The Prostate Papers–A Biopsy Dilemma

Before we begin, the usual caveat: I’m just a guy sharing his experience dealing with the possibility I might have prostate cancer. I am not a medical professional. Please don’t go too far down this path without the guidance of a doctor. Do your research to understand what you are dealing with, but don’t make critical decisions without talking to a physician, preferably a urologist with deep experience in prostate cancer.

Do Your Research About Prostate Biopsies

As a prelude to this discussion, let me encourage you to visit at least one of the many websites offering detailed explanations and depictions of the biopsy procedure. Just google the phrase “prostate biopsy.” You don’t want to visit your urologist’s office for a biopsy without a clear understanding of what will happen when you arrive.

What’s the first step if your PSA levels start increasing significantly? It wasn’t too many years ago that the next stop in the diagnostic portion of this journey was to go directly to a prostate biopsy. Today, an MRI scan is often done before the biopsy. The good news is that if your MRI shows no lesions (or small lesions with low scores) and you have moderate PSA values, your urologist may suggest foregoing the biopsy for now. You’d continue “active surveillance” with regular PSA testing, digital rectal exams, and possibly another MRI scan at some point. Not undergoing a prostate biopsy unless it is necessary is a positive thing. In my case, the MRI scan showed a couple of lesions, one with a relatively high score for cancer risk. A prostate biopsy is necessary.

Liquid Biopsies

We now have PSA results and an MRI scan. Let me add to the diagnostic complexity by bringing up biomarker tests (or “liquid biopsies”). These pre-biopsy tests aim to gather more data and assess whether a biopsy is necessary. In my view and that of my urologist, the PSA data and MRI results suggested a biopsy was necessary, and more data wouldn’t change that. An intense marketing push is behind convincing patients and doctors to add these tests to the diagnostic arsenal. Remember, prostate cancer is Big Business. If you want more information, you can Google “biomarker tests prostate cancer” or “liquid biopsies prostate cancer.” And, as always, talk to your urologist. Biomarker tests might be tools they use.

Types of Prostate Biopsies

Ok, back to the MRI radiology results and the PSA data. It’s time for a prostate biopsy, which is the definitive diagnostic tool for determining whether you have a cancer that needs treatment. We are now facing the biopsy dilemma…what type of biopsy should we get? A prostate biopsy is not just any old biopsy. Depending on the technique, prostate tissue samples are taken using either a transrectal or a transperineal approach. It’s a significant difference. In either approach, to guide the placement of the needles used to retrieve the samples, your urologist can use an ultrasound probe alone or include MRI imagery. Making it even more complex, an MRI-guided approach can also be done using special equipment and software fusion of MRI and ultrasound imagery.

A Top-of-the-Line Prostate Biopsy

We’re not done yet. Let’s not forget the far less common but state-of-the-art “in-bore MRI-guided biopsy.” For this approach, the patient returns to the MRI machine for 30-45 minutes (not a pleasant thought if you ask me) while the system dynamically generates imagery, which the urologist uses to take real-time tissue samples. This may be the optimum approach for getting the best possible prostate biopsy. However, it’s expensive and probably not covered by Medicare, and finding a urologist who performs this type of biopsy may be challenging. The evidence of better results over MRI-guided fusion biopsies isn’t strong enough at this point to justify the expense for most men.

Your Location Matters

Confusing, right? This wide range of options for what should be a straightforward procedure honestly left my head spinning, but I needed to choose the procedure I wanted for my biopsy. The default TRUS biopsy (transrectal ultrasound) may be the go-to procedure, but it’s 30 years old and no longer considered state-of-the-art. It’s not for me, but this is when things get difficult for guys in similar geographic situations. I live in Santa Fe, a smallish northern New Mexico town where the newest and frequently more effective medical procedures are often unavailable. I wanted what I considered the safest method that offered the best biopsy results for my case. I do have serious concerns about the risk of infection from a transrectal biopsy. Medicare coverage is also important to me. My MRI also indicated an anterior lesion, which is harder to biopsy using the transrectal approach. It was obvious to me—I needed a transperineal, MRI-guided fusion biopsy, and Denver, 400 miles away, was the closest place for having this procedure. Geography has always mattered in healthcare delivery, and it applies equally to prostate cancer diagnosis and treatment. That doesn’t mean you can’t get high-quality care away from large metro areas. It just means your choices are more limited unless you can travel.

A Trip to Denver

So, I made the trek to Denver for my biopsy. It’s a three-beer story about how difficult it was to find and arrange this diagnostic procedure, but it illustrates the biopsy dilemma we’ve been discussing. It’s like everything else in prostate cancer—a seemingly endless series of decisions. Your choices depend on your situation, preferences, urologist’s recommendation, and where you live.

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