A better biopsy? Local prostate center's test finds hidden cancers

John Tomasiewicz suspected something was wrong with his prostate, but he wasn't sure what.

Tomasiewicz, a father of two from Elgin, was only 49 when blood tests showed he had an elevated PSA, or prostate-specific antigen, a potential indicator of prostate cancer.

But several prostate biopsies found no sign of a malignancy.

His doctor recommended a more extensive type of biopsy offered at the Chicago Prostate Center in Westmont. Tomasiewicz underwent the procedure, which found cancer at an early, treatable stage.

With an uncle who died young from the same condition, Tomasiewicz chose to get radioactive seeds implanted in his prostate, which should kill the cancer. After getting the implants in January, he was back at work with no side effects in less than two weeks.

"It's important people don't feel embarrassed to go through these procedures," he said, "because it could save their lives."

A new approach

The biopsy technique that found Tomasiewicz's cancer was developed by Dr. Brian Moran, a radiation oncologist and medical director at the Chicago Prostate Center. His research results are published this month in the journal Urology.

The test is known as stereotactic transperineal prostate biopsy, or STPB. Rather than inserting a needle into the prostate through the rectum, as is typically done, Dr. Moran gets tissue samples by inserting a needle through the perineum, the space between the rectum and the scrotum.

He believes his approach allows easier access to the top front of the prostate, while reducing the chance of infection from the rectum. The external access also allows him to use a grid to mark exactly where in the prostate each piece of tissue comes from based on x, y and z three-dimensional coordinates.

Moran did not invent the technique of transperineal biopsy, which is used more widely in Europe. But he did adapt the use of the pinpoint grid system, typically used for radiation seed implants, or brachytherapy, which is his specialty.

Moran's study of 747 patients who had elevated PSA levels and negative transrectal biopsies found cancer in 39 percent of the patients.

Of those, 60 percent were deemed significant cancers requiring treatment, generally with Gleason scores of 7 or more on a scale of 10.

"Some positive biopsies will do fine without treatment," Moran said. "But there's also a group we find with potentially lethal malignancies we otherwise wouldn't have known were there. Those are the ones with enormous benefit."

Overdiagnosis?

Some doctors question the value of such tests.

In an essay titled "Finding more cancer isn't the answer," doctors at Dartmouth Medical School argue that some very early cancers do not progress, so tests that detect them can lead to unnecessary treatment. The article focused on breast cancer, but the authors note that some prostate cancers bear "watchful waiting" to see whether they need treatment at all. Many older men with slow-growing disease will die of other causes rather than prostate cancer, and treatment can cause incontinence and erectile dysfunction.

What's needed, they say, are tests that find cancers that kill.

Of course, the prostate biopsy is meant to not only find cancer but also help determine whether or how to treat it.

Dr. Anthony Smith, a board-certified urologist at the University of New Mexico and a member of the public media committee for the American Urological Association, called the transperineal biopsy "a reasonable approach because we don't have a perfect approach for those patients."

The biopsy does carry the risks that come with general anesthesia, and a small risk of problems urinating, which can require a catheter for a day or so.

Because the transperineal biopsy takes up to 40 tissue samples, rather than a typical 12 in the standard test, Smith said the increase in detection might be because of the extent of the "saturation" biopsy, rather than the origin point. He also questions whether a traditional biopsy might also find cancers a transperineal biopsy missed if the order of tests was reversed.

What's needed next is a randomized, controlled study to see which biopsy finds cancer more effectively, and ultimately, leads to a higher survival rate for patients with fewer side effects.

Dr. Moran - who was motivated to work in oncology after surviving testicular cancer at 17 - agreed more study is needed. But if his technique holds up, he hopes to take it a step further, and use it to pinpoint where treatment is needed.

By identifying exactly where in the prostate the cancer is located, treatment can be targeted to that area, reducing cost, recovery time and side effects.

Michelle Braccioforte, director of research and education at the Chicago Prostate Center, said this biopsy technique finds serious cancers that require treatment that otherwise have gone undetected.

"I don't think the doctor should be the one to say we're diagnosing cancers that don't matter," she said. "Ultimately, it's the patient's choice."

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