Some dramatic news from across the pond is suggesting that MRI (magnetic resonance imaging) scans can reduce biopsies by 90%.
That could be huge if the study holds up. (More on the study below.)
Some background.
The prime directive for patients on active surveillance is to avoid biopsies, the so-called gold standard for diagnosing prostate cancer. We want to avoid them because they can put us at risk for serious infections and also because they can provoke anxiety as we anticipate the tests and then await the pathology report,
Yet don’t we want to know if we have prostate cancer so we can decide what to do about it?
I’ve had six biopsies in 12 years on AS and hope—and expect—never to have another.
I tolerated the procedures with minimal discomfort, but I know some guys get very upset and anxious at the very thought of undergoing a prostate biopsy, fearing pain and risk of infections from the transrectal biopsy and also experiencing anxiety throughout the process.
European malpractice?
A leading urologist in Belgium told me this week that transrectal biopsies, sometimes called transfecal biopsies, would be considered grounds for malpractice in Europe. Transperineal biopsies have been considered the standard of care in Europe since last year, when the European Association of Urologists made them the preferred diagnostic tool for prostate cancer.
But transrectal biopsies remain as American as hot dogs, apple pie, and Chevrolet.
It’s just the way things are done here. Last I heard a year ago, 95% of prostate biopsies in the U.S. are performed through the germ-laden rectum.
(Going transrectal with a biopsy gun.)
The American Urological Association plans to release new guidelines on biopsies in 2023. But who knows what they’ll do?
A lot of medical economics and politics may be in play.
Many urologists are transperineal-resistant because transperineal procedures take longer, and insurers in effect pay urologists less by paying urologists the same fees as they do for transrectal procedures.
American urologists also balk at the $40k it takes to get set up for transperineal procedures. Many are infection deniers even if they haven’t checked their infection rates.
(See below a link to a debate on transperineal v. transrectal. AnCan is sponsoring the event. I will be the moderator. Also, check out my articles on the “Ugly American Urologist”:
Transperineal biopsies are a better choice with reduced infection rates. But some men wince at the thought of the pain from having any biopsy needles pushed into their prostates, even through their numbed perineal, the space between the anus and the scrotum. Some opt to go under general anesthesia.
Some tests are done to help us avoid biopsies, such as the IsoPSA, PHI, and 4kscore.
MRIs have gained a foothold as patients are found to have rising PSA (prostate-specific antigen) blood tests in the range of 4-10. There no longer should be a rush towards having biopsies.
Finally, the news
Now, British researchers are reporting a new way of using existing technology to reduce use of biopsies.
It sounds almost too good to be true.
But it comes from researchers at University College London backed with a £450,000 ($546,000) grant from Prostate Cancer UK and Movember from Prostate Cancer United Kingdom and November, the men’s health charity, which has become a huge backer of active surveillance.
Results from the INNOVATE trial were published last week showing that using an innovative type of scan – called VERDICT MRI – alongside standard imaging techniques was significantly better at identifying men who do not have prostate cancer. These men could safely avoid biopsy altogether, reducing the number of unnecessary biopsies by 90%, researchers reported. Three hundred patients were in the study and a bigger study is planned.
Wow. Good news if proven in bigger studies. I hope U.S. researchers can get funding to join in.
PC UK explained that VERDICT (Vascular, Extracellular, and Restricted Diffusion for Cytometry in Tumor) is “a new MRI technique that gives additional information about the prostate based on exactly where water molecules are and how they are behaving. This can give a quantitative indication of how ‘normal’ or ‘abnormal’ the cell structure within the prostate is. Aggressive prostate cancer is more likely to result in very abnormal cell structures, so researchers have been able to define a threshold that is likely to be reached only when aggressive prostate cancer is present.”
Radiologist and medical physicist Shonit Punwani, professor of Magnetic Resonance and Cancer Imaging at UCLH and lead investigator of the INNOVATE trial, said of VERDICT: “It potentially has the added benefit of reducing the cost of diagnosing prostate cancer to the NHS [National Health Service}, which is hugely important given the additional strain on the system caused by the pandemic. Our next step is to use VERDICT MRI in an even bigger study across multiple hospital sites. If successful, the trial should provide the evidence needed to change practice in the NHS in the near future.”
(Dr. Shonit Punwani)
Dr. Sarah Hsiao, Director Biomedical Research and Impact at Movember, said: “It’s yet another win for Prostate Cancer UK’s longstanding partnership with Movember, which has seen us fund over 90 grants together since 2012. Today’s exciting results show that we are now seeing those grants make real improvements for men with prostate cancer.”
Dr. Matthew Hobbs, Director of Research at Prostate Cancer UK, added: “It’s rare to see such a big improvement on current practice, both in terms of accuracy and driving down harms caused by testing. These results are a massive leap forward for an exciting new test that could spare thousands of men each year unnecessary anxiety and pain.”
PC UK said: “Biopsies are how we diagnose cancer. They allow doctors to take cells to study under a microscope so they can say for certain whether a man has cancer or not. They’re absolutely necessary if we want to save treat cancer and save lives. But they can cause unintended side effects such as infections, as well as causing unnecessary anxiety for men. We want all men who have prostate cancer to have access to a safe, accurate biopsy but we want men who don’t have prostate cancer not to have to have one at all. Many of the men who currently have a biopsy for suspected prostate cancer, turn out not to have cancer at all.”Developing, as they say.