Improving Prostate Cancer Screening and Biopsy
Improving Prostate Cancer Screening and Biopsy
From serum prostate-specific antigen (PSA) to magnetic resonance imaging (MRI) to liquid biomarkers, the debate lingers over how to best screen for prostate cancer. Claire de la Calle, MD, a urologic oncology surgeon in the UW Medicine Department of Urology, says a better understanding of inherited risk could hold the key to more effective screening and early detection. And UW Medicine is leading the charge for those investigations.
For de la Calle, delivering a personalized approach to diagnosing and treating prostate cancer means two things. She’s taking a deeper dive into a patient’s genetic makeup, and she’s expanding use of transperineal biopsy, an alternative to the gold standard of prostate cancer biopsy.
Finding ways to better risk-stratify patients undergoing prostate cancer screening and patients with low-grade prostate cancers
When viewed together, genetic testing for rare pathogenic mutations, polygenic risk scores and family history can reveal whether a patient has an inherited prostate cancer risk. These three datapoints contribute to a provider’s decision to pursue active surveillance with a patient. But there’s a lingering question about whether physicians should do more than surveillance when these patients still have localized disease.
To start trying to address some of these questions, de la Calle plans to examine data from the Canary Prostate Active Surveillance Study (PASS) Cohort. UW Medicine and Fred Hutch Cancer Center, an independent organization that serves as UW Medicine’s cancer program, launched the cohort in 2008, and PASS is now one of the largest active surveillance cohorts in the world. Its multi-institutional database documents observational outcomes on 2,200 patients on active surveillance for low-grade prostate cancers.
“This is the perfect database for me to look into these patients with low-grade prostate cancers and retrospectively see if they have high-risk family histories, sequence their DNA to see if they harbor any mutations, or see if they have high polygenic risk scores,” she says. “We want to see if any of those measures of inherited risk affect their outcomes on active surveillance. The goal is to determine whether these patients can be safely monitored on active surveillance and how closely they need to be watched. This ultimately helps us decide when a prostate biopsy is needed.”
Reducing prostate biopsy risk
Alongside research that could improve prostate cancer screening, UW Medicine offers a leading-edge procedure that could reduce prostate biopsy risks — transperineal biopsy. And de la Calle is unique among her colleagues as the first provider at UW Medicine to provide this alternative to transrectal biopsy.
Traditionally, transrectal biopsy has been the go-to procedure for detecting and diagnosing prostate cancer. This technique still accounts for 80% of these tests in the U.S. However, transrectal biopsy does carry a significant disadvantage, de la Calle says.
Transperineal biopsy eliminates this risk. Consequently, the patient can avoid being exposed to antibiotics, which removes the risk of potentially developing multi-drug-resistant bacteria, also known as superbugs. This technique also makes it easier to biopsy the anterior prostate, which is not easily accessible with the transrectal technique.
A transperineal biopsy is a good option for patients who are at high risk of getting an infection after a prostate biopsy, such as patients who are immunocompromised. Urologists should also consider it for patients with a history of prostatitis or recurrent urinary tract infections, those who experienced an infection after a previous transrectal biopsy or those who had a prior negative transrectal prostate biopsy yet have a rising PSA.
Performing a risk-reducing biopsy
De la Calle uses a needle guide that only requires two small incisions in the perineum. She inserts the needle guide after injecting local anesthesia in the skin and in the prostate, then uses the needle guide to insert the biopsy needles, with ultrasound guidance to collect tissue samples.
“This technique takes 5 to 10 minutes longer than a transrectal biopsy. But ultimately the vast majority of patients tolerate the procedure well. And, the incisions are so small, they don’t even require a Band-Aid,” she says. “Recovery time is similar, around one day only, and usually there is no rectal bleeding.”
Although more research is needed, de la Calle wonders if the transperineal biopsy can better preserve erectile function long term, especially for patients who need repeated prostate biopsies. Unlike during the transrectal procedure, the biopsy needle never touches the neurovascular bundle that controls erections.
De la Calle is optimistic that the transperineal biopsy will slowly become more and more common in urology clinics and continue to benefit a growing number of patients at UW Medicine and around the United States.
“UW Medicine has a long history of urological research and innovation,” she says. “And there’s an increasing need for this type of risk-reducing prostate biopsy, so I’m excited to launch the transperineal program here.”
