The New York Times 6 October headline was repeated in one form or another across the US. It read: ‘US Panel Says No to Prostate Screening for Healthy Men’, and was followed by this paragraph:
‘Healthy men should no longer receive a PSA blood test to screen for prostate cancer because the test does not save lives overall and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.’1
As so often happens after any ‘official government pronouncement,’ the media attack on whatever the target of the pronouncement may be – in this case the PSA test – came rapidly. Very shortly after, the Associated Press circulated to all its news media clients (including the Seattle Times) a longish article concerning the sometimes-deadly hazards of prostate biopsies done following abnormal PSA tests. Here’s an excerpt:
Donald Weaver was a healthy 74-year-old Kansas farmer until doctors went looking for prostate cancer. A PSA test led to a biopsy and surgery, then a heart attack, organ failure and a coma. His grief-stricken wife took him off life support…
Since Friday, when a task force of independent scientists said routine PSA testing does more harm than good, urologists who make a living treating prostate cancer have rushed to defend the test, as have patients who believe it saved their lives.
Less visible are men who have been harmed by testing, as Dyroff and Weaver were. The harm is not so much from the test itself but from everything it triggers – biopsies that usually are false alarms, and treatments that leave many men incontinent or impotent for cancers that in most cases were not a threat.’2
Men with a suspicious prostate examination and/or PSA are frequently told to get a needle biopsy right away, even though no other preliminary diagnostics were used to determine if a biopsy was really necessary. Beyond the risk of infection, this can be especially dangerous, since studies have shown that the needles can spread cancer cells, which can actually worsen the chances of the cancer moving to lymph nodes or even further.
But when looking for alternatives to the PSA, the medical literature is not at all clear, and physicians’ opinions differ, so prostate cancer patients are understandably confused.
Let’s sort out the facts and show you an important way to assess and track prostate cancer using the best, yet least-publicised diagnostic tool available.
Don’t be fooled into getting an unnecessary biopsy
The most important thing to know about prostate cancer is that not all prostate cancers are equal. Medical professionals often separate prostate cancer into at least two types. The first and more rare type is the aggressive form, most often associated with high genetic risk. When highly aggressive tumours are biopsied and closely examined, they often receive a high ‘Gleason score’, the diagnostic standard for determining the aggressiveness of prostate cancer. The higher the Gleason score, the poorer the prognosis. Aggressive tumours have a Gleason score above 7, as well as many biopsy sites within the prostate positive for cancer.3
On the other hand, the more common prostate cancer type is non-aggressive and slower growing. This is the kind of cancer that grows so slowly that most men will probably die of something else before the prostate cancer itself becomes a problem. These types have a Gleason score of no more than 6 or 7 and have at most one site positive for cancer out of the 12 sites that are usually assessed during biopsy.4
While there is clearly a difference between the risk and rate of progression of the two types of prostate cancer, conventional medical practice very often treats both in the same way, responding to any PSA above 4 ng/ml with a digital rectal examination (DRE) and a needle biopsy to confirm whether this is cancer or not. This treatment approach creates a dilemma for both patient and doctor, since it leads to many more unnecessary biopsies (not unlike the situation women face with screening mammography).
Quite often, the cause of the elevated PSA has nothing to do with prostate cancer, but is an indication of other underlying conditions, such as prostatitis or benign prostatic hypertrophy (BPH).
How misleading can a diagnosis be if intensive PSA screening and DRE are used as the sole basis for getting a prostate cancer biopsy? In 2002, the results of an 11 year study were reported comparing the prostate cancer death rates in two regions in the US, Seattle and Connecticut. Studies had shown that the use of PSA, biopsy, and ‘radical prostatectomy’ (removing the entire prostate and sometimes more) was higher in the Seattle region than those in Connecticut, suggesting more aggressive screening and treatment.
Yet when researchers compared the use of intensive PSA screening, DRE, and cancer treatment follow up between the two regions, they found no meaningful difference between the results of the two. They reasoned that, if PSA, DRE and surgery were more effective, the death rates from prostate cancer should be lower in the Seattle area. However, over the course of the 11-year period, no significant difference was found.
This study rebuked the belief that intensive DRE and PSA screening, followed by biopsy, surgery and radiation, lowered the death rate from prostate cancer.5 A second study looking at the use of PSA and DRE for routine prostate cancer screening also found limited benefit from these.6
In fact, studies have found that only 25 per cent of elevated PSA values are associated with positive prostate cancer biopsies. What this means is that approximately 75 per cent of men who have a PSA in this range may be urged to undergo an unnecessary needle biopsy – especially if you’re working with an ‘aggressive’ doctor (or even a doctor nervous about malpractice lawsuits).
The fastest way to spread cancer cells
Any amount of ‘needling’, even a standard 12-needle biopsy, can’t penetrate every part of the prostate gland. Many times, needle biopsies miss cancer tissue and are reported as negatives, when in fact they are ‘false negatives’. Because of this, another conventional approach is to biopsy and biopsy and biopsy until a ‘positive core’ (of cancer) is found. The latest trend is to do saturation biopsy with as many biopsies as it takes to find a positive core, typically between 20 and 30.7
But as noted above, even a single needle biopsy risks spreading cancer cells unnecessarily, called ‘seeding’, anywhere along the needle track. If there is a cancer, the risk is that the cancer cells will be dislodged from the primary cancer tumour and pulled out into the bloodstream or lymphatic system, seeding cancer cells throughout the body.
In addition to seeding cancer cells and potentially causing serious or even lethal infection, there is an increased risk of pain and development of scar tissue within the prostatic ducts every time the biopsy needle enters the prostate. It can also make pre-existing conditions like prostatitis worse, increasing the need for antibiotics.
After needle biopsy, many men have problems with erectile dysfunction, urination, and increasing PSA numbers, ironically the very thing that prompted the biopsy in the first place. The side effects that are experienced appear to be related to the number of needle sticks done during biopsy: Those who have had the greatest number of biopsies done have the most side effects.8
Yet another hazard of doing too many biopsies is that one may find cancer cells of the less aggressive type that may be found to occur ‘naturally’, common even within a younger, low-risk population, and ultimately lead to unnecessary treatment and distress.9
Unfortunately, despite the lack of evidence supporting the benefits of PSA and DRE, and despite the dangers of the fine-needle biopsy, any man who declines to follow this ‘established’ protocol risks losing insurance coverage, since conventionally this is considered the only viable approach to identification and treatment. Anyone who wishes to have other care and non-invasive treatments – and who does not have an aggressive tumour – faces the risk of potentially losing insurance coverage.
So how can a man proceed if the only ‘accepted’ way to diagnose prostate cancer is by biopsy?
What colours does your prostate reflect? Knowing the answer could save your life
As I said earlier, the best diagnostic tool for detecting prostate cancer also happens to be one of the least publicised. It’s a type of ultrasound called colour Doppler. This important tool can not only make needle biopsies unnecessary, but can possibly save a few deaths from infection, and can prevent the spreading of cancer cells by ‘needle track’ if there is a cancer present.
Colour Doppler imaging is a form of ultrasound that ‘translates’ ultrasonic frequencies into shades of colour to better detect blood flow within tissues and glands and to determine where the blood is going. The value of colour Doppler in evaluating potential cancer is that it gives a better, more readable image than standard ultrasound, which is based on grey-scale (shades of grey) visual report format. Over the course of the last 20 years, many studies have used colour Doppler ultrasound to look at the prostate and surrounding tissue and evaluate for prostate cancer.10-18
Sound waves generated by the ultrasound beam ‘bounce’ back and reveal images of varying density (indicated by varying colours) that suggest possible pathology. In addition to being able to see the density of an image, the colour Doppler is able to assign colour values to the direction and velocity of blood flow.
This is valuable in assessing any cancer, since cancerous tumours of nearly all types increase the blood vessels ‘feeding’ them blood. Cancers need blood flow to provide nutrition to their rapidly growing cells. When the colour Doppler is aimed at cancer cells, it sees an increase in blood flow when images are compared to non-cancerous lesions.19
The ability to identify vascular anatomy greatly helps in differentiating normal and abnormal flow patterns in the prostate. The patterns observed in blood flow – diffuse flow, focal flow and surrounding flow – can be associated with prostate cancer, with the most commonly observed pattern being diffuse flow.20 The differences in observed patterns also helps differentiate between BPH, prostatitis and prostate cancer.
Studies suggest that when colour Doppler is used, it picks up areas of increased blood flow in the prostate gland of men who have cancerous tumours larger than 5 millimetres. Because of that, it’s useful in looking at tumours that are harder to see and that do not show up well on a regular ultrasound. One study found that up to 86 per cent of all prostate cancers show abnormal flow with colour Doppler imaging.21
When to choose the ‘wait and see’ approach
Colour Doppler imaging helps define where a tumour is within the prostate and improves detection sensitivity.22 Even if a cancer is suspected or proven using the colour Doppler, you might still be able to avoid getting a needle biopsy by tracking the progress of many early cancers with follow-up colour Doppler examinations. This is called ‘active surveillance’.
If the active surveillance programme indicates that cancer could be present, there’s still one more option you can use instead of the ‘regular’ needle biopsy route. Many urologists use a transrectal ultrasound-guided biopsy of the prostate (TRUSP) for even greater accuracy.
The colour Doppler-TRUSP approach allows the doctor to get a better image of the prostate. This helps identify a patient’s overall risk of prostate cancer and allows tracking of any changes over time.23 A particular advantage of a colour Doppler-TRUSP study is the ability to identify the zones of the prostate, especially the peripheral zone, where many prostate cancers start.24
Studies indicate that using newer ultrasound techniques, such as the colour Doppler, along with targeted biopsy, have a detection rate as much as two times higher than systematic biopsy.25,26,27
Colour Doppler imaging has also shown advantages in determining the ‘stage’ of a cancer28 and – because it allows the doctor to see more accurately just where to biopsy – it also helps reduce the number of biopsies needed in patients already diagnosed with high-grade prostate cancer.
Colour Doppler evaluation allows an assessment of ‘qualitative risk’ (presence or absence) of prostate cancer – as well as a ‘quantitative’ estimation of size and shape if a cancer is detected – without a needle biopsy, and ultimately allows a better choice to treat surgically as a last resort.
In the UK, colour Doppler imaging is still considered a relatively new technique and, as a result, it is not in widespread use as a diagnostic tool for prostate cancer. Hopefully, this situation will change in the near future. In the meantime, speak to your doctor about the possibility of having a colour Doppler examination performed if you are recommended to undergo prostate tests.
Wishing you the best of health,
Dr. Jonathan V. Wright
Nutrition & Healing
Volume 6, Issue 3 – March 2012
Full references and citations for this article are available in the downloadable PDF version of the monthly Nutrition and Healing issue in which this article appears.