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Alternatives To A Prostate Biopsy

Apart from skin cancer, cancers that affect the prostate is prevalent in men.

While sometimes not life-threatening when localized to the prostate gland, there are still a significant number of men who die each year from this disease.

In 2019, about 174,650 men were diagnosed with prostate cancer in the United States1.

The majority of men diagnosed with this cancer are over the age of 65, but the condition can still occur in younger patients.

Local prostate cancer accounts for 90% of cases, which is generally easier to treat when the disease is detected during early-stage prostate cancer.

The diagnosis of prostate cancer is critical to ensure treatment can be initiated during the earlier stage of the disease.

While a prostate biopsy is often considered the ideal solution for the diagnosis of prostate cancer and other abnormalities detected in the prostate gland of a patient, there are certain side-effects that men are concerned about.

This post considers the prostate biopsy alternatives available to assist in screening tests for an enlarged prostate and prostate cancer.

What is a Biopsy?

The process of conducting a biopsy is considered a critical part of diagnosing prostate cancer in male patients for many doctors.

A biopsy is not only a diagnostic tool used in men suspected to suffer from prostate cancer warning signs, but also forms an integral part of diagnosing other cancers too.

During a biopsy, a small piece of the tissue suspected to be affected by cancer is removed from the patient’s body. In the case where a male patient is suspected of suffering from prostate cancer, the doctor will remove a tiny piece of the prostate gland.

The doctor usually looks at the prostate with an imaging test such as transrectal ultrasound (TRUS) or MRI, or a ‘fusion’ of the two (all discussed below).

The doctor quickly inserts a thin, hollow needle into the prostate. This is done either through the wall of the rectum (a transrectal biopsy) or through the skin between the scrotum and anus (a transperineal biopsy).

With prostate cancer, many doctors prefer to remove tissue from different parts of the prostate gland. This helps to cover a larger area and provides for a more accurate way of diagnosing the patient with this disease.

Once the doctor removed the tissue sample from the prostate gland, it is placed in a specialized tube. The tube is then sent to a laboratory, where the biopsy is tested.

Scientists at the laboratory facility will look at the tissue underneath a special microscope and see if cancerous cells are present in the prostate gland of the patient.

When is a Biopsy recommended?

In the majority of cases, a biopsy will only be taken if a doctor suspects that the patient might have prostate cancer.

A PSA test is done first to see if there is an abnormally high level of prostate-specific antigen in the patient’s bloodstream. In some cases, the doctor may also perform a digital rectal exam first before ordering a PSA test.

When the doctor feels an abnormality in the region where the prostate is located, then they might suspect prostate cancer.

In this case, the use of a biopsy may assist the doctor in getting more insight into the abnormality that was detected. The anomaly might be a sign that the patient has developed prostate cancer in some cases.

The biopsy taken to assist in prostate cancer diagnosis forms a critical component in allowing a doctor to provide the patient with appropriate treatment.

The treatment plan will depend on the severity of the patient’s condition. In some scenarios, active surveillance will be preferred – this is usually in the case of mild prostate cancer that is localized to the gland.

There are, of course, cases where more intensive treatment would be needed. This is usually the case when the biopsy returns results of more aggressive prostate cancer. In such a case, the use of certain drugs may be advised to the patient. The doctor may also prefer to have the patient undergo radiation therapy for prostate therapy.

How effective is a Prostate Biopsy?

When it comes to undergoing a more invasive procedure as part of the diagnosis process for cancer or any other disease, patients generally want to understand how effective the option will be.

With a prostate biopsy, in particular, many patients may experience discomfort during the actual procedure. A small tool is used to get to the prostate gland through the wall of the patient’s rectum.

While most patients will not experience pain during this diagnostic process, it can still make a man feel exceptionally uncomfortable while the biopsy is being taken.

For this reason, men want to be assured that this particular test will offer them accurate results when looking to gain a diagnosis for the abnormality that was detected in their prostate gland.

Studies have looked at how effective prostate biopsies are. This is where one concern regarding these procedures come in. Evidence shows that prostate biopsies are not always accurate.

A study2 in the Canadian Urological Association Journal is an excellent example. The 12-core prostate biopsy was used in the study. The purpose was to determine how useful this specific biopsy is in detecting prostate cancer.

A total of 90 patients with prostate cancer were included in the study. The average age of the participants was 64. Some younger individuals participated too.

The youngest age among the participants was 49. All patients had previously undergone radical retropubic prostatectomy. Additionally, a 12-core prostate biopsy was performed on all of these patients.

Pre-and postoperative prostate biopsies were compared in the study. Several markers were analyzed among these patients. In addition to biopsies, additional tests were taken too. These tests include:

  • Prostate weight

  • Level of prostate-specific antigen in the blood

  • Free and total prostate-specific antigen ratio

  • The density of prostate-specific antigen in the prostate biopsy

In addition to these tests, the Gleason scores of patients were also recorded.

The accuracy of prostate biopsies was lower than what is generally expected. The detection rate of prostate cancer with an initial 12-core prostate biopsy was considered low. Repeated biopsy procedures and tests were required for a more accurate way of detecting prostate cancer in patients.

The detection rate of the 12-core prostate biopsies was higher in those patients who were younger.

Those with elevated PSA levels also had a better chance of effective detection of cancer without too many repetitive biopsies. Gleason score also seemed to play a role. A higher Gleason score made it easier to detect cancer with a 12-core prostate biopsy.

Apart from this, another finding was made. The prostate biopsy used in the study yielded more effective results in patients who had smaller prostates.

The results of the study are relatively disappointing. Prostate biopsies are the most common diagnostic tool used by doctors. These tests are requested when the patient is suspected of suffering from prostate cancer. Due to the low detection rate with an initial 12-core prostate biopsy, a prostate cancer patient may get a false negative result.

What this means is the patient may experience a growth in the prostate cancer unknowingly. This can be pointed to the low effectiveness of the prostate biopsy. Multiple biopsies might be needed for an effective way of diagnosing prostate cancer.

Results are somewhat mixed, however. There are cases where the failure rate of biopsies seems to be lower.

A study3 published in the Reviews in Urology, for example, found that biopsies may be more effective in some cases. The study explains that at least ten lateral cores are necessary during an initial prostate biopsy. This provides a more effective approach to testing for cancer in the prostate gland.

Additionally, on a second biopsy, more than 20 cores might be needed to improve the accuracy of the test.

The study found that the rate of a prostate biopsy missing the presence of cancer ranges between 23% and 25%. At the same time, the study also refers to a previously published paper.

In this paper, by Svetec and Colleagues, a failure rate of 46% was noted. A total of 90 prostate biopsies were performed in this paper. Among these, 41 biopsies returned a false negative result.

What side effects can a Prostate Biopsy have?

The possibly low rate of success in prostate biopsies is not the only concern with the procedure.

Patients have raised other concerns when they undergo this diagnostic procedure as well. This would, of course, include the potential side-effects that may occur.

Individuals suspected of prostate cancer need to realize what to expect with any advised procedure. This includes the use of a prostate biopsy to detect cancer cells in their prostate glands.

Certain risks have been associated with a prostate biopsy. Most of these risks are considered mild.

There are, however, a couple of risks that need to be taken more seriously. These risks may lead to more significant damage. The complications can also sometimes become more severe.

1) Bleeding

The location where the biopsy is made will usually bleed following the procedure. This is a normal side-effect due to a small incision that is made when the biopsy is taken.

Since the biopsy is taken through the rectum wall, it is normal for a patient to experience rectal and anal bleeding after the procedure. This particular side-effect should clear up relatively quickly after the biopsy.

Men may also notice bleeding in both semen and urine. These are also relatively common and considered a normal side-effect.

Semen in men may have either a rustic or red color to it. The color change of semen means some blood has escaped into the semen – remember that sperm combines with fluid from the prostate gland to form semen.

The biopsy was taken from the prostate gland. This means it is normal for bleeding to occur. The same can happen with urine. In most cases, if blood is present in urine, it will be relatively mild.

These side-effects may last for a couple of weeks after the patient had the biopsy, but should not take more than a month to clear up.

2) Urination difficulty

There have been cases of urination difficulty in men. In these cases, a man might have to wear a urinary catheter for a small period. This can be uncomfortable.

The urinary symptoms can also make it difficult for the man to control their urination effectively. The use of the catheter can be helpful but does come with its own set of risks.

3) Infection

A more severe complication of a prostate biopsy is infection. While quite rare, there are cases where men develop an infection after a biopsy. The infection may occur in several parts of the body.

It will commonly develop in the prostate gland. In some cases, the urinary tract may rather be affected by a bacterial infection.

If complications occur with the area where an incision was made in the rectum wall, there may be a risk of infection here as well.

When an infection develops, treatment becomes critical. Antibiotics need to be prescribed to the patient. This helps to clear up the infection. Failure to treat the infection can cause serious side-effects. In rare cases, the bacteria that causes the infection can enter the patient’s bloodstream.

Are There Alternatives To A Prostate Biopsy?

Certain alternatives can sometimes be used to assist in diagnosing prostate cancer. It is important to note that these alternatives will not take the place of a biopsy. In many cases, the patient will still need a biopsy.

The use of these alternative methods can still be useful. They can be used as a way to ensure a biopsy is only conducted if completely necessary.

There are cases where a tumor in the prostate may be confirmed even before a biopsy is performed.

Some of the alternative tests that can be used are discussed below.

Free PSA Test

Prostate-specific antigens are often part of a routine test. Levels of these antigens can provide an indication when something is wrong with a patient’s prostate gland. Doctors often focus on free prostate-specific antigens. These antigens have not bound to a protein.

When there is a high level of prostate-specific antigens in the patient’s blood, then the doctor will usually be concerned. Further testing becomes essential at this point.

Digital Rectal Exam

If abnormalities are suspected with a free PSA test, a digital rectal exam will usually follow. This can be a somewhat uncomfortable test but is far less invasive than a biopsy.

During a digital rectal exam, the doctor will insert a finger into the rectum of the male patient. The doctor wears gloves during the procedure. The finger will be used to feel for abnormalities with the prostate gland.

There are many cases where a digital rectal exam brings up abnormalities. In most situations, these abnormalities relate to benign prostate hyperplasia. The chance of prostate cancer should not be overlooked.

Transrectal Ultrasound

An ultrasound is often considered an effective alternative to a biopsy. During this procedure, a small device is inserted into the rectum. The device is equipped with technology that can use sound to produce ultrasound images.

The goal is to generate an image of the patient’s prostate gland. The image allows the doctor to determine if there are abnormalities with the prostate gland. This may be in the form of an enlargement. In some cases, growths related to prostate cancer tumors may also be detected.

The procedure is generally considered painless. No incisions are made to conduct a transrectal ultrasound. The patient may feel uncomfortable while the device is placed in their rectum.

MRI

Magnetic resonance imaging (MRI) scans create detailed images of soft tissues in the body using radio waves and strong magnets.

MRI scans can give doctors a clear picture of the prostate and nearby areas. MRI scans can show if cancer has spread outside the prostate into the seminal vesicles or other adjacent structures.

This can be very important in determining prostate cancer treatment options.

Multiparametric MRI is a newer technique that can be used to help better define possible areas of cancer in the prostate, as well as to get an idea of how quickly cancer might grow. It can also help show if cancer has grown outside the prostate or spread to other parts of the body.

MIPS Score Test

While a PSA test can indicate an elevation in prostate-specific antigens, this can mean a lot of things. Many doctors prefer to conduct a MIPS score test, as well. This test looks for three different markers in the patient’s body.

The markers that the test looks for include serum PSA, PCA3, and TMPRSS2: ERG. The TMPRSS2: ERG marker is often also referred to as T2: ERG.

The T2: ERG and PCA3 markers are genes that can be identified in a urine sample.

An elevation in these two markers is generally considered harmful. In most cases, elevated levels of T2: ERG and PCA3 would be seen as an indication of prostate cancer. It is considered extremely rare for a patient not to have prostate cancer when these markers are elevated.

The test is often considered a risk assessment tool. It also functions as a way to help doctors make a more accurate decision.

Conclusion

The process of prostate cancer screening often includes the use of a biopsy to identify the presence of prostate cancer cells.

Due to the damaging effects of clinically significant prostate cancer, male patients should ensure appropriate tests are conducted when abnormalities with their prostate gland are detected.

The side-effects of a prostate biopsy can be a serious concern, however, we looked at some of the alternative options that are available to men, from the use of a PSA screening to imaging tests that assists with the diagnosis process without a biopsy.

Sources

  1. Cancer.Net. (2019) Prostate Cancer: Statistics. [online] Available at: https://www.cancer.net/cancer-types/prostate-cancer/statisticshttps://www.cancer.net/cancer-types/prostate-cancer/statistics
  2.  Canadian Urological Association Journal. (2013) How reliable is the 12-core prostate biopsy procedure in the detection of prostate cancer? [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668408/
  3.  Reviews In Urology. (2008) Using Biopsy to Detect Prostate Cancer. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2615104/
  4. Minervini A, Vittori G, Siena G, Carini M. Morbidity and psychological impact of prostate biopsy: the future calls for a change. Asian J Androl. 2014;16(3):415–417. doi:10.4103/1008-682X.126388
  5. Coyle C, Morgan E, Drummond FJ, Sharp L, Gavin A. Do men regret prostate biopsy: Results from the PiCTure study. BMC Urol. 2017;17(1):11. Published 2017 Jan 26. doi:10.1186/s12894-016-0194-y

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