Can Men AVOID Prostate Biopsies?

Recently, I have been hearing more and more about the possibility of detecting prostate cancer without having to do a biopsy. Biopsies are done after the urologist detects an abnormality on the rectal exam or blood PSA test. The rectal exam and PSA test are only screening tools. They don't tell us if the patient has cancer or not. Biopsies are performed by taking 10 to 12 "cores" with a needle gun through the rectum with an ultrasound probe. Yes, not too fun. So what is this new way of detecting cancer?

MRI and MRI spectroscopy
Magnetic Resonance Imaging, or MRI, can depict prostate anatomy with excellent contrast resolution and can uncover cancer in areas not routinely sampled on biopsy and not palpable on rectal examination. In addition, MRI allows assessment of local extent (read: extracapsular extension and seminal vesicle invasion), which can help with staging the cancer. The addition of spectroscopy to MRI can improve prostate cancer detection- combining the detail of MRI and the ability to "sniff" the biological aggressiveness of cancer with MR spectroscopy.

Would I operate based on the data from this new technology, without biopsies? The test is very sensitive and specific, but I still would not because you would try to avoid an unecessary operation at all costs. What if there was no cancer? However, there are situations where this test would be useful.

For example, if the patient has had prior biopsies done for an elevated PSA and they were negative. Unfortunately, the PSA keeps going up. The MRI might help the urologist FOCUS his area of biopsies.

Another case: a low but rising PSA. Many biopsies are uneccesary. The MRI could spare the patient the trauma of biopsies if the risk of cancer is low.

Also, the growing popularity of "watchful waiting" where the disease is monitored in low-risk patients- the MRI could give us a better idea than just depending on PSA. A picture of the disease could be compared yearly, giving us a precise view of the progress of disease.

Smart Bombs for Prostate Cancer

One of the benefits with working with a large group of urologists is the ability to support clinical trials. These trials are funded by the pharmaceutical and medical device companies as well as academic centers. For example, we can offer patients cutting-edge treatments in prostate cancer that can save them from making long trips to unfamiliar places at a time when they may be most vulnerable.

One trial right now is with
Protox Therapeutics. They are currently conducting a Phase I clinical trial for patients with local recurrent prostate cancer using PRX302.

What is that and who is it for?

PRX302 is like a smart bomb for prostate cancer. The drug enters the body in a nonactivated form. Prostate cancer cells release PSA, which can cleave a protein off the drug and activate it into its cancer-killer state. The drug binds to the nearby prostate cancer cell and drills a hole into it, causing the cell to die.

This is very exciting because it can potentially minimize toxicities that are associated with the "shotgun" approach associated with chemotherapy, hormones and radiation. Only prostate cells are targeted. Also, the cancer is treated whether it is a slower growing cancer or a rapidly growing one, which is a potential drawback when treating with radiation or chemo. These treatments work better on faster growing tumors, and prostate cancer is often a relatively slower growing one.

This trial is for localized recurrent prostate cancer. For example, a patient who underwent radioactive seed placement and now has a rising PSA would have to undergo biopsies to verify cancer is present. Also, we would need to make sure the cancer has not spread elsewhere in the body.

The patient will then be injected with PRX302 into the prostate gland under ultrasound guidance. Changes in PSA levels will be measured and prostate biopsies performed after 30 days.

Early reports and animal studies have been very promising.

Is the robot just a powertool?

Over the past year, I have been amazed at how fast robotic surgery is becoming the standard for patients who need surgery for their prostate cancer. Even surgeons who don't perform robotics have decided to refer patients to me as a service to their patients. Initially, I thought that the learning curve for robotics would be too steep for busy surgeons to fully master. That's why I took a year to do a fellowship and travel to see expert surgeons perform cases. Now that I have done hundreds of cases and travel to "proctor" new robotic surgeons as they do cases, my original opinion has changed a bit.

If a surgeon is dedicated enough, there are finally enough good surgical videos and trained proctors available to considerably shorten the learning curve. How many cases? I'm not sure, but I still would not want to be one of the initial 25 patients or so. The robot is just a fancy powertool. If you know how to use it, you can do great things. Otherwise you could risk a lot of damage to the patient and to yourself. A useful website by Intuitive Surgical lists surgeons who have done at least 20 cases. This at least is a start- some reports suggest that you should look for surgeons who have done at least a hundred cases!