Pinpointing Prostate Cancer
About 240,000 men are diagnosed with prostate cancer each year in the U.S. One of the biggest challenges for doctors is correctly diagnosing this type of cancer. Now, there's a new way to pinpoint prostate cancer that's more accurate than ever.
Three years ago, Don Buck had a biopsy to check for prostate cancer. It came back clear. A year later – a second biopsy showed no cancer.
"I'm thinking I'm in pretty good shape," Don told Ivanhoe.
But a prior test—known as the PSA—told a different story. Don's levels kept rising. They went up 600 percent in five years! So Don decided to see Urologist Leonard Marks to find out if his biopsies could be wrong.
"The conventional way to biopsy the prostate is not a perfect method," Leonard S. Marks, MD, Professor of Urology, Geffen School of Medicine at UCLA, told Ivanhoe.
Traditional biopsies are blind, meaning doctors randomly remove pieces of the prostate in hopes of locating a tumor. Nearly 1,000,000 prostate cancer biopsies are performed each year and 75 percent come back negative.
"Some of them will contain a cancer," Dr. Marks said.
UCLA's Dr. Marks is performing a new, targeted biopsy that's more accurate.
First, patients undergo an MRI. A special device fuses the pictures with real-time 3D ultrasound, allowing doctors to see the lesion during the biopsy.
"Before, we were never able to target like that," Dr. Marks said.
The targeted biopsy showed Don did have cancer and it was aggressive.
"Within two years of the time that I came in to see Dr. Marks, I could have been dead," Don explained.
It's a test that Don says saved his life.
In a study published in the Journal of Urology, Dr. Marks performed the targeted biopsy on 171 men who either had slow-growing prostate cancer or elevated PSA levels. Prostate cancer was found in 53 percent of the volunteers. Of those cancers found using the targeted approach—38 percent had a Gleason score greater than seven, indicating an aggressive tumor which is more likely to spread.
BACKGROUND: Prostate cancer affects hundreds of thousands of men each year in the U.S. This disease only affects men, but can be very deadly if not caught in enough time. The disease progresses slowly, so slow that doctors may not even catch it until it has taken a life. (Source: http://www.medicalnewstoday.com/articles/150086.php)
RISK FACTORS: There are no known causes of prostate cancer, but there are some risk factors that doctors warn their patients about. Though doctors do not understand the exact cause of prostate cancer, they do know that it is caused by the change in DNA of a prostate cell. Some risk factors of developing prostate cancer can be altered or changed, while others cannot. Risk factors including smoking, diet, weight and STIs can be changed or treated to help prevent the development of prostate cancer but family history, age, race, genes, and nationality are some that cannot be controlled. (Source: http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-risk-factors)
SYMPTOMS: Prostate cancer is a slow-moving process, but in its advanced stages, symptoms of prostate cancer can include:
• Blood in urine
• Bone pain
• Erectile dysfunction
• Blood in semen
• Issues in urinating
• Discomfort in pelvic area
• Pain in thighs, lower back, and hips
• Decreased force in stream of urine (Source: http://www.mayoclinic.com/health/prostate-cancer/DS00043/DSECTION=symptoms)
NEW TREATMENT: There is now a new way to determine if a male has prostate cancer. Traditional tests include a biopsy, but almost half of them are wrong. Dr. Leonard Marks from the University of California Los Angeles is conducting a new method to test his patients of prostate cancer. First, an MRI is done to pinpoint the differences in tissue. Then an ultrasound is the next step in the process, and this helps the doctor target the cells that need to be treated. Doctors can then go into the tumor with a needle and determine the size and severity of the tumor. (Source: http://urology.ucla.edu/body.cfm?id=618)
Dr. Leonard Marks, MD, Professor of Urology, Geffen School of Medicine at UCLA, talks about a new way to detect prostate cancer.
Can detecting cancer in the prostate be very, very difficult?
Dr. Marks: Yes the conventional way to biopsy the prostate is not a perfect method. It is frequently blind; it usually is blind to the tumor location. Ultrasound which was an advance twenty five years ago showed us where the prostate is but didn't show us where tumors were. Ultrasound has been used to guide prostate biopsy systematically but not specifically to tumor areas and that's been the state of the art for the past twenty five years. Now comes along sophisticated MRI which is capable of identifying many tumors in the prostate. This has been an evolution of MRI since the early eighties, but now, ultrasound using a multi-parametric approach using T-2 weighted imaging, higher power magnets than before, so called three tesla magnets and using diffusion weighted imaging and dynamic contrast enhancement all of these add-ons helped to make MRI much better than it has been in the past. And some prostate cancers can finally be seen. Prostate cancer has been the only serious malignancy, serious solid malignancy which could not be identified on an image within the organ of origin. MRI is changing all of that.
Is early stage prostate cancer really hard to tell the tissue from other tissue?
Dr. Marks: Early stage prostate cancer has very little tissue differences between malignant and benign tissue surrounding it in the prostate. That's why it has been very difficult to image. Sophisticated MRI with the multi-parametric approach has enabled us to identify many prostate cancers. Now comes along a device which allows fusion of MRI images with real time ultrasound images so that an urologist while imaging the prostate using conventional ultrasound guidance can simple toggle a switch and blend in the MRI features that were seen by the MRI. What this technology does is to bring the diagnostic accuracy of MRI in to a clinical setting where we can use it to identify, to find, and to target biopsy specific areas of the prostate which appear to be regions of interest on the MRI.
Dr. Marks: What this technology does is to bring the diagnostic accuracy of sophisticated MRI in to a clinical setting, an outpatient local anesthetic setting. MRI has gotten quite good at finding many tumors within the prostate —this has evolved since the early eighties--- but the current modern MRI technology allows a multi-parametric approach, is both anatomic and functional imaging that comes in to play here and many prostate regions of interest such as the one seen here, this orange area which can be seen in this 3-D reconstructed model of the prostate will contain cancer. And so this is the only area in this entire prostate which appears to be suspicious. And we are able to target biopsy, I think you can see how these tan lines which represent biopsy cores move right though this area of interest showing here.
Where before you would never be able to target it like that?
Dr. Marks: Before we were never able to target like that. Before we were able to do systematic biopsies shown by the green dots systematically placed throughout the prostate but this area of interest was not apparent prior to the advent of sophisticated MRI.
This orange dot does not mean cancer?
Dr. Marks: This is the orange target area here, and this is the prostate 3-D reconstructed model, shown in relation to the ultrasound probe here and the body position here. This shows us an area of interest so we can't say for sure that this is cancer. You'll notice on our scale here this is graded high or orange so it's more highly suspicious than a yellow or a green would be, but we won't know if it's cancer or not until the biopsy report has come back. Therefore, we need to sample this prostate both systematically and in a targeted fashion. I think you can see how a number of these tan lines, which represent biopsy cores, go right through this area of interest.
Let's talk about Don; can you give me a little bit of his history?
Dr. Marks: Yes, Don was a gentleman just like shown here in this 3-D reconstructed model of the prostate. Don came to us having had two prior sets of negative biopsies done elsewhere by a conventional method. One of them was even done in what's called a saturation biopsy technique, where twenty-four cores of tissue were taken but they were taken blindly, and they were not taken in a directed fashion as shown here. This is not his study, but he had a study not unlike this where a target was identified, targeted biopsies were obtained and they did show the tumor and he has subsequently had his prostate removed and he's cured. Without this, Don might have gone many years before this prostate was realized, it might not have been in a curable state at that time.
When you say ‘blind biopsy,' does that mean that the doctor is going in taking biopsies where ever?
Dr. Marks: The conventional method of prostate biopsy is a blind biopsy. It is blind to tumor location, it is not blind for the prostate location, since ultrasound shows us where the prostate is and allows us to take samples throughout the prostate, but it doesn't show tumor. That's been the big problem with ultrasound guided biopsies of the prostate; that's why they are not as accurate as using MRI to identify prostate cancers.
Is it a hit or miss, or can you have cancer if you don't get in there with the right biopsy area?
Dr. Marks: When traditional ultrasound guided biopsies are obtained, it's frequently fortuitous that the tumor has been identified.
Can you tell me about Mr. Lewis?
Dr. Marks: Mike Lewis is a gentleman who came to us having had one of these conventional outside biopsies. A routine ultrasound guided biopsy which did identify a microscopic focus of prostate cancer. It did not appear to be a serious amount of prostate cancer; he appeared to be a good candidate for what we call active surveillance where we watch the men carefully. We do this using targeted prostate biopsy for a confirmation that the original biopsy, the one that showed the microscopic focus only, was in fact indicative of the true situation in the prostate. In other words, we do confirmatory biopsy to establish that little spot shown wasn't the tip of an iceberg, it was only a microscopic spot, one of these tiny little spots that men are destined to die with rather than of.
I kind of compare this to a mammogram but it's taken a long time for you to get it as sophisticated as a mammogram.
Dr. Marks: For many years the concept of a ‘MAN-ogram' has been out there but elusive. And it's been in an evolutionary stage with these MRIs getting bigger and bigger magnets, better and better resolution and more functional information about areas of interest seen that we now are evolving to an area where many prostate cancers can be seen on MRI. The beauty of this device is it then brings that sophisticated MRI imagery in to a clinic setting where in an outpatient quick fifteen or twenty minute study under local anesthesia, we can do targeted biopsies as shown here.
Can you use these images over and over again?
Dr. Marks: The other benefit of this method is that each one of these biopsy locations is remembered by this device. If any one of these cores is problematic, we can go right back to that spot and resample it all over again to be sure there's not more there than was originally detected.
You want to talk about your study, about the 170 men?
Dr. Marks: We published in the Journal of Urology earlier this year the results of our first one hundred and seventy men who had undergone fusion biopsy, many of whom had, had prior negative biopsies. Our findings were that there was a much greater incidence of positive results when the area of interest was targeted biopsied versus random systematic biopsies. There are about a million prostate biopsies done every year in the United States of which about a quarter are positive, leaving three quarters of the men with elevated PSAs and a history of negative biopsies. This is a group of men with a lot of anxiety-some of them will contain a cancer. The MRI and the targeted prostate biopsy are helping to bring resolution for many of these men.
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