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Prostate Cancer: Combined Biopsy Strategy Makes for More Accurate Diagnosis

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Last year, nearly 175,000 American men were diagnosed with prostate cancer [1]. Most got the bad news after a blood test or physical exam raised concerns that warranted a biopsy of the prostate, a walnut-sized gland just below the bladder.

Traditional biopsies sample tissue from 12 systematically placed points within the prostate that are blind to tumor locations. Such procedures have helped to save many lives, but are prone to missing or misclassifying prostate cancers, which has led doctors both to over and under treat their patients.

Now, there may be a better approach. In a study of more than 2,000 men, NIH researchers and their colleagues recently found that combining the 12-point biopsy with magnetic resonance imaging (MRI)-targeted biopsy during the same session more accurately diagnoses prostate cancer than either technique alone [2].

The findings address a long-standing challenge in prostate cancer diagnostics: performing a thorough prostate biopsy to allow a pathologist to characterize as accurately as possible the behavior of a tumor. Some prostate tumors are small, slow growing, and can be monitored closely without treatment. Other tumors are aggressive and can grow rapidly, requiring immediate intervention with hormonal therapy, radiation, or surgery.

But performing a thorough prostate biopsy can run into technical difficulties. The 12-point biopsy blindly samples tissue from across the prostate gland, but it can miss a cancer by not probing in the right places.

Several years ago, researchers at the NIH Clinical Center, Bethesda, MD, envisioned a solution. They’d use specially designed MRI images of a man’s prostate to guide the biopsy needle to areas in the prostate that look suspicious and deserve a closer look under a microscope.

Through a cooperative research-and-development agreement, NIH and the now- Florida-based Philips Healthcare created an office-based, outpatient prostate biopsy device, called UroNav, that was later approved by the Food and Drug Administration. The UroNav system relies on software that overlays MRI images highlighting suspicious areas onto real-time ultrasound images of the prostate that are traditionally used to guide biopsy procedures.

The new technology led to a large clinical study led by Peter Pinto, a researcher with NIH’s National Cancer Institute. The study results, published in 2015, found that the MRI-targeted approach was indeed superior to the 12-point biopsy at detecting aggressive prostate cancers [3].

But some doctors had questions about how best to implement the UroNav system and whether it could replace the 12-point biopsy. The uncertainty led to a second clinical study to nail down more answers, and the results were just published in The New England Journal of Medicine.

The research team enrolled 2,103 men who had visible prostate abnormalities on an MRI. Once in the study, each man underwent both the 12-point blind biopsy and the MRI-targeted approach—all in a single office visit. Based on this two-step approach, 1,312 people were diagnosed with prostate cancer. Of that total, 404 men had evidence of aggressive cancer, and had their prostates surgically removed.

The researchers then compared the diagnoses from each approach alone versus the two combined. The data showed that the combined biopsy found 208 cancers that the standard 12-point biopsy alone would have missed. Adding the MRI-targeted biopsy also helped doctors find and sample the more aggressive cancers. This allowed them to upgrade the diagnosis of 458 cancers to aggressive and in need of more full treatment.

Combining the two approaches also led to more accurate diagnoses. By carefully analyzing the 404 removed prostates and comparing them to the biopsy results, the researchers found the 12-point biopsy missed the most aggressive cancers about 40 percent of the time. But the MRI-targeted approach alone missed it about 30 percent of the time. Combined, they did much better, underestimating the severity of less than 15 percent of the cancers.

Even better, the combined biopsy missed only 3.5 percent of the most aggressive tumors. That’s compared to misses of about 17 percent for the most-aggressive cancers for the 12-point biopsy alone and about 9 percent for MRI-targeted biopsy alone.

It may take time for doctors to change how they detect prostate cancer in their practices. But the findings show that combining both approaches will significantly improve the accuracy of diagnosing prostate cancer. This will, in turn, help to reduce risk of suboptimal treatment (too much or too little) by allowing doctors and patients to feel more confident in the biopsy results. That should come as good news now and in the future for the families and friends of men who will need an accurate prostate biopsy to make informed treatment decisions.

References:

[1] Cancer State Facts: Prostate Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program.

[2] MRI-targeted, systematic, and combined biopsy for prostate cancer diagnosis. Ahdoot M, Wilbur AR, Reese SE, Lebastchi AH, Mehralivand S, Gomella PT, Bloom J, Gurram S, Siddiqui M, Pinsky P, Parnes H, Linehan WM, Merino M, Choyke PL, Shih JH, Turkbey B, Wood BJ, Pinto PA. N Engl J Med. 2020 Mar 5;382(10):917-928.

[3] Comparison of MR/ultrasound fusion-guided biopsy with ultrasound-guided biopsy for the diagnosis of prostate cancer. Siddiqui M, Rais-Bahrami, George AK, Rothwax J, Shakir N, Okoro C, Raskolnikov D, Parnes HL, Linehan WM, Merino MJ, Simon RM, Choyke PL, Wood BJ, and Pinto PA. JAMA. 2015 January 27;313(4):390-397.

Links:

Prostate Cancer (National Cancer Institute/NIH)

Video: MRI-Targeted Prostate Biopsy (YouTube)

Pinto Lab (National Cancer Institute/NIH)

NIH Support: National Cancer Institute; NIH Clinical Center

4 Comments

  • leonard gasperin says:

    can prostate radiation cause problems in the kidneys? why does everyone get the same number (43) of radiation treatments?

  • David R. Anderson says:

    Since patients with a pacemaker are not allowed to have an MRI scan, because it would end up like a scene from The Merchant of Venice, especially the pound of flesh, does that mean that this procedure is not open to them ? Or is a lead shield used ? Thanks.

  • DR. SAUMYA PANDEY, PH.D. says:

    Robotic prostatectomy, MRI-directed prosate cancer diagnosis, combinatorial immunotherapy refimens coupled with aberrant metabolic flux/death-signaling cascades, primarily Autophagy, are current burning areas of interest amongst emerging and established scientific as well as clinical invstigators worldwide!
    In this context, the expert highlights regarding recent public health oriented prostate cancer management by expert Dr. Collins, Director NIH, USA, provide critical insights in successfully diminishing the disproportionate share of morbidity and mortality in symptomatic benign prostatic hyperplasia and advanced stage/Gleason/TNM grades/stages’-specific prostate cancer cohorts of ethnically distinct population-subsets of varying genetic landscapes.
    In fact, my academically enriching robotic prostatectomy-prostate cancer-autophagy-public health-cancer research experiences at University of Texas Medical Branch, Galveston, TX and New York Presbyterian-Weill Cornell Medical College-Cold-Spring Harbor Laboratory, NY, USA gave me a brilliant opportunity to interact with American prostate cancer patients and their families; it is indeed distressing to observe the anxiety, restlessness, stigma and psychosocial/financial stress associated with prostate cancer diagnosis at pre-/post-prostatectom and/or chemo-radiotherapy regimens.
    Adequate surveillance and prostate cancer patient’s follow-ups should be undertaken for developing a global cost-effective public health prostate cancer prevention model with adequate federal/state-grants’ fund support to encourage meaningful scientific clinically impactful research endeavors in the complex men’s health/urolog/prostate cancer arena in USA!

  • Juliana says:

    This was a great read and so informative. Thank you for posting …

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