The first thing you should know is that there’s still plenty of room for confusion after a biopsy. The prostate in a young man is about the size of a walnut; with age and BPH it can get bigger – think of a lime, or a lemon, or even an orange. Now, imagine that you have about 14 tiny needles; each needle has a hollow center, and when it is stuck into the prostate, it takes out a very small core of tissue. There’s a lot of potential to miss any cancer that might be hiding in there. (Men of African ancestry have an even tougher situation; if they get cancer, it tends to develop in an out-of-the-way place that’s hard to reach. See story: HYPERLINK)
This is why “many men end up getting multiple repeat biopsies,” says NYU urologist Stacy Loeb, M.D. This means that you might have a PSA that is elevated. Your doctor orders a biopsy, and no cancer is found. But the PSA keeps on creeping up, so your doctor recommends another biopsy, and maybe even another. “About a third of men in one study got another biopsy within five years of a negative biopsy,” says Loeb. “If the PSA is elevated, do we do another biopsy, or what do we do? This is where some of the second-line PSA tests, like the Prostate Health Index or 4K Score, can be helpful (see “Interview with an Expert.” HYPERLINK).
A urine test, called the PCA3 test, may also be helpful. Unlike the PSA test, which is prostate-specific but not cancer-specific (it can be raised by other factors, including benign enlargement), the PCA3 test targets genes produced by prostate cancer cells.
MRI, a noninvasive imaging test, “is another option to help us see if there is a lesion in the prostate that the initial biopsy may have missed. Then we can target that area with a repeat biopsy.” Another tissue test for men with a negative biopsy is called Confirm MDX. It looks at three genes that are known to be involved with prostate cancer; specifically, it looks for “methylation changes.” Basically, it searches for cancer in a different way, looking for weird changes to the cells’ DNA. Sometimes, says Loeb, “if a biopsy was near a cancer but missed the tumor, if there is hypermethylation, that can suggest a hidden cancer.”
Another possible result on prostate biopsy is called high-grade PIN. PIN stands for prostatic intraepithelial neoplasia, and the cells are not cancerous, but they’re not normal, either. If there is high-grade PIN in multiple regions of the prostate, a doctor may recommend repeating a biopsy to make sure there is no problem. The presence of atypical cells on a biopsy– “not cancer, but abnormalities of the prostate tissue” — also suggests the need for another biopsy, probably within six months.
Having to get one or more repeat biopsies is definitely not fun, and for some men it can be very frustrating. “Albert Einstein said the definition of insanity is doing the same thing over and over again, and expecting different results,” says Loeb. “If we just kept doing the PSA test over and over again and taking random biopsies, we might not get a different result. For a patient who has had eight biopsies and who has a high PSA, this can be very upsetting. It is great that we finally have other tests to help us either rule out cancer, or to do a targeted biopsy and focus our search.”
What’s so bad about a biopsy? Why not just get a bunch of repeat biopsies? What’s the big deal? Three words: Pain, bleeding, infection. A biopsy is not a thing to be taken lightly, and it’s not just a procedure you want to go around getting if you don’t have to.
First, it can hurt. To get to the prostate, the doctor goes through your rectum. With needles. To minimize pain, your urologist may use conscious sedation or an anesthetic called a prostatic block (injected, similar to the injection a dentist uses to numb up part of your mouth if you’re going to get a cavity filled).
Second, there may be bleeding. You may have blood in your urine after the procedure, and you also may see traces of blood in your semen. You may even pass a blood clot in your urine; although it can look scary, if there is no significant bleeding, this is not something to worry about. The urethra, the tube that carries urine from the bladder, runs right through the prostate, and it is common for the needle to stick the urethra. It’s worth saying again, a few drops of blood in the urine or semen are not harmful, although they are certainly disconcerting. However, if you have large hemorrhoids, it is possible that the biopsy needle may accidentally puncture one, and a broken vein can cause significant rectal bleeding. This is different from the small bits of blood described above, and it needs to be treated right away.
Third, and most serious: Even though you will be given a course of antibiotics at the time of your biopsy, there is a risk of infection. Some men are at higher risk than others. They include:
Men with diabetes. You may be more susceptible to infection and may need a longer course of antibiotics or different antibiotics.
Men with prostatitis, urinary tract infection, or men who use a urinary catheter: Your risk of infection is higher. Also, if you have been on antibiotics recently, or if you have taken antibiotics for a long time, tell your doctor. You may need different antibiotics. “Patients are not necessarily asked routinely about certain things, such as if they have recently taken antibiotics for another problem.” Just because your doctor doesn’t ask, doesn’t mean that the answer doesn’t matter.
How to reduce the risk: “One big way to reduce the risk of a biopsy is for the doctor to assess for risk factors,” says Loeb, such as those mentioned above. Another is a swab test. As the name suggests, this means taking a swab, inserting it in the rectum to take a culture, and then looking for antibiotic resistance. “Usually fluoroquinolones are used for prostate biopsy, but if the patient’s rectal culture shows bacteria that are resistant, he can be given a different antibiotic.”
Not all hospitals offer a rectal swab test. Another option is to ask your doctor to check with the Infectious Diseases doctors in the hospital for antibiograms. An antibiogram is the result of lab tests for “antibiotic sensitivity.” Resistance to antibiotics can vary, not just from person to person, but in groups and places. For instance, “fluoroquinolone resistance varies a lot,” says Loeb. “Some regions have much higher rates of resistance to this type of antibiotic than others. If you’re in an area where there’s higher resistance to one type of antibiotic but low resistance to another, that may be a much better choice.” Loeb practices at three hospitals affiliated with New York University. “All three of them have different antibiograms.” In other words, antibiotics that work well at one hospital may not work nearly as well at another.
Most important of all: If you don’t feel well after the biopsy, go to the Emergency Room. “The main reason why complications after a biopsy can really escalate is a delay in treatment,” says Loeb. If you have a fever of 101 or higher, or chills after biopsy, go to the ER. Men tend to be stoic. Don’t be stoic. Don’t call and leave a message on the doctor’s answering machine and sit home and wait until the next day for someone to call you back. “You don’t want to do that. A biopsy infection has the potential to be serious, so go to the ER, tell them about your procedure, about recent exposure to antibiotics, and if you’ve been hospitalized recently or had another medical procedure. These are the kinds of situations where you may have been exposed to other bacteria.” If you are unable to urinate, you should also go to the ER. Although it is common to have a few drops of blood or even to pass a blood clot in the urine (see above), if you have significant bleeding, go to the ER. You need medical evaluation, and the only thing waiting will do is run the risk that your situation will become much more serious.
A final note: “All of these things are part of the general discussion of risks and benefits of a biopsy,” says Loeb. “Just because you have a PSA test doesn’t mean you have to have a biopsy, and just because you are diagnosed with cancer, doesn’t mean you need treatment. At each decision point, there should be a discussion with your doctor about the pros and cons of taking the next step.”