The Biopsy

Now we are really getting to the meat and potatoes of this whole mess.  A so-called abnormal PSA test could easily lead to an immediate biopsy.  However, if that were the normal progression of events, then many Urologists would just be doing biopsies all day.  Many of these physicians do have a conscience and look for a way to reduce the number of biopsies they are doing rather than increasing them.

I make that statement since when Hybritech got the first FDA approval as a “monitoring tool” back in the late 80’s there was a robust argument as to what the PSA number should be to trigger a biopsy and where the number was derived.  Dr Catalona, Hybritech’s medical expert, who was an expert because he had done so many Prostatectomies (which makes my cousin an expert driver because she has run over so many people).?  Seems to be a low bar to clear to be an expert.  Enough commentary! Just the facts, mam!

Hybritech submitted the “normal” number at 4.0 and when challenged, Dr Catalona rationalized that the number was derived arbitrarily!  There is absolutely no science involved in where the number 4.0 was derived!!  It could have been 3.0 or maybe 6.0.  A few panel members argued that maybe the number should be 2.5 because that would produce many more biopsies than 4.0!  Nothing like conscientious professionals to help the situation along!!  Somehow Hybritech’s number was adopted as the normal number for PSA. Sadly most doctors were taught this number beginning back in the 80’s and to them it is still normal.  Enough said.

In my last post I mentioned that when you had an MRI or CT based on the results of that test one of two things happens:  You are good, and this nightmare is over for now or you have a suspicious result.  We are going to focus on the bad result rather than the good result so we can get to the bottom line of getting a biopsy! The MRI comes back, and the Radiologist sees some suspicious images.  Hopefully the Prostate capsule is intact, and the other adjacent areas are normal or at least unremarkable. 

Again, I will refer to my situation for clarity and a starting point here!  The Radiologist saw a single lesion.  In his exact words:  1.7cm lesion within the left posterolateral peripheral zone of the mid gland.  And here comes the fun part:  PI-RADS 5 -very high (clinically significant cancer is highly likely to be present).  Hamster wheel, here I come, and the odyssey begins in earnest!

The Urologist will next explain what his goals are in doing a biopsy.  He will also describe what type of biopsy procedure he will perform, and I can say I am surely no expert on getting needles stuck into your Prostate or what is the best way to get there.  However, I can say the most common type of Prostate biopsies is the Transrectal approach or the Transperineal approach. I will not get off color and say this is determining what way they will stick needles into your Prostate, either through the rectum or through the perineum. OK so maybe I will get a little off color, but just for a good reference point! (And nobody better say rectum hell, it nearly killed the fool, cause I resemble that remark!)

The transrectal approach is the most common so we will use that approach for our discussion.  The Urologist explains that this is his approach of choice and explains that the Prostate is divided into 12 zones or areas.  For biopsy purposes he will do a prober for each zone and for the 3-4 most important zones he will do 2-3 biopsies.  We do not want to miss anything!  A little simple math quickly tells you this simple biopsy is now not a single needle stick into your Prostate, but 18 to 24 needle sticks.  Dang, sounds like fun, where can I sign up for 2!?

The Urologist is going to go further in the discussion to set your expectations and try to alleviate your fears.  He explains that when he does the biopsy, he is going to do a biopsy using a transrectal ultrasound system, referred to as TRUS.  It is an ultrasound guided process designed to help the doctor be precise in his biopsies.  Further he tells you that he will use local anesthetic to keep you more “comfortable” and to his credit he did not warrant the kick to his teeth he would get if he said, “you may feel a bit of discomfort in this process.”  Instead, he says you may feel some of the biopsies but not much as the local will work well. Lastly, we can do the biopsy in his office next Thursday!

On the day of the biopsy, you need to do a simple Fleet enema (ever notice when you are the patient how often the experts call something simple)? I would like to say that feeling you are getting is just my foot going so far up your butt that Marcus Welby could not get it out!!  If you are under fifty, ask me and I’ll be happy to explain who Dr. Welby was!  Or you can use that Google thing. Back to work. Day of:  You do the Fleet enema, so your system is cleaned out since that part of your anatomy is going to get a bit crowded for a few minutes soon.

I am not going to drag everyone down the rabbit hole of describing blow by blow or better said, prick by prick, what happens during the biopsy as by now you can imagine the process.  I’ll just say that I had 16 biopsies, one per zone and 2 in 4 zones.  Honestly yes you could feel some of the biopsies, but it is a very fast gun that shoots the needle into the Prostate.  Under the circumstances it was not as bad as a jab with a sharp stick!

But when it is over, we are back to the waiting and hoping game.  Remember you have not been declared a cancer patient.  The purpose of this biopsy process is to determine conclusively if you do or do not have Prostate cancer and if it is cancer, how extensive it is.  Now you are pulling for 2 results.  The best is No cancer; but if you are not so lucky you just hope the cancer is still in the Prostate capsule.  That is, it is still totally contained in the Prostate and has not grown out of the Prostate and into nearby structures like Lymph Nodes or the Rectum or Bladder. Hey, sometimes life is all about small victories or at least it should be!

It will take about a week for the biopsy samples to be sent to a lab for results.  So a week passes and you get a call from your Urologist to say you have Prostate cancer and we need to make a decision as to how you want to proceed soon, so let’s schedule an appointment for next week.  By now your head will be spinning so fast you are thinking I don’t want to wait an eternity until next week.  I want to meet today and decide how quickly we can get this damn thing out of my body!  But take a deep breath or twenty.  You have time for panic and time to think as Prostate cancer grows very slowly.

This is the right spot to interject the Gleason score discussion.  We will stop here, and our next post will be about the Gleason score.  What it is, what it means and why you care!  Then we will conclude the discussion about your now confirmed Prostate cancer and what your next move is or should be.

One writer’s note here. I mention that the TRUS process is the most popular Prostate Biopsy method.  As I am writing this and it is 2024, I am learning that today many more progressive Urologists are starting to do the Transperineal approach for Prostate biopsy and claiming that process has less complications and poses less risk than the TRUS procedure. At some point in the future, I’ll do more research and post about this procedure so you can compare.  In the meantime, if you are dealing with this fun house, do all of the research you need to do to decide which biopsy process is best for you, even though we usually go with whatever the Urologist is comfortable with doing.  I don’t know about you, but I do not want to be the first patient with a new process.  If you are adamant about a different approach, it may require talking to a different Urologist.