“What if it were you, doc?” Patients ask this question a lot. Especially about prostate cancer. It’s fraught in some ways, as my preferences will never be the same as those of my patient sitting opposite. But the question is well worth a doctor’s honest reflection. The answers can be telling.
Prostate biopsy
When I was training to be a urologist, I’d do a weekly prostate biopsy list. Men would sit quietly in the waiting room at the hospital and I’d call them in, one by one.
The procedure room was little more than a basic hospital consulting room – a desk and a chair, and an examination table with steps underneath. The only other furnishings were the ultrasound machine and a stainless steel trolley to hold the specimen jars. It was stark, sterile, functional.
I’d ask the patients to pull their trousers and undies down and lie in a foetal position, facing the wall. Then I’d daub some gel on my gloved index finger and insert it through the anus to feel the prostate gland, which sits just in front of the rectum. Was it hard or soft, big or small, nodular or smooth?
Not a pleasant experience for the patient, certainly. But nothing on what was coming next.
Having given the patient, who was now usually highly alert and somewhat alarmed, due warning, I’d then insert the ultrasound probe into the rectum. The calibre of this probe was more that of a fat thumb than of my slender finger. This part of the procedure alone would often cause a yelp.
Occasionally, one of my bosses would pop into the room and attempt to lighten the situation. His favourite line at this point was “Now this won’t hurt me a bit!” A good dose of dark humour can be just the tonic for us doctors. I’m not sure how amused the patients were.
Once the probe was in position with a clear view of the prostate on the ultrasound screen, it was time to take the biopsies. This was done by firing a spring-loaded biopsy needle through a channel fixed to the side of the probe. It made a short, sharp, clicking sound. Each time I fired the biopsy gun (yes, it’s called a gun), the needle would pierce the rectal wall, enter the prostate and take a tiny sliver of tissue, all in a split second. I’d repeat this six times or more. This was how we did transrectal prostate biopsy then. No anaesthesia. Little dignity.
Some patients were silent during this process, but they were pretty rare. Mostly, despite our warnings of what was coming, men couldn’t help but let out some exclamation of pain or shock. A few would even blurt, “Ohh fuck!”
“All done,” I’d say, then tell them I’d see them next week for the biopsy results.
“Oh, and if you feel feverish and start shaking uncontrollably, that’ll be septicaemia from this procedure, so make sure you come straight back to Emergency if that happens.” Despite prescribing preventative antibiotics, sepsis was an all-too-frequent complication of this procedure.
I’ve had several patients from those years who went on to have a radical prostatectomy (surgery) to treat their cancer. They’d later say that the biopsy was the worst part of their whole cancer experience.
I hated doing those biopsy lists. How did we ever get to that chamber of horrors? And how were we doctors active participants, inflicting pain and humiliation on those we were supposed to be caring for?
I think it’s a classic example of how healthcare can be so skewed towards what works for doctors and hospitals, rather than being there to truly care for patients. And once a method of diagnosis or treatment has been done for long enough, it becomes dogma. Everyone does it like this, so it must be the right way, right? Wrong.
So, back to that question patients often ask. What if were you? Would I ever have this procedure myself? No, I would not. Something is clearly amiss when we as doctors wouldn’t undergo what we are subjecting our own patients to.
So, a decade ago now, we set about researching an alternative. Transperineal biopsy, when we started doing it, was done under general anaesthesia. Instead of passing the biopsy needle through the rectum, we passed it via the skin of the perineum (just behind the scrotum). Unlike transrectal biopsy, our results, as well as those of many others, showed a near-zero rate of sepsis. And with no procedural pain due to the GA, it was clearly a preferable option.
Thankfully, transperineal biopsy has now become the standard of care for prostate biopsy in Europe and Australia. And I would certainly undergo a transperineal biopsy myself if it was indicated.
Focal therapy
Fast forward to today and there’s another aspect of prostate cancer that patients ask me that same question about – “What would you do, if it were you?”
Not all prostate cancers are the same. In fact, there’s a whole spectrum of disease, all the way from harmless to lethal. What we call “active surveillance” is now standard of care for low-grade (non-aggressive) prostate cancers*. This is a much-needed step forward for minimising harm from excessive treatment. With our now far more accurate diagnostic tools like MRI scans and targeted transperineal biopsy, it means we can safely watch these patients with follow-up tests and only intervene if it looks like the cancer is changing into something more aggressive.
*Some argue that these low-grade types should not even be called cancer – an ongoing debate.
And at the other end of the spectrum of localised prostate cancer, we have high-grade bulky tumours, which clearly require treatment to match the aggressiveness of the disease. This means treating the whole prostate gland, whether it be by surgical removal or radiotherapy. These radical treatments are standard of care. They necessarily risk causing erectile dysfunction and urinary symptoms such as incontinence simply due to the proximity of the prostate to surrounding nerves and organs.
So, when we doctors provide these treatments, there’s no question we risk harming our patients. But these treatments also provide the best possible chance of stopping the cancer from spreading – and of cure. Most patients accept this trade-off.
But there’s a large proportion of prostate cancers that sit between these extremes of low- and high-grade disease – the so-called Gleason 7s (Grade Groups 2 and 3), or intermediate-risk disease. Prostate cancers that we label intermediate-risk are called this because they contain a mixture of both high grade and low grade components. Because of the high-grade components, these cancers are also at risk of spreading. But because there’s also a low-grade part, the risk of spreading is lower than for cancers that are only high grade.
The trouble, then, with these intermediate risk cancers, is that the trade-off between cancer control and the side effects of treatments becomes a lot murkier.
Some Gleason 7 cancers will never spread beyond the prostate in a patient’s expected lifetime. They won’t ever harm that person, let alone kill them. But some Gleason 7 cancers will. The problem is that, right now, we can’t reliably tell which is which.
Some patients with small Gleason 7 cancers will opt for active surveillance, just like patients with low grade disease, and take the small risk of the cancer spreading. But most will undergo radical treatment.
How many individual patients who sit across the desk from us are we benefiting by doing this? And how many are we harming? We don’t know. I hate the thought that I might be doing these patients more harm than good.
But could there be a way for patients to hedge their bets? As it happens, there could.
Focal therapy is a new way of treating intermediate-risk prostate cancer. Focal therapy is called this because it focuses on just the cancer, killing it, and preserving the rest of the normal prostate. By doing this, the idea is to avoid damage to those all-important surrounding structures which provide normal bladder, bowel and erectile function.
The principle is no different from that of lumpectomy, which has long been standard of care in early breast cancer: achieve equivalent cancer outcomes without subjecting patients to radical treatments and their side effects. Except focal therapy is not done surgically due to the anatomical constraints of the male pelvis, but instead by using various different energy sources that ablate (kill) cancer tissue. These range from established modalities like radiotherapy (such as radioactive seed implantation - called brachytherapy) to more novel methods such as irreversible electroporation (NanoKnifeTM). Right now, we don’t know which of all these techniques works best, which is why there’s a multitude of trials and clinical registries underway globally to help figure this out.
Early results have indeed shown what we’d hoped for in preserving normal function, with low rates of side effects. What we’re still waiting for are the longer-term cancer outcomes. Until we have that information, focal therapy shouldn’t be seen as a standard evidence-based option.
But for some men with a single focus of Gleason 7 prostate cancer who want to hedge their bets and have their disease treated in a new way that minimises the risk of side effects, it might be worth at least considering one of the various focal therapy trials or registries available.
If it were me, I would*.
*My bias: I have performed focal therapy for highly selected prostate cancers for the last 9 years and am Co-Chief Investigator of the LIBERATE focal brachytherapy clinical registry (ACTRN 12619001669189).