Homing in on prostate cancer with fusion biopsy

Left Image: The target from an MRI is merged with an ultrasound image for targeting. Right Image: The biopsy locations are captured by the MRI-Ultrasound fusion technology.

Ideally, doctors would catch every case of prostate cancer early, before it has time to grow and spread. Early detection gives men more options, whether that involves treatment or active surveillance to make sure the cancer doesn’t continue to develop.

But standard approaches can’t always locate the prostate cancer. That’s an issue for many of my patients. One man had previously had five standard biopsies, all of which were negative for prostate cancer. But he still had high levels of PSA, or prostate-specific antigen, which is a potential indicator of prostate cancer. I told him, “You really should get an MRI.”

The patient’s MRI (magnetic resonance imaging) test showed there was an abnormality in an area of the prostate where we don’t usually see tumors—one that’s difficult for us to access during a standard biopsy. So we used an advanced technique called an MRI/ultrasound fusion biopsy, which uses both MRI and ultrasound, to help detect this patient’s prostate cancer.

This patient would not have been diagnosed as early as he was without having an MRI/ultrasound fusion biopsy. And this is just one of the many examples I’ve seen of this technology’s value to patients.

The benefits of MRI/ultrasound fusion biopsy

Prostate cancer is a serious problem, both nationwide and in the Washington, D.C., area. Locally, we have a prostate cancer incidence rate of 120.1 men per 100,000. That means more than 120 men out of every 100,000 in the area have prostate cancer—a rate that’s nearly 18 percent higher than the national average.

I recommend a prostate biopsy for men who repeatedly have test results that show high PSA levels. We traditionally use an ultrasound probe to first see if there are any abnormal areas in the prostate. If there are, we target the biopsy in those areas. If there aren’t, we sample 12 random areas to see if we can locate any cancerous cells. The challenge with this approach is that it’s possible to still miss cancerous cells.

As we’ve begun to use MRI scans more often, we’re able to find tumors within the prostate. MRI scans are especially helpful for detecting aggressive prostate tumors. Many times, I see patients who have high PSA scores but negative biopsies, and prostate tumors show up on an MRI scan.

MRI/ultrasound fusion biopsy combines the best parts of MRI and ultrasound for prostate biopsies. The fusion approach starts with an MRI scan of the prostate. We then use that to guide us as we perform an ultrasound and biopsy at the same time. Merging these images is almost like having a homing device in the prostate, telling us to change angles or move our probe slightly.

MRI/ultrasound fusion biopsy combines the best parts of MRI and ultrasound for prostate biopsies. via @MedStarWHC

Following the completion of the procedure, the distribution of the biopsy sites in relation to the targets can be easily visualized.

This technique increases the number of cases of prostate cancer we’re able to diagnose, especially higher-risk cases of the disease. One study found that targetedMRI/ultrasound fusion biopsy helped doctors diagnose 30 percent more high-risk cases of prostate cancer compared to standard biopsy.

During my training at Georgetown University, I had the opportunity to train at the National Institutes of Health (NIH) for four months. The NIH is where the MRI/ultrasound fusion biopsy system was developed. I use it frequently, and other centers are starting to use it more as well.

Related reading: Can an advanced MRI improve prostate cancer screening?

MRI/ultrasound fusion biopsy harnesses the strengths of both MRI and ultrasound to do more than either can do alone. The result: We can catch more cases of prostate cancer that might not otherwise be found. My hope is that MRI/ultrasound fusion biopsy becomes the standard method doctors everywhere use to detect prostate cancer.

Request an appointment with one of our urologists if you’ve had several high PSA scores but negative prostate biopsy results in the past.

What to do when prostate cancer biopsy/PSA test results conflict

Prostate cancer can be challenging to detect. Our screening and diagnostic tools—prostate-specific antigen (PSA) testing and transrectal ultrasound-guided (TRUS) prostate biopsy—aren’t perfect. And it becomes even more difficult when those tools contradict each other.

Finding high levels of PSA, a protein made in the prostate gland, in a man’s bloodstream can indicate prostate cancer. However, PSA testing has a 15 percent false-positive rate, which means the test may detect cancer that isn’t present.

And a high PSA level usually leads to a biopsy. A TRUS prostate biopsy samples less than 1 percent of the prostate, and the false-negative rate can approach 35 percent, meaning it shows no cancer even though cancer is present.

Learn more: Should men get a PSA test to screen for prostate cancer, and when?

So what are a man and his doctor to do when his PSA level indicates he has prostate cancer but his biopsy says he doesn’t?

Your doctor may suggest doing another traditional biopsy, but because it takes random samples, it can be like trying to find a needle in a haystack. Your biopsy also may find a low-grade cancer, which means the abnormal cells are unlikely to impact your life and may only need close monitoring, not treatment. Also, there are risks associated with repeat biopsies, including bleeding and infection.

When we encounter cases like these, we turn to two advanced options to guide our decision to do a repeat biopsy: MP-MRI or checking biomarkers. These options can:

  • Rule out clinically significant prostate cancer, which can reduce your anxiety and potentially avoid a repeat biopsy.
  • Indicate you may be harboring undetected cancer, which may prompt another biopsy and, potentially, treatment.

Using MP-MRI to target prostate cancer

Multi-parametric magnetic resonance imaging (MP-MRI) has emerged over the years as an imaging test that can improve the accuracy of detecting aggressive prostate cancer.

MP-MRI uses the same machine as other MRI imaging but differs in that it uses multiple, specific imaging sequences instead of just one. If a patient has an elevated PSA level but a negative biopsy, we can use MP-MRI to detect suspicious lesions. If such lesions are found, we can target them with a biopsy using a unique platform that fuses the previously obtained MRI images with real-time ultrasound in our clinic.

When an MP-MRI shows no suspicious lesions, the results are 89 percent accurate. And in men with a prior negative biopsy, up to 87 percent of tumors detected by MP-MRI are considered “clinically significant,” which means there is a tendency for these tumors to grow and potentially become metastatic.

While we regularly use MP-MRI for repeat biopsies, it’s also being studied as a first line of testing for prostate cancer. We might be able to avoid the potential negative effects of PSA testing and biopsy by screening at-risk men with MP-MRI instead. Until we have more data on that use, we’re glad to offer MP-MRI to men whose other test results are inconclusive.

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 it—the MRI machine and special biopsy platform—or 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:

  • Urine-based: This test looks for prostate cancer gene 3, or PCA 3. These genes make prostate cells produce a particular protein, and prostate cancer cells make more of this protein than normal cells. There are two parts to this test. First, you doctor will do a rectal exam to massage the prostate gland. This helps move the PCA3 into the urine. Then, you’ll give a urine sample. The reading will give an indication of your risk of prostate cancer. A higher PCA3 score also can indicate a higher-grade cancer.
  • Blood-based: Tests, such as the Prostate Health Index (PHI) or 4K score, are based on PSA testing but are more sensitive than PSA alone. They combine multiple biomarkers, including total PSA, free PSA, proPSA and human kallikrein-2, to come up with a score that can tell what your risk of prostate cancer might be.
  • Genomic: Noncancerous prostate tissue located near a tumor will show a “cancerization” process at the DNA level. The ConfirmMDx text looks for that process in a sample from the first biopsy in which cancer was not detected. This can indicate whether that sample is near cancerous tissue. These tests have been shown in clinical practice to decrease repeat-biopsy rates from 43 percent to 4.4 percent, helping men avoid unnecessary biopsies.

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 don’t have access to that technology, you may get a traditional prostate biopsy. However, if a traditional biopsy still doesn’t 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.

If you’re considering your next step after a high PSA result and negative biopsy, or you want to know what type of prostate cancer screening you may need, request an appointment with one of our doctors.

How Doctors are Screening Smarter for Prostate Cancer

Washington, D.C., September 27, 2017 - The prostate-specific antigen (PSA) test is one of the best screening tools for prostate cancer. While there’s no doubt this simple blood test has saved lives over the years, it’s not perfect. There’s been a lot of debate over who should be screened and when—and whether men should be screened at all.

Since the PSA test became widely available in the late 1980s, deaths related to prostate cancer began to decrease. In fact, mortality rates fell nearly 40 percent between the early 1990s and 2008. However, there also have been some negatives associated with the test, the biggest being its 15 percent false-positive rate. This means 15 in 100 men who get an elevated PSA test result do not actually have prostate cancer.

PSA testing also can increase the risk of overtreatment. Most diagnosed prostate cancers are low-grade, which means the abnormal cells are unlikely to impact a man’s life in any way. Prostate cancer is a slow-growing cancer, taking 10 to 15 years to progress and even longer to cause death. These tumors may only need close monitoring over the years, also known as active surveillance, and not treatment.

“PSA testing is not a one-size-fits-all approach to prostate cancer screening,” said Ross Krasnow, MD, a urologic oncologist at MedStar Washington Hospital Center. “The key is to have an honest conversation about the potential benefits and harms for each man based on his specific risk factors.”

For a man at average risk for prostate cancer, the discussion may center more on the potential benefits and harms of a PSA test. However, the conversation may take on a more urgent tone if the man has factors that put him at increased risk for prostate cancer. These can include:

  • Family history: Having a first-degree relative, such as a father or brother, who had the disease.
  • Genetic mutations: Continually learning more about how certain gene mutations can increase a man’s risk for prostate cancer. This includes mutations of the BRCA1 and BRCA2 genes, which are more commonly associated with breast and ovarian cancers.
  • Race: African-Americans have double the incidence of prostate cancer compared with white men, and their risk of dying from the disease is two to three times higher.

A man’s age also should be taken into effect. “Because prostate cancer grows so slowly, there’s little benefit to screening older men whose life expectancies are less than 10 to 15 years,” said Dr. Krasnow. “When I see a patient who is 70 or older and has been referred to me for a PSA test, I usually advise against it unless they are extremely healthy for their age.”

Prostate cancer is the most common cancer in men, with one in seven men in the United States projected to get the disease in their lifetime. And the District of Columbia has the second highest prostate cancer incidence rate in the country behind only Louisiana, with 123 out of 100,000 men diagnosed with the disease in a given year.

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Should men get a PSA test to screen for prostate cancer, and when?

Prostate cancer is the most common cancer in men, with one in seven men in the United States projected to get the disease in their lifetime. And the District of Columbia has the second highest prostate cancer incidence rate in the country behind only Louisiana, with 123 out of 100,000 men diagnosed with the disease in a given year.

One of the best screening tools we have for this disease is the prostate-specific antigen (PSA) test. While there’s no doubt this simple blood test has saved lives over the years, it’s not perfect. There’s been a lot of debate over who should be screened and when—and whether men should be screened at all. Even national health organizations differ slightly on their PSA testing guidelines.

PSA testing is not a one-size-fits-all approach to prostate cancer screening. The key is to have an honest conversation about the potential benefits and harms for each man based on his specific risk factors.

Tune in to this podcast to hear Dr. Krasnow further discuss PSA testing, including what men may expect from future prostate cancer screening.

Benefits and risks of PSA testing

Prostate-specific antigen is a protein made in the prostate gland and present in semen. A small amount of PSA enters the bloodstream, but high levels in a man’s blood can indicate prostate cancer. After the PSA test’s introduction in the late 1980s, deaths related to prostate cancer began to decrease. In fact, mortality rates fell nearly 40 percent between the early 1990s and 2008.  

This was a huge win in our fight against prostate cancer. However, there also have been some negatives associated with the test, the biggest being its 15 percent false-positive rate. A false positive is when the test detects cancer that is not present.

This means 15 in 100 men who get an elevated PSA test result do not actually have prostate cancer. Unfortunately, to confirm this, they’ve likely undergone an unnecessary biopsy. While generally safe, biopsies can cause complications, such as bleeding or infection and can induce unnecessary stress for the patient.  

PSA testing also can increase the risk of overtreatment. Most diagnosed prostate cancers are low-grade, which means the abnormal cells are unlikely to impact a man’s life in any way. Prostate cancer is a slow-growing cancer, taking 10 to 15 years to progress and even longer to cause death. These tumors may only need close monitoring over the years, also known as active surveillance, and not treatment.

Do the potential benefits of PSA testing outweigh the potential harms? It depends on the person. Some of my patients who have received a false positive were relieved to know their cancer status for sure. Others, while relieved, continued to worry about their elevated PSA level as we monitored them over the following years. And still others were frustrated that they had to go through the biopsy process, which, while not painful, is awkward and uncomfortable.  

What studies and guidelines say about PSA testing

Actor Ben Stiller made waves in 2016 with a blog post titled “The Prostate Cancer Test That Saved My Life.” In the article, he attributed surviving prostate cancer to having a PSA test at age 46—earlier than most guidelines would recommend—despite having no indicators that he was at increased risk for the disease.  

He wrote: “If (my doctor) had waited (to get me a PSA test), as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated. If he had followed the U.S. Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.”

If you’re looking to various health organizations for guidance on when you should have a PSA test, you may be confused by the differing recommendations. And these recommendations also may change over time. For example, the U.S. Preventive Services Task Force slightly revised its guidelines since Ben Stiller had his PSA test based on new evidence and studies.

Here is what some health organizations currently recommend:

  • American Cancer Society: The organization recommends that men at average risk for prostate cancer begin discussing screening with their doctors at age 50. Men at increased risk should consider screening at age 45.
  • American Urological Association: The organization recommends that doctors begin discussing screening at age 40 to 54 for men at high risk, 55 to 69 for men at average risk, and 70 and older for some men in excellent health with a 10- to 15-year life expectancy.
  • U.S. Preventive Services Task Force: The group in 2017 recommended that while the PSA test should not be used routinely, physicians should discuss the benefits and harms with men age 55 to 69. It recommends against PSA screening for men 70 and older. This is in contrast to its 2012 guidelines that recommended against PSA screening in men without prostate cancer symptoms.  

So what’s a man supposed to do? The answer lies in the common theme to these recommendations: a discussion between doctor and patient.  

How I advise men about screening for prostate cancer

I once treated a man in his 40s who was exhibiting signs of benign prostatic hyperplasia, a condition in which the prostate is enlarged. We decided to do a PSA test, despite most guidelines recommending against PSA testing for a man younger than 50 with no increased risk factors for prostate cancer. The test showed elevated PSA levels, but a traditional biopsy only found very low-grade cancer.  

This didn’t make sense considering his high PSA levels. We had a long conversation about how to proceed, and we decided to do advanced testing. An MRI-guided biopsy that is increasingly being used to detect prostate cancer revealed a high-grade prostate cancer that, left unchecked, would have been lethal.  

PSA test guidelines aren’t hard and fast rules—as my patient and Ben Stiller would attest to. The key is an open, honest conversation in which the patient and doctor come to a decision together.

Related reading: Shared decision-making: It’s no longer “doctor knows best”

For a man at average risk for prostate cancer, the discussion may center more on the potential benefits and harms of a PSA test. However, the conversation may take on a more urgent tone if the man has factors that put him at increased risk for prostate cancer. These can include:

  • Family history: Having a first-degree relative, such as a father or brother, who had the disease.
  • Genetic mutations: We’re continually learning more about how certain gene mutations can increase a man’s risk for prostate cancer. This includes mutations of the BRCA1 and BRCA2 genes, which are more commonly associated with breast and ovarian cancers.  
  • Race: African-Americans have double the incidence of prostate cancer compared with white men, and their risk of dying from the disease is two to three times higher.

A man’s age also should be taken into effect. Because prostate cancer grows so slowly, there’s little benefit to screening older men whose life expectancies are less than 10 to 15 years. When I see a patient who is 70 or older and has been referred to me for a PSA test, I usually advise against it unless they are extremely healthy for their age.  

I think as medical professionals, we’re doing a better job of screening smarter and being more selective in who gets a PSA test. But discussion is the key.

Request an appointment to talk to a doctor about your prostate cancer risk and screening options.   

Can an advanced MRI improve prostate cancer screening?

Prostate cancer is notoriously tricky to detect. It often doesn’t cause symptoms until it’s advanced, and there are no routine imaging tests, like mammograms for breast cancer.

But a new study published in January 2017 in The Lancet showed promise for an advanced MRI to detect potentially aggressive prostate cancer, while also sparing some men from undergoing invasive biopsies.

After skin cancer, prostate cancer is the most common cancer in American men. According to the American Cancer Society, more than 160,000 new cases will be diagnosed in 2017 and nearly 27,000 men will die from the disease. The District of Columbia has one of the highest prostate cancer incidence rates in the country, with 120 out of 100,000 men getting the disease.

Our current prostate cancer screening process isn’t perfect. We hope this study is the first of many that leads to an improved standard of care.

How we screen for prostate cancer now

Most prostate cancers are first detected when a patient is found to have an elevated prostate-specific antigen (PSA), which is a blood test used for prostate cancer screening. The prostate is a walnut-sized gland that produces the fluid in semen. PSA is a protein made in the prostate, and elevated levels often are found in men with prostate cancer.

There has been some controversy about when men should get PSA tests, but we follow the guidelines of the American Urological Association, which recommend patients and their doctors discuss the test at age:

  • 55-69 for men at average risk
  • 40-54 for men at higher risk for prostate cancer, such as black men and men with a family history of prostate cancer
  • 70 and older for men in excellent health with a 10- to 15-year life expectancy

While a PSA test can give us a clue that something may be wrong, it isn’t fool-proof. For example, the test can be elevated in patients who have benign enlargement of their prostate or prostatic inflammation. In such cases, the abnormal PSA test can lead to an unnecessary biopsy.

If your PSA levels are elevated, we’ll likely perform a transrectal ultrasound-guided (TRUS) prostate biopsy to gather small samples of the prostate to examine in the lab. We use a transrectal ultrasound to visualize the prostate. Then we insert a small needle into the gland to remove about 12 samples from different parts of the prostate.

Unfortunately, this approach is not perfect and can miss a significant cancer. If we suspect you have prostate cancer even after clear biopsy results, we may recommend a repeat biopsy or multi-parametric magnetic resonance imaging (MP-MRI), which may help to identify an occult site of prostate cancer that can then be targeted by a subsequent biopsy.

Study shows MRI can help detect prostate cancer more accurately

The January 2017 study looked at the effect of using an MP-MRI earlier in the prostate cancer screening process. MP-MRI uses the same machine as other MRI imaging, but differs in that it uses multiple, specific imaging sequences to make a diagnosis instead of one essential MRI sequence.

In the study, patients with an elevated PSA level underwent a MP-MRI before having a biopsy. The investigators then performed a standard TRUS biopsy on the patients, as well as a comprehensive “template” biopsy under anesthesia. This template biopsy was used as the “gold standard” for which to compare the performance of standard biopsy versus the MRI findings.

The results were fairly dramatic. The study found that 27 percent of patients did not have MRI findings that would warrant a biopsy. Thanks to the MP-MRI, one in four men would avoid an unnecessary biopsy. For the patients who did need a biopsy, the MRI-guided biopsy found 93 percent of aggressive cancers, compared with just 48 percent when the biopsy was done at random.

What does this mean for men today?

While the results of this study are promising, routine MP-MRIs to screen for prostate cancer are not ready for clinical practice just yet. However, it’s studies like this that eventually lead to new standards of care. We can imagine a day when routinely using MP-MRI is considered best practice, allowing us to specifically target our biopsies to areas of concern, or even considered “good enough” at diagnosing cancer so that we can skip the biopsy altogether and move straight to treatment.

While we won’t routinely be using MP-MRIs in the near future, if an informed patient asks for an MP-MRI early in the process, it’s reasonable to consider ordering one. And this study’s results may help us convince an insurance company to cover the cost.

Until we have further data confirming the accuracy of MP-MRIs to detect prostate cancer, we urge men to talk to their primary care physicians about the pros and cons of PSA testing and at what age they should consider it.

Schedule an appointment online or call 202-877-3627 to talk to a doctor about your prostate cancer risk and screening options.

No imaging test is 100 percent perfect, but we’re working toward screening smarter. We hope in the future this process will be a win-win for patients and doctors as we catch more aggressive cancers and avoid unnecessary biopsies.

With Early Detection, Prostate Cancer Is Treatable

For men approaching the age of 40, as well as those who have already crossed that milestone, prostate cancer is one of the most talked-about health issues today. Prostate cancer is diagnosed more frequently than skin cancer and is second only to lung cancer in leading causes of cancer death in men. And according to a recent study from Northwestern University, more men than ever before are being diagnosed with metastatic prostate cancer, where the cancer has spread to another place in the body, speaking to a need for “nationwide refinement” around prostate screenings and treatments.

Stark as these numbers may be, don't let such information frighten you. Prostate cancer is not only common, it’s also treatable with an early diagnosis.

Who Is at Risk for Prostate Cancer?

The average age for a prostate cancer diagnosis in men is 66 years old, and it is not seen typically before the age of 40. It should be noted, however, that African-American men represent a high-risk group for prostate cancer and are 1.6 times more likely to receive such a diagnosis than a Caucasian male. Also, they are more likely to develop prostate cancer at a younger age, with a higher rate of mortality.

While there are different schools of thought around why African-American men are more prone to prostate cancer, including differences in tissue genetics, nothing has been proven with any certainty to date.

What Treatment Options Are Available?

The mortality rate for prostate cancer is approximately one in 39 men, which speaks to the fact that treatment of the disease at an early stage can prevent prostate-cancer related death. Various treatment options exist, including surgical removal of the prostate (prostatectomy), radiation therapy or cryotherapy.  These options will be reviewed by a multidisciplinary team with expertise in each modality, with the choice of treatment being individualized for each patient’s specific case. 

No matter the course chosen, early detection is the key to reducing the risk of death from prostate cancer. Once it has spread to a patient’s lymph nodes or bones, the cancer becomes more difficult to treat. (Although in those cases, chemotherapy and hormone therapy may still be able to help extend the life of a patient.)

It’s Treatable When Caught Early

Since early detection is so critical to the treatment of prostate cancer, one of the most common questions men have is when - or how often - they should be screened. Screening options include a digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood test.

If you’re in a high-risk group - either due to age, family history or other factors - you should speak with your doctor about what is best for you, as there is uncertainty around whether the risk of unnecessary treatment is outweighed by the potential benefits of screening.

Life After Prostate Cancer

Men who undergo successful treatment for their prostate cancer can be left with some degree of erectile dysfunction or problems with urination. The good news is that treatments exist for these problems and can help prostate cancer survivors maintain fulfilling, active lives with maintained, positive outcomes for their urinary and sexual health.

While the prospect of a prostate cancer diagnosis can be stressful, know that it is common and treatable. So with early detection, you can spend more time being focused on treatment and recovery.

Have questions?

We are here to help! If you have any questions about MedStar Washington Hospital Center, call us at 202-877-3627.

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