

Why do I blog about my prostate  cancer and the assorted tests,  treatments? Well, let's start with the fact this is the second leading cancer killer of men, up to 30,000 a year. But that often takes no account at all of the hell many men endure in terms of the tests (like biopsies) as well as treatments - often described as more savage than the disease.  One can scan and google but unless one is actually a member of a prostate cancer survivor group (as I am) he or she will have scant idea of the pain and suffering aroused by this disease, including in spouses.

Thus, the point here is not anything to do with some narcissistic disease obsession but rather getting information out about how one might very well have to deal with this cancer - especially after recurrence. (More men than you think, in fact, kill themselves after undergoing treatment then having the cancer recur - on being plunged into deep depression).

The other aspect is to show not all cancer narratives are of the saccharine form, e.g.:  'I beat the cancer and it never came back! NO, that's a tall tale, one often peddled by a sappy PR-based media and lackeys that don't know any better, or have an agenda to avoid any negativity. But, they avoid mentioning that in nearly 1 of 3 instances prostate cancer returns, even for those who have radical prostatectomy.

Six days ago, the local urologist's office  phoned to tell me the result of the Prolaris genetic test (of tissue extracted at my MRI fusion biopsy) was that the prostate adenocarcinoma was aggressive. To fix ideas, the sample shown on the image above yields a score of 3.0 and is in the "less aggressive" region.  This in concert with other  clinical-pathologic values enabled an estimate for a 10-year prostate cancer-specific mortality risk. This patient then has a 10-year prostate cancer specific mortality risk of 2%..

My score by comparison was 6.6, corresponding with a 12.5 % specific risk of mortality at ten years. That translates to a 1 in 8  probability of croaking from it if I decided to do nothing. While this sounds like a fair risk to take for many, it would be roughly analogous to walking through a South Side Chicago neighborhood at 3 a.m. and expecting to get back home in one piece. In other words, a no go. In addition, it leaves out all the nasty side effects you'd have to deal with if the cancer breaks out of the capsule (metastasis)  which it is now on the verge of doing given the "perineural invasion" cited in my recent post on the MRI fusion biopsy result, e.g.

http://brane-space.blogspot.com/2016/09/biopsy-result-shows-writing-on-wall.html

It is via the nerve pathways by which the cancer escapes, gets into the bones (bone mets) as well as lungs, etc. The PET scan image below shows bone mets even in the spine. Each met is in reality a locus of prostate cancer.



The question for the medical assistant who phoned was: What is the risk of metastasis?  She gave me the five year risk of metastasis as 39.5% or nearly 2 in 5.  Again, if I chose to do nothing.

Since then, with further research, including gleaning insights from a prostate cancer survivors' group called Team Inspire, I have opted to do a salvage treatment known as focal cryotherapy. This will entail a 150 point 3D staged biopsy. Then that will be used as a guide to freeze the specific tumor regions in the gland. It is described as an "outpatient treatment" but done under general anesthesia, see e.g.

https://www.youtube.com/watch?v=-OnqA-mJDWg

The plan is to have it done at the University of Colorado Anschutz Center, with focal cryotherapy  specialist Dr. E. David Crawford, e.g.

http://www.edavidcrawford.com/targeted-prostate-cancer-treatment

A phone consult with Dr. Crawford's medical assistant, after seeing the MRI fusion biopsy and Prolaris reports, indicated I had the leeway to wait into until the new year to get it done.  This meant not having to contend with any side effects, etc. during the holidays. In addition, Janice six days ago experienced a mini-stroke (TIA or transient ischemic attack) so that means she must also get much better before we can move forward . I suspect all the tension with Trump and this election played no small role in her attack.

Anyway, I will need to have a preliminary meeting with Dr. Crawford in November, at the Aurora UC center, then we will discuss when to have the biopsy and  the treatment.  The latter, I am informed, is usually done at least two months later to allow enough healing time after 150 sticks through the perineum.

By now most everyone has also seen or read of actor Ben Stiller's bout with prostate cancer, e.g.

http://www.cnn.com/2016/10/04/health/ben-stiller-prostate-cancer/


But what they may have ignored is how the treatments and testing can often be worse than anything else - especially if one has a slow growing cancer. The risks of further tests, treatments include sexual impotence and incontinence  The latter means wearing diapers - as in Depends - permanently. This is also why Otis Brawley of the American Cancer Society, has warned that most men need to be very careful before stepping through that testing and treatment door.  Nine times out of ten the cancer will be so slowly growing that you can do 'watchful waiting' - especially for Gleason scores of 6 or less.

Once you go further - based on the PSA test-  be prepared for the biopsy which doesn't always treat a lot of men very well, not only the pain but possible sepsis, or other complications (e.g. incontinence). And if you decide to act on the biopsy results, be prepared for having to decide which treatment is best for you, realizing whichever you choose is a crap shot. As one member of Team Inspire put it (perhaps a tad hyberbolically):: "If there's even one cancer cell left it can grow back."

Well, if there is tissue left at the margins after a surgery, it certainly can!

See also:

https://www.youtube.com/watch?v=HDGAQdHid1c


And:

http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html

And:

http://brane-space.blogspot.com/2012/10/is-there-sex-after-prostate-cancer.html

And:

http://brane-space.blogspot.com/2012/10/penile-rehabilitiation-what-most-docs.html