‘hidden’ Prostate Cancer On Biopsy Usually Means Good Outcome: Study
HealthDay Reporter
MONDAY, Nov. 23, 2020 — Negative biopsies among early-stage prostate cancer patients who’ve chosen active surveillance are associated with a low risk of disease progression, but they aren’t a sign that their cancer has completely vanished, a new study indicates.
Active surveillance refers to close monitoring for signs of cancer progression — what’s often called “watchful waiting.” Patients sometimes get regular prostate-specific antigen testing, prostate exams, imaging and repeat biopsies.
The objective of active surveillance is to avoid or delay treatment and its side effects without putting patients at risk of cancer progression and death.
Sometimes, active surveillance patients have negative biopsies that show no evidence of prostate cancer. While some of these patients may believe that their cancer has “vanished,” they most likely have low-volume or limited, hidden areas of prostate cancer that weren’t detected in the biopsy sample, according to the authors of the study published recently in The Journal of Urology.
“While a negative biopsy is good news, the long-term implications associated with such ‘hidden’ cancers remain unclear,” said study author Dr. Carissa Chu, from the University of California, San Francisco.
Of those patients, 37% had at least one negative biopsy, including 15% with consecutive negative biopsies, according to the report.
More information
There’s more on prostate cancer at the U.S. National Cancer Institute.
Study: New Prostate Cancer Test Could Avoid Unnecessary Biopsies
Urine test found to be extremely accurate at detecting aggressive prostate cancer with few false negatives.
A urine test based on University of Michigan Rogel Cancer Center research could have avoided one third of unnecessary prostate cancer biopsies while failing to detect only a small number of cancers, according to a validation study that included more than 1,500 patients. The findings appear in the March issue of the Journal of Urology.
The MyProstateScore test, which is being commercialized by LynxDX, a U-M startup company, measures levels of cancer-specific genes in a patients urine. It is based on U-M research that discovered that half of all prostate tumors harbor a certain genetic anomaly in which the genes TMPRSS2 and ERG relocate on a chromosome and fuse together creating an on-switch for prostate cancer development.
Currently, one of doctors best methods for detecting prostate cancer is a blood test for prostate-specific antigen, commonly known as the PSA test. Elevated PSA levels may indicate cancer, but the majority of men with an elevated PSA do not actually have prostate cancer.
Our ultimate goal was to determine whether the MyProstateScore test could be a practical, reliable test that could rule out the need for more costly or invasive testing in men referred for a prostate biopsy, says study lead author Jeffrey Tosoian, M.D., M.P.H., a clinical lecturer in urology at Michigan Medicine.
When Do I Need A Biopsy
Your doctor may order a biopsy if your prostate-specific antigen level in your blood work is elevated or there is an abnormal lump found during a digital rectal exam. During a digital rectal exam, your doctor inserts a finger up your bottom to feel if your prostate is enlarged or has bumps. Another option before a biopsy is an ultrasound. Instead of a finger, a small probe is inserted to take pictures of the prostate.
An MRI-guided prostate biopsy may be used in patients who have a rising PSA level, yet a negative ultrasound-guided biopsy. It also may be used in situations where a diagnostic prostate MRI performed because of rising PSA demonstrates a very small abnormality that may not be easily targeted by ultrasound. An MRI image to guide a biopsy can improve the ability to detect prostate tumors which may require treatment.
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What Should I Expect During A Breast Biopsy
Patients typically have an FNA or core needle biopsydone in the surgeons office and dont require a trip to the hospital. The medical provider will most likely use medicine to numb the area around where the needle will be inserted. However, this isnt always necessary, specifically with FNA biopsies, as the needle is so small.
The patient will lie on their back and have to remain still during the procedure. An ultrasound may be used to help guide the doctor so they can see where to place the needlethis doesnt hurt but can feel like pressure as they move the handpiece around.
FNA biopsies and core needle biopsies only take a few seconds to obtain, but the entire procedure start to finish typically takes 20-30 minutes to complete.;
Since no incisions are needed, patients dont require stitches, but probably will have a small bandage placed over the biopsy site while it heals.
Surgical biopsies are usually done in an outpatient surgical setting. They are more invasive than FNA or core needle biopsies, but patients typically go home after the procedure. In addition to local anesthesia, patients are given intravenous medicationoften called twilight anesthesiato help them feel drowsy. In certain scenarios, patients need general anesthesia, which involves being put into a deep sleep during the procedure.
Using Biomarkers To Guide Our Next Step
While MP-MRI has proven to be an effective tool in diagnosing prostate cancer, not every facility has the technology needed to perform itthe MRI machine and special biopsy platformor radiologists with the expertise to read a prostate MRI. In addition, the test can take up to an hour in an MRI machine, which can be uncomfortable for patients, particularly if he is claustrophobic.
In these cases, biomarkers can be useful to potentially avoid repeat biopsy. Biomarkers indicate whether a certain body process is normal or abnormal. These biomarkers can pinpoint men who actually need a repeat biopsy, as well as help us find more aggressive cancers.
Types of biomarkers we can use to detect prostate cancer include:
If a biomarker test suggests that the initial biopsy failed to diagnose prostate cancer, a repeat biopsy is recommended. Ideally, you would get an MP-MRI, but if you dont have access to that technology, you may get a traditional prostate biopsy. However, if a traditional biopsy still doesnt find high-grade prostate cancer despite biomarkers indicating it, you may want to travel to the nearest facility with MP-MRI.
A high PSA level and negative biopsy can certainly cause you and your doctor to feel nervous. But MP-MRI and biomarkers can provide reassurance that our next step is the right one.
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Patients Reports May Aid Prostate Cancer Treatment Choice
But the genetic tests are pricey, around $3,000 or $4,000, and not necessarily covered by insurance. More problematic, they do not give a yes/no answer to whether cancer cells are harmless. Instead, they indicate whether a man has a very low, low, intermediate, or high risk of harboring an aggressive, metastatic cancer.
The problem is, genetic tests dont necessarily shift the risk much, said Mayos Karnes. A man might have a 30 percent risk of an aggressive cancer, before a genetic test, and the test might shift that to 35 percent. What you want is a test that tells you the risk is more like 0 percent or 100 percent.
Even short of perfection, however, genetic tests are offering men reassurance that they can choose active surveillance rather than treatment. Duane Foulkes, 70, recently sold the manufacturing business he founded near Madison, Wis., when, in late 2015, his PSA test came back over 5. It rose to above 9 three months later, and he had a biopsy at Mayo. His Gleason score of 6 concerned me at first, Foulkes said.
But a genetic test;indicated that he had at most a slow-growing, non-aggressive type of cancer, Foulkes said, giving him confidence to;choose active surveillance.
Positron Emission Tomography Scan
A PET scan is similar to a bone scan, in that a slightly radioactive substance is injected into the blood, which can then be detected with a special camera. But PET scans use different tracers that collect mainly in cancer cells. The most common tracer for standard PET scans is FDG, which is a type of sugar. Unfortunately, this type of PET scan isnt very useful in finding prostate cancer cells in the body.
However, newer tracers, such as fluciclovine F18, sodium fluoride F18, and choline C11, have been found to be better at detecting prostate cancer cells.
Other newer tracers, such as Ga 68 PSMA-11 and 18F-DCFPyl , attach to prostate-specific membrane antigen , a protein that is often found in large amounts on prostate cancer cells. Tests using these types of tracers are sometimes referred to as PSMA PET scans.
These newer types of PET scans are most often used if its not clear if prostate cancer has spread. For example, one of these tests might be done if the results of a bone scan arent clear, or if a man has a rising PSA level after initial treatment but its not clear where the cancer is in the body.
The pictures from a PET scan arent as detailed as MRI or CT scan images, but they can often show areas of cancer anywhere in the body. Some machines can do a PET scan and either an MRI or a CT scan at the same time, which can give more detail about areas that show up on the PET scan.;
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Getting The Results Of The Biopsy
Your biopsy samples will be sent to a lab, where they will be looked at with a microscope to see if they contain cancer cells. Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer. The results might be reported as:
- Positive for cancer: Cancer cells were seen in the biopsy samples.
- Negative for cancer: No cancer cells were seen in the biopsy samples.
- Suspicious: Something abnormal was seen, but it might not be cancer.
If the biopsy is negative
If the prostate biopsy results are negative , and the chance that you have prostate cancer isnt very high based on your PSA level and other tests, you might not need any more tests, other than repeat PSA tests sometime later.
But even if many samples are taken, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer , your doctor might suggest:
- Getting other lab tests to help get a better idea of whether or not you might have prostate cancer. Examples of such tests include the Prostate Health Index , 4Kscore test, PCA3 tests , and ConfirmMDx. These tests are discussed in Whats New in Prostate Cancer Research?
- Getting a repeat prostate biopsy. This might include getting additional samples of parts of the prostate not biopsied the first time, or using imaging tests such as MRI to look more closely for abnormal areas to target.
Prostate cancer grade
Gleason score
What Are The Side Effects Of A Biopsy
Having a biopsy can cause side effects. These will affect each man differently, and you may not get all of the possible side effects.
Pain or discomfort
Some men feel pain or discomfort in their back passage for a few days after a TRUS biopsy. Others feel a dull ache along the underside of their penis or lower abdomen .;If you have a transperineal biopsy, you may get some bruising and discomfort in the area where the needle went in for a few days afterwards.
If you receive anal sex, wait about two weeks, or until any pain or discomfort from your biopsy has settled, before having sex again. Ask your doctor or nurse at the hospital for further advice.
Some men find the biopsy painful, but others have only slight discomfort. Your nurse or doctor may suggest taking mild pain-relieving drugs, such as paracetamol, to help with any pain.
If you have any pain or discomfort that doesnt go away, talk to your nurse or doctor.
Short-term bleeding
Its normal to see a small amount of blood in your urine or bowel movements for about two weeks. You may also notice blood in your semen for a couple of months it might look red or dark brown. This is normal and should get better by itself. If it takes longer to clear up, or gets worse, you should see a doctor straight away.
Infection
Symptoms of a urine infection may include:
- pain or a burning feeling when you urinate
- dark or cloudy urine with a strong smell
- needing to urinate more often than usual
- pain in your lower abdomen .
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What Are The Implications
The impetus for change has come from the PROMIS and PRECISION trials, both run from University College London Hospital.
The multicentre PROMIS trial, involving 740 men with clinical suspicion of prostate cancer and no previous prostate biopsy, tested whether an mpMRI scan before biopsy could identify men who might safely avoid a biopsy. It found that using mpMRI to triage men might allow more than one in four men referred on suspicion of prostate cancer to avoid a primary biopsy.
If subsequent TRUS biopsies were directed by mpMRI findings, up to 18% more cases of clinically significant cancer might be detected compared with the standard pathway of TRUS biopsy for all. A linked study found that an mpMRI-first strategy is effective and cost-effective for diagnosing prostate cancer.
The PRECISION trial went on to look further along an mpMRI-based diagnosis pathway, investigating the accuracy of mpMRI in guiding biopsies, when suspicious lesions have been identified through scanning. The study randomly allocated 500 men with suspected prostate cancer from 23 international centres and found that using mpMRI to perform prostate biopsies led to significantly more of the harmful prostate cancers and significantly fewer harmless cancers being diagnosed, compared to standard TRUS biopsy.
That same trial, he added, showed that using pre-biopsy mpMRI diagnosed over 90% of significant cancers and fewer insignificant cancers.
mpMRI vs TRUS biopsy in numbers
Which Patients Are Candidates For Repeat Biopsy For Prostate Cancer
Patients should carefully consider whether they need a repeat biopsy based on how at risk they are for prostate cancer, says Dr. Herman.
These risk factors include things such as a family history of prostate cancer, how high the PSA is, certain genetic conditions, age or even ethnic background.
There are newer, simple blood tests that are more specific than PSA for prostate cancer.
These tests, along with MRIs, can help determine which men truly need a repeat biopsy versus those men who just have an elevated PSA for benign reasons .
How Does a Biopsy Miss Prostate Cancer?
The traditional prostate biopsy is a random sampling of the prostate, so if the biopsy needle just happens to miss the tumor, the biopsy can come back falsely negative, explains Dr. Herman.
This can also happen for small prostate cancers or prostate cancers that are in areas that are difficult to biopsy, such as the front of the prostate.
This is why MRI-targeted biopsies have proven so useful.
By guiding the urologist to the areas that are most likely to have cancer, MRI-targeted biopsies are much more accurate than traditional biopsies.
Dr. Hermans interests include reducing the over-diagnosis and over-treatment of prostate cancer by utilizing the latest biomarkers and imaging techniques. He is at the forefront of treatment and research of urologic cancers.
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Urine Test Found To Be Extremely Accurate At Detecting Aggressive Prostate Cancer With Few False Negatives
- Date:
- Michigan Medicine – University of Michigan
- Summary:
- A urine test could have avoided one third of unnecessary prostate cancer biopsies while failing to detect only a small number of cancers, according to a validation study that included more than 1,500 patients.
A urine test based on University of Michigan Rogel Cancer Center research could have avoided one third of unnecessary prostate cancer biopsies while failing to detect only a small number of cancers, according to a validation study that included more than 1,500 patients. The findings appear in the March issue of the Journal of Urology.
The MyProstateScore test, which is being commercialized by LynxDX, a U-M startup company, measures levels of cancer-specific genes in a patient’s urine. It is based on U-M research that discovered that half of all prostate tumors harbor a certain genetic anomaly in which the genes TMPRSS2 and ERG relocate on a chromosome and fuse together — creating an on-switch for prostate cancer development.
Currently, one of doctors’ best methods for detecting prostate cancer is a blood test for prostate-specific antigen, commonly known as the PSA test. Elevated PSA levels may indicate cancer, but the majority of men with an elevated PSA do not actually have prostate cancer.
Tosoian and two of his co-authors were founders of LynxDX and hold an equity stake in the company.
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Prognostic Factors That Determine The Need For Further Investigation Following A Negative Biopsy
In developing a recent UK National Institute for Health and Care Excellence clinical guideline for the diagnosis of treatment of prostate cancer, the UK National Collaborating Centre for Cancer undertook a systematic review to identify the prognostic factors that determine the need for further investigation following a prior negative biopsy in men who have been referred with suspected prostate cancer. The review included retrospective and prospective cohort studies that reported on the following potential prognostic factors: age, ethnicity, family history of prostate cancer, DRE, total PSA, free-to-total PSA%, PSA density, PSA velocityii and PCA3 score at the time of initial biopsy, and histopathological features reported on initial biopsy .
The NICE systematic review classified the results of relevant predictive studies into two broad groups: results of univariate analyses and results of multivariate analyses . The multivariate analyses are likely to provide more reliable evidence, because they reduce the risk of bias due to confounding variables. The most frequently addressed potentially confounding variables were age, DRE, PSA, free-to-total PSA%, PSA density, PSA velocity, high-grade PIN, ASAP and prostate volume.
Age
Ethnicity
Family history
Digital rectal examination
The updated NICE systematic review found one additional study, which reported an OR of 1.36 for abnormal DRE relative to normal DRE in a multivariate model.
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