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Doctors Debate Criteria For Prostate Biopsy

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Doctors Debate Criteria For Prostate Biopsy

Doctors Debate Criteria For Prostate Biopsy

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  • <iframe src="" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player">
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It's MORNING EDITION from NPR News. Good morning. I'm Renee Montagne.


And I'm Ari Shapiro.

Today in "Your Health," we'll hear that many women are having unnecessary surgery to check for breast cancer. But first, a different controversy over diagnosing cancer. This one involves men, prostate cancer, and a study that challenges the conventional wisdom. NPR's Richard Knox reports on whether a rising level of a chemical called PSA really does mean a man should have a prostate biopsy.

RICHARD KNOX: OK, guys, fair warning. We're about to hear something many of you dread - a biopsy of the prostate gland.

Dr. MICHAEL O'LEARY (Brigham and Women's Hospital): Slide your bum way over here to the side of the table.

KNOX: The patient's on his side, on an examining table in Boston.

JIM: I'm feeling great.

KNOX: He's a 57-year-old businessman named Jim. He doesn't want us to use his last name, but he was brave enough to let us watch his biopsy.

JIM: My PSA level more than doubled over the course of a year.

KNOX: So Jim's doctor sent him to Dr. Michael O'Leary.

Dr. O'LEARY: Perfect. Perfect.

KNOX: He's a urologist at Brigham and Women's Hospital.

Dr. O'LEARY: The hardest part, Jim, is the probe going in.

KNOX: Right.

Unidentified Woman: We're going to go nice and slow.

KNOX: A technician inserts an eight-inch-long ultrasound wand into Jim's backside.

Dr. O'LEARY: Now I'm going to go ahead and put some Novocaine in, all right? A little stick - and you might feel that part - and then a little pressure.

KNOX: Then O'Leary inserts a long, slender tube through the probe. It's actually a spring-loaded gun that will fire a dozen needles into Jim's prostate. Each one grabs a tiny piece of tissue.

Dr. O'LEARY: OK, here's the first one.

(Soundbite of click)


JIM: Yeah, didn't feel it at all.

Dr. O'LEARY: Good. All right. Another little pop.

(Soundbite of click)

Dr. ANDREW VICKERS (Memorial Sloan Kettering Cancer Center): There are about three-quarters of a million unnecessary prostate biopsies every year. It's a biopsy done in a man who does not have prostate cancer.

KNOX: That's Andrew Vickers of Memorial Sloan Kettering Cancer Center, in New York. He says the level of a man's PSA, or prostate-specific antigen, isn't a very good indicator of who should be biopsied.

Dr. VICKERS: The real big problem is that if you have a high PSA, you don't know whether it's to do with cancer, or whether it results from a benign disease in your prostate.

KNOX: Benign disease meaning enlargement of the prostate. It's a very common thing as a man ages. Many doctors recommend a prostate biopsy if a man's PSA rises above four. And for several years, many have also focused on how much the PSA rises over time. Vickers says this seemed to make sense.

Dr. VICKERS: The point about cancer is, it's a growth process. What really matters is how fast it's growing, not its current size. So with PSA, the thought was well, let's see how it's changing.

KNOX: But now a new study, led by Vickers and published in the Journal of the National Cancer Institute, says this thinking is wrong.

Dr. VICKERS: We found out, you know, in many cases, to our complete surprise, that it didn't really tell us very much at all. Once you knew what somebody's PSA level was, their change in PSA was essentially uninformative, particularly for the aggressive cancers, the ones that we should really be worrying about.

KNOX: This kind of data has already changed what doctors do in Europe. Vickers says they don't use the rate of increase in a man's PSA as a trigger for a first-time biopsy.

But there are experts in America who aren't convinced. Dr. Anthony D'Amico, of Brigham and Women's, questions whether many of the men in Vicker's study had high PSAs for reasons that had nothing to do with cancer. They might have been doing a lot of bike riding. Or they might have had sex before having their PSA test, or a recent colonoscopy. All can increase PSA. So D'Amico maintains rising PSA is a good indicator of cancer.

Dr. ANTHONY D'AMICO (Brigham and Women's Hospital): You are under the age of 60, and you've had a PSA rise of more than half a point in a year, your likelihood of having prostate cancer is markedly increased, and you should have a prostate biopsy.

KNOX: Still, some other U.S. experts say, because of the new study, they won't use increases in PSA as much when deciding if a man should get a biopsy.

(Soundbite of click)

Dr. O'LEARY: OK, my friend, we are done.

KNOX: Back at Brigham and Women's, Jim's biopsy is almost finished in the time it's taken to listen to this report.

Unidentified Woman: I'm going to take this out.

Dr. O'LEARY: The probe's coming out.

KNOX: As long as the old way of using PSA holds, one thing is clear: It means lots of men will continue to get biopsies that don't find cancer. And many biopsies will find cancers that grow so slowly, they don't even need to be treated.

By the way, there's no question that Jim needed his biopsy. That's because his PSA recently spiked to 10.

Dr. O'LEARY: This is enough of a rise that you have to explain it. It could well turn out to be benign disease, and that'll be great. But I think the responsibility is for us to prove that this is benign disease.

KNOX: Once a man's PSA level gets that high, O'Leary says there's little choice. A doctor has to find cancer or rule it out, if he can.

Richard Knox, NPR News, Boston.

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