Abnormal results on screening tests may mean a patient has prostate cancer, but these tests alone can’t diagnose prostate cancer. A prostate biopsy is needed for a definitive diagnosis.
Edward M. Schaeffer, MD, PhD, shares the latest prostate biopsy techniques. He discusses transrectal ultrasound-guided (TRUS) biopsy and the ways that Northwestern Medicine is working to optimize cancer detection and ensure patient safety.
Selected Podcast
Prostate Biopsy Techniques: Ways to Optimize Cancer Detection and Ensure Patient Safety
Featured Speaker:
Dr. Schaeffer is chair of the Department of Urology at Northwestern Medicine and program director of the Genitourinary Oncology Program at Robert H. Lurie Comprehensive Cancer Center of Northwestern University at Northwestern Memorial Hospital.
Learn more about Edward Schaeffer, MD
Edward Schaeffer, MD
Edward M. Schaeffer, MD, PhDDr. Schaeffer is chair of the Department of Urology at Northwestern Medicine and program director of the Genitourinary Oncology Program at Robert H. Lurie Comprehensive Cancer Center of Northwestern University at Northwestern Memorial Hospital.
Learn more about Edward Schaeffer, MD
Transcription:
Prostate Biopsy Techniques: Ways to Optimize Cancer Detection and Ensure Patient Safety
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we discuss prostate biopsy techniques, new ways to optimize cancer detection and ensure patient safety. Joining me is Dr. Edward Schaeffer. He's a professor and chair in the Department of Urology at Northwestern Medicine.
Dr. Schaeffer, it's a pleasure to have you join us today. Does PSA or prostate specific antigen values, does this establish with absolute certainty whether a patient has prostate cancer? I'd like to kind of give us a starting point here.
Dr. Schaeffer: Great question, Melanie, and the shorter answer is it does not. As most of the clinicians on the call will probably realize, it is an early warning sign for something that is amiss or wrong in the prostate. We think about PSA as one of the several ways that we can identify individuals at risk for prostate cancer. So elevated PSA values, abnormalities on rectal exam are the mainstays of the initial screening for an individual who has prostate cancer. As everyone on the call also knows, family history is important as is your ancestry or race. Black men have a higher prevalence of prostate cancer.
If any of those factors are amiss, then we typically at our institution recommend additional testing with furthermore refined blood work with the prostate health index, consideration of a multiparametric MRI, and those factors all put together along with the patient's consent are really the main indications for us to think about a prostate biopsy.
Melanie: So then, doctor, let's talk about the indications for prostate biopsy. For which patients might this be the study of choice and how do you go about making the decision to proceed with a biopsy?
Dr. Schaeffer: Yeah, prostate biopsies are done to make a diagnosis definitively of prostate cancer. Without tissue reviewed by a pathologist, we don't know that someone has prostate cancer. So that is the core of establishing a diagnosis of prostate cancer. Now, before we move forward with a prostate biopsy at Northwestern, we use a couple of tools that provide further clarity and direction.
As we've discussed, we begin with a PSA blood test, but at Northwestern, almost universally, if the PSA blood test is elevated, we then moved to a more specialized, more accurate test called a prostate health index. That is kind of like a PSA blood test on steroids. I like to compare it to tell patients it's like an iPhone 12 versus the original iPhone. It's just much more accurate and it performs better. If that test is abnormal too, I highly recommend an MRI of the prostate. A multi-parametric prostate MRI will provide us with very direct insight into areas of concern within a prostate.
So if the PSA test is abnormal, we do a special, additional blood test called a prostate health index. If that's abnormal, we recommend an MRI of the prostate. And if the MRI of the prostate points to cancer also, then we do a prostate biopsy. Now in our clinics, we don't just do regular systematic kind of "random biopsies." Rather in our clinic, we do special MRI-guided biopsies. This allows us to put the needle or place the biopsy needle directly into this suspicious area within the prostate, the suspicious area that was noted on the MRI.
Melanie: Wow. So this is such an interesting topic. And Dr. Schaeffer, you're leading a national multicenter trial evaluating the transperineal MRI-targeted biopsy approach for prostate biopsies. Give us a little overview of this study.
Dr. Schaeffer: Yeah, it's a great question. So right now in its present state, prostate biopsies are performed as an outpatient in an office-based setting. We have an ultrasound probe that helps us localize the prostate and this ultrasound probe is inserted into the rectum of a man. And that allows for very easy visualization of the prostate.
And traditionally, if we see an abnormal area in the prostate or something that correlates with an abnormal area on the MRI, we then stick the needle biopsy through the rectal wall, into the prostate and sample that area. That's how a traditional prostate biopsy has been performed for the last 40 years.
And although it's accurate in detecting prostate cancers, it does have some downsides. Number one, there can be bleeding in the rectum when you do that. You may nick a blood vessel in the rectum causing bleeding there. And additionally, when you introduce the needle into the prostate through the wall of the rectum, you can also see the prostate with bacteria, rectal bacteria that would persist in the stool or the rectal vault of a man. And an infection that results from this can be lethal in some men.
Now, not all men get prostate biopsy-related infections, but nationally, the reported rates of infection are between 2 and 4%. So this is not an inconsequential number because oftentimes those men who develop biopsies have to be hospitalized, they sometimes have to go to the ICU. They almost always require long-term IV antibiotics to try to quench or kill the infection.
So this is a dilemma. We know that prostate biopsies are necessary to pick up prostate cancers. We know prostate cancers are common and biopsies are important, but we need a safer way to do it. And so I wrote, and I'm now leading a national trial that aims to study alternate approaches to prostate biopsy that are safer, less bleeding risk, less infection risk, but don't compromise the cancer detection.
And so the obvious approach for us was to not place the needle through the rectal wall into the prostate, but rather place the needle into the prostate, through the skin of the perineum, the space between the anus and the scrotum. And that also is a way to easily access the prostate tissue and we believe obtain very accurate diagnostic material.
So with this in mind, we actually petitioned for and wrote a national trial through the National Cancer Institute. It was selected as one of the top proposals of last year, and has now been funded for us to further explore this new innovative technique.
Melanie: Well, Dr. Schaeffer, as long as we're talking about safety and the current standard and what you're seeing in your practice, tell us how you feel that the advances in radiologic imaging have augmented this ability that you have. Speak about how this has changed the landscape and how it's involved in your study.
Dr. Schaeffer: Yeah, multi-parametric prostate MRI has really changed how we diagnose prostate cancer. It has allowed for the optimization of detection through biopsies of high-grade aggressive prostate cancers, but simultaneously has allowed us to reduce the detection of low-grade inconsequential cancers that may not necessarily need to be diagnosed overall.
So prostate MRI in a man in a pre-biopsy setting can enhance the detection of aggressive high-grade cancer while minimizing the number of detections of low-grade, potentially worrisome, but inconsequential cancers. So it really has changed the landscape for how we think about men who have abnormal PSA blood tests for example.
Melanie: When do you expect to have data to share, Dr. Schaeffer, as far as your study? And what do you see as some of the other implications of this procedure that you've been discussing long-term?
Dr. Schaeffer: Yeah, that's a great question. So we have preliminary data that we used as part of our proposal for the trial. And we've done transperineal prostate biopsies on approximately 500 men within our multi-institutional cohort. And in those men, for example, we showed that there was close to a 0%, one infection out of 500, close to 0% infection rate with this technique. So we think we have a pretty good idea that if you actually randomized men to transperieal approach versus transrectal approach, that you'll reduce infections.
In terms of cancer detection, that's critical. We cannot compromise that. And that's one of the main components of the study is to ensure that in equally equal men that we're not compromising our ability to detect cancer. I think we'll have results from the trial probably in about three to four years. It is a multi-institutional trial. I am leading the study along with colleagues at Cornell, Dr. Jim Hu, Johns Hopkins, Memorial Sloan Kettering. So it's a real all-star team of hospitals, and I'm really excited to be the only hospital, frankly, off of the East Coast, who will be participating in and doing this study.
Melanie: That certainly is exciting. So before we wrap up, what other strategies would you like to recommend urologists implement to optimize and improve their cancer detection?
Dr. Schaeffer: Yeah, I strongly endorse the approach that we use at our institution, which involves advanced blood-based tests like prostate health index, advanced imaging like multiparametric prostate MRI, and always keeping an open mind to alternate cancer detection techniques, transperineal prostate biopsy is a great one, to reduce potential side effects of the biopsy.
So with that multi-pronged approach, we think that we're really addressing all concerns that our patients have. And I would strongly encourage other urologists to think about these approaches in their own clinical practices.
Melanie: Thank you so much, Dr. Schaeffer, for joining us today. And I hope you'll join us again and update us as your studies continue.
And to refer your patient, please visit our website at nm.org/urology to get connected with one of our providers. That concludes this episode of better edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.
Prostate Biopsy Techniques: Ways to Optimize Cancer Detection and Ensure Patient Safety
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we discuss prostate biopsy techniques, new ways to optimize cancer detection and ensure patient safety. Joining me is Dr. Edward Schaeffer. He's a professor and chair in the Department of Urology at Northwestern Medicine.
Dr. Schaeffer, it's a pleasure to have you join us today. Does PSA or prostate specific antigen values, does this establish with absolute certainty whether a patient has prostate cancer? I'd like to kind of give us a starting point here.
Dr. Schaeffer: Great question, Melanie, and the shorter answer is it does not. As most of the clinicians on the call will probably realize, it is an early warning sign for something that is amiss or wrong in the prostate. We think about PSA as one of the several ways that we can identify individuals at risk for prostate cancer. So elevated PSA values, abnormalities on rectal exam are the mainstays of the initial screening for an individual who has prostate cancer. As everyone on the call also knows, family history is important as is your ancestry or race. Black men have a higher prevalence of prostate cancer.
If any of those factors are amiss, then we typically at our institution recommend additional testing with furthermore refined blood work with the prostate health index, consideration of a multiparametric MRI, and those factors all put together along with the patient's consent are really the main indications for us to think about a prostate biopsy.
Melanie: So then, doctor, let's talk about the indications for prostate biopsy. For which patients might this be the study of choice and how do you go about making the decision to proceed with a biopsy?
Dr. Schaeffer: Yeah, prostate biopsies are done to make a diagnosis definitively of prostate cancer. Without tissue reviewed by a pathologist, we don't know that someone has prostate cancer. So that is the core of establishing a diagnosis of prostate cancer. Now, before we move forward with a prostate biopsy at Northwestern, we use a couple of tools that provide further clarity and direction.
As we've discussed, we begin with a PSA blood test, but at Northwestern, almost universally, if the PSA blood test is elevated, we then moved to a more specialized, more accurate test called a prostate health index. That is kind of like a PSA blood test on steroids. I like to compare it to tell patients it's like an iPhone 12 versus the original iPhone. It's just much more accurate and it performs better. If that test is abnormal too, I highly recommend an MRI of the prostate. A multi-parametric prostate MRI will provide us with very direct insight into areas of concern within a prostate.
So if the PSA test is abnormal, we do a special, additional blood test called a prostate health index. If that's abnormal, we recommend an MRI of the prostate. And if the MRI of the prostate points to cancer also, then we do a prostate biopsy. Now in our clinics, we don't just do regular systematic kind of "random biopsies." Rather in our clinic, we do special MRI-guided biopsies. This allows us to put the needle or place the biopsy needle directly into this suspicious area within the prostate, the suspicious area that was noted on the MRI.
Melanie: Wow. So this is such an interesting topic. And Dr. Schaeffer, you're leading a national multicenter trial evaluating the transperineal MRI-targeted biopsy approach for prostate biopsies. Give us a little overview of this study.
Dr. Schaeffer: Yeah, it's a great question. So right now in its present state, prostate biopsies are performed as an outpatient in an office-based setting. We have an ultrasound probe that helps us localize the prostate and this ultrasound probe is inserted into the rectum of a man. And that allows for very easy visualization of the prostate.
And traditionally, if we see an abnormal area in the prostate or something that correlates with an abnormal area on the MRI, we then stick the needle biopsy through the rectal wall, into the prostate and sample that area. That's how a traditional prostate biopsy has been performed for the last 40 years.
And although it's accurate in detecting prostate cancers, it does have some downsides. Number one, there can be bleeding in the rectum when you do that. You may nick a blood vessel in the rectum causing bleeding there. And additionally, when you introduce the needle into the prostate through the wall of the rectum, you can also see the prostate with bacteria, rectal bacteria that would persist in the stool or the rectal vault of a man. And an infection that results from this can be lethal in some men.
Now, not all men get prostate biopsy-related infections, but nationally, the reported rates of infection are between 2 and 4%. So this is not an inconsequential number because oftentimes those men who develop biopsies have to be hospitalized, they sometimes have to go to the ICU. They almost always require long-term IV antibiotics to try to quench or kill the infection.
So this is a dilemma. We know that prostate biopsies are necessary to pick up prostate cancers. We know prostate cancers are common and biopsies are important, but we need a safer way to do it. And so I wrote, and I'm now leading a national trial that aims to study alternate approaches to prostate biopsy that are safer, less bleeding risk, less infection risk, but don't compromise the cancer detection.
And so the obvious approach for us was to not place the needle through the rectal wall into the prostate, but rather place the needle into the prostate, through the skin of the perineum, the space between the anus and the scrotum. And that also is a way to easily access the prostate tissue and we believe obtain very accurate diagnostic material.
So with this in mind, we actually petitioned for and wrote a national trial through the National Cancer Institute. It was selected as one of the top proposals of last year, and has now been funded for us to further explore this new innovative technique.
Melanie: Well, Dr. Schaeffer, as long as we're talking about safety and the current standard and what you're seeing in your practice, tell us how you feel that the advances in radiologic imaging have augmented this ability that you have. Speak about how this has changed the landscape and how it's involved in your study.
Dr. Schaeffer: Yeah, multi-parametric prostate MRI has really changed how we diagnose prostate cancer. It has allowed for the optimization of detection through biopsies of high-grade aggressive prostate cancers, but simultaneously has allowed us to reduce the detection of low-grade inconsequential cancers that may not necessarily need to be diagnosed overall.
So prostate MRI in a man in a pre-biopsy setting can enhance the detection of aggressive high-grade cancer while minimizing the number of detections of low-grade, potentially worrisome, but inconsequential cancers. So it really has changed the landscape for how we think about men who have abnormal PSA blood tests for example.
Melanie: When do you expect to have data to share, Dr. Schaeffer, as far as your study? And what do you see as some of the other implications of this procedure that you've been discussing long-term?
Dr. Schaeffer: Yeah, that's a great question. So we have preliminary data that we used as part of our proposal for the trial. And we've done transperineal prostate biopsies on approximately 500 men within our multi-institutional cohort. And in those men, for example, we showed that there was close to a 0%, one infection out of 500, close to 0% infection rate with this technique. So we think we have a pretty good idea that if you actually randomized men to transperieal approach versus transrectal approach, that you'll reduce infections.
In terms of cancer detection, that's critical. We cannot compromise that. And that's one of the main components of the study is to ensure that in equally equal men that we're not compromising our ability to detect cancer. I think we'll have results from the trial probably in about three to four years. It is a multi-institutional trial. I am leading the study along with colleagues at Cornell, Dr. Jim Hu, Johns Hopkins, Memorial Sloan Kettering. So it's a real all-star team of hospitals, and I'm really excited to be the only hospital, frankly, off of the East Coast, who will be participating in and doing this study.
Melanie: That certainly is exciting. So before we wrap up, what other strategies would you like to recommend urologists implement to optimize and improve their cancer detection?
Dr. Schaeffer: Yeah, I strongly endorse the approach that we use at our institution, which involves advanced blood-based tests like prostate health index, advanced imaging like multiparametric prostate MRI, and always keeping an open mind to alternate cancer detection techniques, transperineal prostate biopsy is a great one, to reduce potential side effects of the biopsy.
So with that multi-pronged approach, we think that we're really addressing all concerns that our patients have. And I would strongly encourage other urologists to think about these approaches in their own clinical practices.
Melanie: Thank you so much, Dr. Schaeffer, for joining us today. And I hope you'll join us again and update us as your studies continue.
And to refer your patient, please visit our website at nm.org/urology to get connected with one of our providers. That concludes this episode of better edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.