IT'S SUMMERTIME - GRAB ALL THE FRESH PRODUCE YOU CAN! AND JOIN ME FOR A FREE WEBINAR THIS SATURDAY, AUGUST 26th, at 12:00 NOON EST!

Hello all. I have been absent from my blog for around three months - but I have a cornucopia of topics to cover while I’ve been on my journey of spinal surgery followed by an unexpected consequence of AUR (acute urinary retention) on which I have several pages to write - about catheterization and my own advocacy around the circumstances which took me there. And, not to, of course, have my physical therapy continue uninterrupted (I’m allowed to be facetious now and then), I’ve been challenged by a new health issue that has had its own difficulties. So, while not out of the woods, I had to notify everyone of a dream come true in the PCa universe where it concerns nutritional and exercise lifestyle,

If you’ve followed me from the beginning of my journey which began with my diagnosis in April 2018 of low-risk PCa for which I’m on Active Surveillance, you would have read that I had taken myself to a health retreat where I embarked on a 3-week program featuring the Hippocrates protocol. Scroll down to my earlier entries and you can re-visit my story about how I adopted a whole food plant-based diet.

Currently, the medical community has not fully embraced the benefits of the WFPB diet; at the most, doctors tout the Mediterranean diet as the heart-healthy diet one can benefit from in all aspects of our health. And, this is true to some extent - many adopt this diet because going off meat, fish, dairy, sugar, etc. is too radical and confining. Understandable. However, anecdotal evidence (which I have encountered) began to rear its head and pointed to this diet as the best in keeping our gut microbiomes clean and buzzing. There are those who have found it to be helpful in bringing their conditions to NED (no evidence of disease) - but, saying that, these cases are NOT documented in scientific and medical journals. Doctors have had very little training in nutrition and it’s hardly their fault that they do not know more on this subject. But, we’ll save that for another day!

For now, I wanted to bring your attention to a very special FREE webinar being held on Saturday, August, 26th, at 12:00 noon sharp hosted by Active Surveillance Patients International, on which I sit on the Board as a volunteer. Again, at 12:00 Noon SHARP - breaking the glass ceiling (to borrow the cliche) in the latest research (presented at the AUA and ASCO 2023 conferences) on the benefits of whole food plant-based nutritional lifestyle is Stacey Loeb, MD of the NYU Grossman School of Medicine.

ONE CLICK TO REGISTER at https://prostatecancerinfo.org/3E2C3S4

or SCAN the QR CODE below

read more details about Dr. Loeb and what she will be covering

in ASPI’s latest newsletter: https://mailchi.mp/060eabe7dc35/as_101-15591175

AND HERE’S THE BEST PART:

A LIVE Q & A WITH DR. LOEB will follow the presentation!

Everything you need to know will be in these materials. Come with an open mind, or come closed. Come if you’re already on this diet, or if you’re enjoying your summer barbecues. This is a judgment-free zone (and BLOG!).

Finally, my excitement is that this sentiment of embracing a WFPB diet is weaving its way through SCIENCE based research studies and clinical trials. Stay tuned! I’ll follow up with a follow-up - and circle back around again with tales that will benefit you in the long run in how to be your own best advocate. See you Saturday! I’ll be co-moderating with Howard Wolinsky, veteran prostate cancer journalist, AS thriver himself, and the founder of the AS101 series which you can read more about by clicking on links in the ASPI newsletter. Bon Appetite! (Photo above shows just some of the veggies I grabbed at last Saturday’s Farmer’s Market!).

NEWSFLASH RE: DR. JONATHAN EPSTEIN

I found out early Thursday morning, May 25,  that world-renowned Dr. Jonathan Epstein, who has offered, with his team, thousands of men second opinions on pathology reports from prostate biopsies,  is on a leave of absence, and it is not known when he'll return.

In answer to a direct query to his office, I received this reply from his long-time assistant, Suzanne Hoffman, who I have spoken to on several occasions regarding patients’ submissions for second opinions: 

May 25, 2023

Dear Martin,

Dr. Epstein is indeed out on a leave of absence, and we don’t know when he’ll return.

In the meantime, however, you can suggest that they continue to contact Johns Hopkins if they’d like a second opinion.  The three other GU pathologists on staff have been trained by him, worked with him for years, and will be assigned his cases to review in the meantime, so they’ll be in good hands. 

Take care,

Suzanne Hoffman

Assistant to Drs. Andres Matoso, Tamara Lotan, and Ezra Baraban

410-614-6330

shoffm29@jhmi.edu

Active Surveillance Patients International hosted the AS101 presentation of Dr.  Epstein last month with a live Q and A, for which the doctor graciously returned to answer patients' questions. You may view a recording of the presentation at: 

https://aspatients.org/meeting/as-101-episode-5-second-opinions-and-biopsies/

Dr. Epstein, with his outstanding professional reputation, firm grasp, and extensive mastery of urologic pathology, has been a go-to for many patients worldwide seeking second opinions on their biopsy pathology.  Receiving an average of 200-300 sets of slides to review each week, the doctor has relied heavily on the team he personally trained and continues to work with him for many years (as his office cited above) to assist him in the timely reporting of results for the patients.  He and his team's passion for helping men understand their reports have been evident in his exceptional willingness to speak with patients and answer questions from them upon receiving his analyses.  

 I wish him well, and look forward to announcing his return, and, as his office stated, his team at Johns Hopkins stands ready, willing, and able to continue to render second opinions on your pathology, with the endorsement of the doctor himself. 

Visit the JOHNS HOPKINS "GETTING A SECOND OPINION" WEBSITE

HERE

For more information on second opinions at Johns Hopkins, please email Suzanne Hoffman at shoffm29@jhmi.edu and/or phone 410-614-6330.

A Bulletin (and editorial) re today's Release of Prostate Cancer: Early Detection Guidelines

In advance of my presentation at the American Urological Association’s annual 2023 conference in Chicago, on Saturday, April 29, as part of the Patients Perspective Program (see my announcement and topic in the previous post), I have just perused the newly-released Prostate Cancer: Early Detection Guideline and, while I have yet to finish, I am disappointed at a conclusion reached regarding the efficacy of the transperineal over the transrectal biopsy. The full transcript can be read HERE. The paragraphs referencing the two types of biopsies appear under the headline “Biopsy Technique.”

In short, the authors suggest no “significant” difference in cancer detection rates between the two approaches in patients with suspected GG2+ prostate cancer. However, they note that transperineal biopsies may be more effective in detecting anterior and apical cancers and may have a lower risk of infection. They suggest that future research should investigate unanswered questions regarding the diagnostic capabilities, risks of infection, and value of antibiotic prophylaxis for each approach.

I wonder what research and data will be enough to move the needle toward urologists making transperineal (TPUS) biopsies their best practice in the United States. In my transperineal series below, I cite numerous studies on the less risky nature of the TPUS, discussions regarding the over-use of antibiotics, and how the free-hand PrecisionPoint Transperinneal Access System obviates the need, in most cases, for the administration of antibiotics. It is well known that TPUS is way more effective in detecting clinically significant cancer in the anterior section. Why the hesitancy, especially when patients are ASKING their urologists for this biopsy if needed?

Perhaps this #AUA23 conference would be an excellent place to continue this discussion. I’d encourage more patients to make their voices known as they did in Australia, where urologists are paid less for utilizing the transrectal technique over TPUS (for which they get an incentive).

You can start with all the authors, contributors, and commenters listed at the end of the guideline.

And read my latest entry focusing on the differences between grid based and FH biopsies with some commentary from Matthew Allaway, MD on his PPTAS invention (below).

More commentary on the release of this Prostate Cancer: Early Detection Guideline soon.

The American Urological Association's Annual Conference 4.28 - 5.1.23

As a patient, patient advocate, and Board Member of Active Surveillance Patients International, I will be making a presentation at the AUA’s Patient Perspectives Program, now in its second year.

As the AUA describes: “….[The Program] is designed to elevate awareness and bring patient voices into the fold. This engaging program aims to help physicians and healthcare providers understand what success looks like in patient-physician communication and shared decision-making.

I am honored to have had my abstract accepted and will be among fourteen patient presenters sharing their journeys through a wide spectrum of Genitourinary Disorders.

My topic will be focused on Presenting Patients’ Voices to Urologists Regarding Prostate Cancer and AS Protocols in Support of Shared Decision Making.

PLEASE NOTE: Any patient who wishes to contribute their voice to my presentation of patients’ collective voices to urologists and the PCa medical community, please email me at mgewirtz@me.com expressing your interest and I will be in touch with you! Any voices represented in my presentation will be strictly anonymous!

Stay tuned for more!

The Transperineal Biopsy: Part Two

(Author’s note: Scroll down to see the first installment in this series.)

In my first installment on the Transperineal Biopsy (TPbx), I noted its history- the prevalence of the procedure for years before a drift back towards the TRUS bx.  And we’re circling back to TP as possibly becoming a best practice:  less risk of infection; friendlier in the office with local anesthesia (LA); the ability to choose general anesthesia (GA) for the procedure in an OR in a hospital; the possibility of no antibiotics administered before or after; less pain (still, a sensitive subject); and, most importantly, complete coverage of your prostate, including the anterior - where a large percentage of significant cancers are missed by a TRUS bx. I have mentioned that TP biopsies have been more prevalent in Europe; in fact, they are the standard of care in several countries and on the Australian continent. The US lags behind. More about that later.  And although I’ve cited this 2020 abstract elsewhere in my blog, it might be a good time to revisit it. Click on:

“TREXIT 2020”: WHY THE TIME TO ABANDON TRANSRECTAL PROSTATE BIOPSY STARTS NOW

A program from the non-profit Active Surveillance Patients International in April 2021 on this subject featuring, among others, Rick Popert and Matt Allaway, can be viewed on ASPI’s YouTube channel: .

 All Transperineal Biopsies Are Not The Same

Prevalent until the invention of the freehand (FH) technique has been the grid-based (GB) method.  I’ve found some simple-to-understand text and accompanying videos to get you up to speed on the two techniques. A short and sweet article from The Journal of Urology with easy-to-understand explanations distinguishing between (GB) and (FH) transperineal biopsies can be found here.

Click on:

Freehand versus Grid-Based Transperineal Prostate Biopsy: A Comparison of Anatomical Region Yield and Complications

Conclusion: “Compared with GB TPbx, FH TPbx demonstrates an equivalent cancer yield with no risk of sepsis, a significantly reduced risk of urinary retention, and reduced anesthesia needs. The higher number of cores with ≥GGG-2 PCa involvement in the FH group suggests that FH transperineal biopsy can sample the prostate better than GB-transperineal biopsy can. "

For those of you more oriented towards visual presentations,  watch this supplementary video to the above study from John Davis, one of the study authors (from The Journal of Urology, October 2021, copyrighted by American Urological Association Education and Research, Inc.)

A report from the Patient-Centered Outcomes Research Institute (PCORI) gives us a review on a trial expected to be completed in March 2025. Click on:

Comparing Two Types of Prostate Biopsy

And check out an online article from the Mayo Clinic from 2019, an excerpt of which follows:

“At Mayo Clinic's campus in Rochester, Minnesota, urologist Derek J. Lomas, M.D., Pharm.D., has chosen to discontinue routine use of the transrectal approach to prostate biopsy and now performs transperineal prostate biopsy. Dr. Lomas gained extensive experience with the technique during his fellowship training in London. Mayo Clinic is one of a few centers in the region that perform high volumes of transperineal biopsy….” [Note: this may have changed during the past three years]. “…..This approach helps to accurately diagnose threatening infectious complications associated with prostate biopsy. It provides good diagnostic yield and is particularly well-suited for patients with previous infectious complications," says Dr. Lomas."  "There are several different techniques by which we can perform transperineal biopsy," says Dr. Lomas. "The choice of technique is based on whether a fusion or a systematic biopsy is needed and if the patient is in the clinic or under sedation.

"The first technique uses a device called a stepper, which is used to cradle the ultrasound probe and provide a guidance grid for biopsy needle insertion. Urologists who have performed brachytherapy for prostate cancer would be familiar with this device. The downside of this approach is that each biopsy of the prostate requires a skin puncture, which limits the utility of this approach in the clinic where we are using local anesthesia only. This technique may still be used, but an excellent skin block is paramount."

Mayo Clinic urologists also employ the freehand approach, using the needle access guide. "In this approach, only one or two skin punctures are needed for each side of the prostate," says Dr. Lomas. "Through a needle access guide placed through the anesthetized skin of the perineum, the biopsy needle can be reintroduced for multiple biopsies without repeat puncture of the skin. The biopsy needles are guided by an ultrasound probe in the rectum. This approach allows for improved patient comfort in the clinic setting.”

Read the article in its entirety here: https://prostatecancerinfo.org/40clV9O

My own fTPbx was performed with the PrecisionPoint Transperineal Access System (PPTAS) invented by Dr. Matthew Allaway, a urologist in Cumberland, Maryland. 

Dr. Allaway is the Founder and CEO of Perineologic and strongly believes in providing an integrative approach to the treatment of urologic disorders. Many of his philosophies and attitudes regarding patient care resulted from his own personal battle with cancer, including his decision to become a urologist.

Dr. Allaway has been a practicing urologist at Urology Associates in Cumberland, Maryland for more than 20 years, with a special focus on prostate cancer and female urology. Many of the techniques and approaches he uses on a daily basis have resulted from ongoing clinical challenges and the need to improve the quality of care delivered to patients. These convictions contributed to his establishment of Perineologic and development of its first product, PrecisionPoint™.

He completed his residency in urology and surgery as well as his internship at West Virginia University. Dr. Allaway earned his Doctor of Medicine degree in osteopathic medicine from Midwestern University and his Bachelor of Science degree from Illinois Benedictine College. - from Perineologic.com

The doctor, who acknowledges that he's a  "big adopter" of Active Surveillance, was growing weary of the risks associated with the transrectal biopsy. He described his thought process before inventing PPTAS: "why do we teach a method of biopsy [transrectal] where you don't even sample half the gland?  [The reason] for that was research cited from decades ago that said.... 'there's just 5% of disease to worry about in other areas. I knew this was wrong, and I said we must sample the whole prostate properly."

The risk of infection in a transrectal biopsy - not often explained to a new patient who receives the biopsy for the first time - often in his urologist’s office - has always been on every patient's mind when choosing whether or not to have repeat biopsies during the Active Surveillance management protocol. And it certainly weighed heavily on Dr. Allaway's mind. "......The infections, of course, [created] a horrible situation....how can this happen in the modern era we live in? And [consider] the number of men who had low-risk disease, and on active surveillance...... the patients [were saying] 'you're absolutely never going to touch me [with that] biopsy again.'"

While Dr. Allaway approached outside sources to have his concerns addressed, they were met with skepticism.  With the belief that "the urologist can do what they're skilled at doing, which is understanding prostate anatomy and knowing how to navigate around and get the needle in the right spot" he was steadfast in his belief that sampling the entire prostate made the most sense.  "I don't want to be a microbiologist. I don't want to be an infectious disease doctor. I don't ...…want to use antibiotics at all.....I knew there was only one way to do this: to go through the perineum."

Expressing his dismay with the grid stepper technique, which he felt could cause too many complications, he recalls being "completely immersed with trying to create the very best possible biopsy."  And thus, PPTAS came into being.  "This is a procedure [which] can be done in the office safely, comfortably, and effectively."

Before I spoke with Dr. Allaway, I had done my research and had concluded that the only biopsy I would want was the PrecisionPoint.  My first concern (remembering my first excruciating 12-core transrectal biopsy on a table in my first urologist's office five years ago) was PAIN. Would the local anesthetic for a transperineal biopsy be the same as administered for a TRUS?

Local anesthesia is not unique to PPTAS or other TP biopsies.   We all know too well that a prostate biopsy is not the most comfortable procedure. As I stated above, many men choose to forego it on their AS protocols - instead, to rely on the results of a regularly scheduled 3T MRI, which has a false negative rate of around 15% - as of this writing.  But the prostate biopsy is our only definitive tool to diagnose prostate cancer.  Thus, reviewing some of the science and data on local anesthesia (LA) is worthwhile for those choosing a TP biopsy in an office setting.

A study in 2022 out of Australia confirms the viability of local anesthesia for a TPbx. Click on:

Outpatient transperineal prostate biopsy under local anesthesia is safe, well-tolerated, and feasible.

Conclusion: "TPB under LA in the outpatient setting is a safe and feasible practice. Our study adds to the current literature supporting the use of TPB under LA with high csPCa detection rates. It shows excellent patient tolerability while minimizing complications....."

I have been told that local anesthetic techniques are constantly improving. That is good news for those who wish to be mildly sedated but not wholly unaware of their surroundings.  Doctors are exploring various sedation methods in an office setting, aware that our healthcare system is overburdened by the costs of having procedures in hospitals. And patients, as well, are forced - if they choose the OR - to find a friend or family member to meet them after they have recovered from general anesthesia when the biopsy is completed. Ergo, less of a burden on the patient as well.

One of the workarounds which have been suggested is the use of nitrous oxide - a mild sedation that wears off after several minutes upon the procedure’s conclusion. You and your doctor should discuss what would be most comfortable for you if you had the procedure in an office setting.  I’ve known several patients who chose that setting - in different locations nationwide.  One reported “no pain at all,” while another reported some discomfort. Several factors are in play here - the urologist’s experience and each individual’s threshold for pain. It’s similar when I read other accounts online, from “easy as pie” to “painful.”  Again, I have been assured that discovering new methods for administering local anesthesia (LA) and improving current methods are ongoing.  Hey, how long does it take to perfect anything on this planet?  I know that if I had been offered the option for my own biopsy to inhale nitrous oxide, I might have chosen an office procedure.  I’m very familiar with the mild sedative effects of the same since, over my lifetime, I’ve availed myself of nitrous for several dental and periodontal visits—different strokes for different folks. Frankly, I was happy to be asleep now that I think back on it. And I was fortunate to be met at the hospital by a fellow support group member.

To buttress the fact that continuing studies are taking place relative to transperineal biopsies and local anesthesia, check out these from clinicaltrials.gov. I found the following trials are still recruiting (as of March, 2023):

Evaluation of Transperineal Biopsy Under Local Anesthesia

Actual Study Start Date: March 22, 2021

Estimated Primary Completion Date: June 2025

Estimated Study Completion Date: June 2025

and the TRANSLATE trial: “The TRANSLATE randomised controlled trial aims to evaluate local anesthetic transperineal biopsy (LATP) versus transrectal ultrasound-guided (TRUS) prostate biopsy, in the evaluation of previously biopsy-naive men being investigated for clinically significant prostate cancer (based on an elevated age-specific PSA, or abnormal digital rectal examination, or MRI-visible lesion). Men under investigation for possible prostate cancer and recruited to TRANSLATE will be randomised to receive either an LATP or TRUS prostate biopsy, with the primary outcome measure being detection of clinically significant prostate cancer (defined as any Gleason pattern 4 disease, i.e., any Gleason Grade Group >=2 disease). Secondary outcome measures include infection, other complications, tolerability, rate of re-biopsy, detection of clinically insignificant prostate cancer, and a full health economics evaluation.”

A Randomised Controlled Trial Comparing TRANSrectal Biopsy Versus Local Anesthetic Transperineal Biopsy in Evaluation (TRANSLATE) of Men With Potential Clinically Significant Prostate Cancer (still recruiting)

Make it stand out

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study.

If you want to participate in trials that have been announced and are “still recruiting," read the requirements for enrollment and look for a contact nearest to you.  (As I’ve iterated in early posts, clinicaltrials.gov is one of the main “go-to’s” for researchers.  The site allows you to plug in keywords, and you’ll most likely find a trial that you might be interested in - either for research or participation.  To participate, choose the field  “still recruiting.”  If you’re searching for studies from which you can glean conclusions from an entire abstract from start to finish, choose “complete.”  It’s that simple.

Now let's dive in to some of the questions I had before my own freehand TP (fTP) biopsy last September and questions which arose afterwards.  Let me be clear that, from hereon in, I’ll be focusing on the freehand PrecisionPoint Transperineal Access System (PPTAS) biopsy which was, again, my third biopsy in September 2022, four years after my confirmatory biopsy.

Aside from PAIN and local and general anesthesia, I was additionally curious about bowel preparation and antibiotics - the latter prevalently used in transrectal biopsies, particularly the "black box" CIPRO.  With transperineal biopsies, administration of antibiotics are normally left up to your urologist while the manufacturer of PrecisionPoint, Perineologic, is upfront about the device not requiring the administration of antibiotics before-and-after. Dr. Allaway and I circled back to his strong feelings about antibiotics,  supporting the burgeoning evidence from studies of the dangers of over-prescribing antibiotics to the point where many become anti-biotic resistant, exposing patients to irreversible infectious conditions.  This was certainly a factor in my pursuit of a practitioner and facility which utilized PPTAS.  (I was not given antibiotics).  However, I’ve known patients who, upon undergoing the PPTAS biopsy by urologists trained by Dr. Allaway’s team, were given antibiotics before-and-after.  So, what gives?  I discussed with Dr. Allaway' his intention around obviating the need for antibiotics and did my own research as well.

But, first, here is a "meta-analysis" of which Dr. Allaway is listed among the authors:

  Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis

See also this report of a randomized controlled trial - published in Lancet Infectious Diseases - where they randomized patients to transperineal biopsy with and without antibiotics and found no difference in infectious complications:

Antibiotic Prophylaxis versus No Antibiotic Prophylaxis in Transperineal Prostate Biopsies (NORAPP): a Randomised, Open-label, Non-inferiority Trial

Dr. Allaway's intention for patients undergoing PrecisionPoint biopsies is not to be administered antibiotics; however, he and other urologists know that others can conceivably develop arguments for antibiotics.  In the end, it's up to the doctors. It could also be up to the institutions under which some urologists practice.  It's debated, which is expected, as in any other practice and profession. But sometimes, doctors’ hands are indeed tied by institutions. This goes directly to your choice, the patient's choice. If you arm yourself with information and scientific data, such as the studies cited above, you can bring it to the table with your doctor, and a discussion can occur.  After all, isn’t that the essence of shared decision-making?

Dr. Allaway's passion for eliminating antibiotics for PPTAS is evident:

“I've seen some groups using Meropenem, [an antibiotic] which covers ... very resistant [and infectious] strains.....and they say...well, we'll just give the patient a dose here and there...and my feeling is that this type of antibiotic can create much harm. I just can't accept that."

I looked up Meropenem on Dr. Google and found corroboration that it indeed is one of the more potent antibiotics around with a myriad of side effects.  I'll leave it to you to investigate for yourself.  The point is, Dr. Allaway underscores the overuse of antibiotics in general.  Read this insightful piece from the Mayo Clinic:

Antibiotics: Are you misusing them?

And for good measure, read this from the CDC, which has completed statistical reports through 2021.  The overuse of antibiotics — especially taking antibiotics when they're not the correct treatment — promotes antibiotic resistance. Period.  prostat...nfo.org/40dyXUk

Given the penchant for the overuse of antibiotics in this country, Dr. Allaway (and others in the camp of supporting no antibiotic administration for PPTAS transperineal biopsies) admits that exceptions exist.  "[In an instance where a patient ] had a - what we like to call a trans-fecal biopsy - within six months of a TP biopsy, I would recommend you consider giving him an antibiotic because a study out of South Korea showed that bacteria hide in the gland after a transrectal biopsy."

New Bacterial Infection in the Prostate after Transrectal Prostate Biopsy

Dr. Allaway continued:  "...We're basically inserting bacteria into the patient's prostate that gets whisked up by the bloodstream. And so, theoretically, even if the patient has normal urine and no symptoms, if you go in [utilizing the TP technique],  it would be like poking a hornet's nest."

While he's still not 100% convinced it would be absolutely necessary to administer antibiotics for the patient example he mentions above, I understand his care for patients and the principle of proceeding with caution.  He admitted a bit of trepidation when he stopped administering antibiotics as it went against the grain of current practice.  The ensuing meta-analysis and randomized trial (links above) gave him confidence and instilled the same in other prominent urologists performing the PPTAS biopsy.

" I [hadn't been] aware of anybody that was eliminating them completely....but it's always been my kind of m.o. in practicing that if I feel strongly about what's right for the patient, I'm going to do it."

He continued to describe his practice of ensuring no contaminants were present in the area where he began to perform the PPTP biopsies.  And he set up a parameter of one year from a man's TRUS biopsy to feel comfortable enough to perform the PP without antibiotics. However, he demonstrates his keen understanding of when to make exceptions:  "If the man had sepsis after a transrectal biopsy, then I would choose to cover him [with antibiotics].  And then there are rare examples, patients who tell me they have [for instance] a fresh knee or hip replacement, and [they] express fear about [having the area subject to] infection."   He complies with the patient's wishes even though he may feel it's debatable. 

This is a doctor who cares about his patients.

He cites "99% elimination [of TRUS biopsies] in Western Maryland," where he practices. "Transrectal has gone out the window; there hasn't been a single transrectal biopsy, and [in] roughly six and a half years, we've looked at the data, and we keep track of every single patient and every single core taken from every patient.....zero hospitalizations, zero sepsis...."  He continues to cite less than 0.5% side effects such as urinary retention. And, since the inception of PPTAS, he states: "we went from, roughly 38% to now 70% [n cancer detection]."

SO…….What’s the Story with the Bowel Prep and/or Enemas?

While I did not bring this up in my conversation with Dr. Allaway, I knew from Perineologic's website that PPTAS is set up with the intention to not have the patient undergo any bowel preparation before the procedure.

As an aside, it has been my experience that this topic is not exclusive to biopsies. I remember a renowned nationally prominent Dr., who shall remain unnamed, vilifying the institution where I received my first prostate MRI.  “You should have been advised to take an enema beforehand,” I remember him saying.  He continued with words which suggested that the report from the radiologist might as well go in the trash. Since that time, I’ve known some patients who were asked to take something akin to the Fleet enema before an MRI; others not. Institutions differ.  The machines differ. Radiologists differ.  Do your homework.  Find an experienced radiologist and find out the requirements beforehand. Enema? Contrast? (for another post….)

Where the biopsy comes into play, I’ve been asked until this past (third) PPTAS biopsy to give myself an enema.  I double checked with the pre-op department several times at Brigham - “are you sure I don’t need to take an enema?” Because I remembered that four years previously, when I had an in-bore GB transperineal biopsy, I needed to give myself an enema several hours prior to my arriving at the hospital. But, for this PrecisionPoint biopsy at the same hospital, this past September, there was no such requirement. 

There are, however, doctors who, even performing the PrecisionPoint biopsy, prefer the patient take an enema pre-biopsy.  (I remember five years ago - for my first AND LAST transrectal biopsy, I was required to take an enema).  I have made some inquiries, for this article, of other doctors and I've concluded that it's pretty much up to them. It also has to do with the equipment they use. If a patient prefers to not take an enema - and the doctor agrees - than the option remains open. 

I hope this discussion around antibiotics, anesthesia, and bowel prep before undergoing a TP biopsy will give patients some guidance to make informed decisions with their doctors.  I cannot emphasize enough how these issues are bandied about in patient support forums.  And those who fervently oppose antibiotics often use that as a reason to postpone their biopsies.  But now, with PrecisionPoint, there is data which supports that there is no need for them, with exceptions, as noted.

Dr. Allaway and I segue to a discussion on his rigorous procedures of training and certifying other urologists in the use of PPTAS.

The doctor tells me: “I don't want anybody to use the product unless they [really] know how to use it. Because if you don't understand how it was engineered and how you're supposed to navigate the anatomy, you could easily perform a bad transperenial needle biopsy.....if you don't know how to get the needle in the right spot....."  He continued: "And [although] training is so expensive, [it is] important for us as a company. A doctor must be certified - signed off by me or one of our urology trainers. Our representatives are out in the field before you can buy a device....Quality is so important here. My goal is not just to sell as many devices as possible. My goal is to try to transform the technique... having it standardized so everyone gets the very best results."

Since PPTAS has hit the international prostate medical community as a near certain alternative to the TRUS biopsy, it has had its most tremendous growth in Europe.  This is not surprising, since the European Association of Urology (EAU) included in their guidelines in 2021 their recommendation of the transperineal biopsy over the transrectal.  The UK, Sweden, and more than a dozen countries have urologists trained in PPTAS.

EAU GUIDELINES 2023 

(see summary on page 36 for European guidelines on prostate biopsies)

And with headlines like this, among other studies in Europe, who could blame them?

Transperineal Prostate Biopsy Is the New Black: What Are the Next Targets?

and from the british journal of urology:

Detection of Clinically Significant Cancer in the Anterior Prostate by Transperineal Biopsy 

 

AND LET’S NOT FORGET ABOUT AUSTRALIA!

Australia dropped the reimbursement to physicians by 50% and increased payment for those performing transperineal biopsies 30%.  The movement to make the transperineal biopsy the standard in Australia was driven by patients who simply felt it was a safer biopsy.

Progress has been slower in America.  First, guidelines have not been as quick to embrace the transperineal method although there remains hope that the evidence will overwhelmingly support their inclusion in the not too distant future.  

Finally, I leave you with a podcast you’ll want to listen to. Dr. Allaway chats with Dr. David Canes about PrecisionPoint, and “his journey towards changing the paradigms of prostate cancer diagnosis.” Access it here:

https://www.backtable.com/shows/urology/podcasts/65/from-device-idea-to-market-precisionpoint-for-transperineal-prostate-biopsies

This concludes Part 2 of the Transperineal Series. The next installment will include issues around “coding” for insurance reimbursements to doctors in the US, additional thoughts and videos from Dr. Allaway.

THE TRANSPERINEAL BIOPSY: PART ONE

In an earlier post, I indicated my choice four years ago to have my confirmatory biopsy at Brigham Women's Hospital in Boston, MA. I chose to have an MRI-guided in-bore transperineal biopsy performed by an interventional radiologist.  At the time, I had read about the differences in approaches – a biopsy through the rectum as opposed to the perineum, and although I didn’t know much more than the advice given to me at the time – that it carried much less risk of infection than the transrectal approach – I made the trip to Boston.  One of the subjective readings on my first MRI contained a PI-RADS 4/5 score, and it was that reading used to target suspicious areas.  As I was also inside the MRI tube, the doctor could see images transmitted from the machine, and with those, he included a systematic sampling of the prostate during the procedure.

The results were all benign, and with some noticeable relief, I continued on a path of Active Surveillance.

Since then, I learned that transperineal biopsy had been around as early as the start of the 20th century.  See this abstract for a comprehensive examination of the TP approach and its history, published by the NIH, https://pubmed.ncbi.nlm.nih.gov/35620643/ with the complete article available at https://journals.sagepub.com/doi/10.1177/17562872221100590.  For your quick reference, the following is the conclusion:

“The modern TP PBx reflects a significant reversion to what was once the gold standard. Dating back nearly one century ago, a TP approach was first utilized to biopsy the prostate with an open perineal PBx persisting as standard for much of the 20th century. Moving forward, the TP approach evolved in efforts to maximize diagnostic accuracy and minimize morbidity. Despite these innovations, TR PBx has persisted as the dominant method since the 1980s due to the convenience and efficacy found with the use of TRUS and sextant sampling. Recently, data have accumulated indicating significant infectious concerns and some diagnostic limitations of a TR approach versus a TP approach. Furthermore, major advancements in prostate imaging, development of effective local anesthesia technique, assistive technology (i.e., TP access systems, robotic assistance), and implications in newer treatments (i.e., focal therapy) have made TP PBx more convenient, safe, and efficacious. This significant evolution over the past 100 years has facilitated the modern TP PBx’s movement into standard practice that will likely persist for years to come.”

Fast forward to an abstract published in February 2021 titled “Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis,” the conclusion of which states:

“…The transperineal approach for prostate biopsy offers superior features when compared with TRPBx and is a feasible procedure in the inpatient and outpatient setting. Multiparametric MRI offers an additional advantage to the transperineal approach. Nevertheless, prospective studies directly comparing TRPBx and TPPBx with mpMRI-targeted biopsies are needed to prove superiority of either concept.

Main Points

·       Transperineal prostate biopsy achieves comparable cancer detection rates with transrectal prostate biopsy in biopsy-naive patients but is superior in cases of prior transrectal biopsies and active surveillance.

·       Transperineal biopsy offers a superior access to the anterior and apical prostate regions.·       Infectious complications are nullified with the transperineal method.

·       Transperineal biopsy can also be performed with local anesthesia, is feasible in an outpatient setting, has a moderate learning curve and a good reproducibility.

·       Multiparametric MRI augments the function of transperineal prostate biopsy and focal therapy can be easily applied transperineally.”

Read the full abstract here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057359/

There are plenty of studies of the transperineal approach’s efficacy over the transrectal in the US and abroad.  The 2022 European Association of Urology guidelines champion its use https://uroweb.org/guidelines/prostate-cancer, although its prevalence of use in Europe has not moved the needle in the US as the preferred approach over TRUS; neither the NCCN nor the AUA has included it in their guidelines.  

TP is gaining more traction lately, especially with patients, given the amount of attention the subject receives in the prostate cancer support circles. With the invention of the Precision Point Transperineal Access System (PPTAS) by Matthew Allaway, MD of Cumberland, Maryland, and CEO of the medical device company, Perineologic, https://perineologic.com/aboutpl-2/ men have a choice, where possible, of undergoing this biopsy in an office setting with local anesthesia only, or a hospital if the patient chooses a form of sedation or general anesthesia.  And although, in certain circumstances, they might be used, the inventor intended to obviate the need for antibiotics—more on this in upcoming installments.

Similar to what lies behind many PCa screenings,  tests, and procedures, patients often hear conflicting viewpoints. The TP approach is no exception to that rule.  My main point in this series of posts on TP biopsies is to unravel some of the mysteries of why it may not be so available to many patients across the country – without some requisite travel.  I aim to inform men following the AS management protocol AND those who have just been screened or are awaiting their first PSA screening test or results from biomarkers such as the MRI (pre-biopsy).  I include the latter group because, down the line, if it comes to pass that a man's urologist gives him the results of a PSA blood draw which could very well eventually lead to a biopsy, my wish is that every one of those men knows that they might want to ask their doctors where they may avail themselves of the transperineal approach, from the get-go, reducing the amount of TRUS biopsies that have been, and still are, performed in urologists' offices.

In the following installments, I’ll discuss the parameters around having a transperineal biopsy and why it hasn’t caught on as fast as it has outside our borders.  I’ll include data from research studies to convince you why you may want to push for the transperineal approach for your next biopsy.

And finally, I have had the pleasure of speaking with several in the prostate cancer medical community, including Dr. Allaway, specifically regarding aspects of PPTAS, and Michael Gorin, MD & Associate Professor of Urology at the Icahn School of Medicine at Mount Sinai in New York, who has embraced the TP biopsy as a best practice for his patients.  You’ll want to stay tuned for more.

BREAKING NEWS: FROM THE PROTECt TRIAL: ANNOUNCED AT #EAU23 3/11/2023

Hi All,

BREAKING NEWS out of Milan, Italy, this weekend, which might be a whisper now, but is a boon for men and men's health worldwide.

LINKS TO ARTICLES ON PROTECT REPORT RELEASED THIS WEEKEND AT EAU23:

CNN: https://www.cnn.com/.../prostate-cancer.../index.html

NBC: https://www.nbcnews.com/.../study-finds-active-monitoring...

STUDY: https://www.nejm.org/doi/full/10.1056/NEJMoa2214122

It's all about #prostatecancer (PCa), the second leading cause of cancer death in American men, behind lung cancer. About one man in 41 will die of PCa. That's to be taken seriously. But, as it happens, most men diagnosed with prostate cancer do not die from it.

As readers of my blog know, I've been on what's called #ActiveSurveillance (AS) (also referred to as "active monitoring" for my low-grade prostate cancer, diagnosed precisely five years ago.) It means I currently have tumors that will neither grow nor metastasize out of the prostate gland. Annual monitoring, which includes periodic PSA testing, imaging, and a biopsy if it's called for, is my protocol to determine if any more aggressive cancer is discovered down the pike.

Active Surveillance was unheard of until a group of doctors in the 1990s courageously came forward to challenge urologists who routinely surgically removed men's prostates no matter what diagnosis was determined. A renowned oncologist, Mark Scholz, wrote a book "Invasion of the Prostate Snatchers," which detailed this practice. Twenty-five years later, the percentage of newly diagnosed men with low-risk prostate cancer choosing Active Surveillance over treatments such as surgery or radiation has risen to 60% (as of a 2021 study). While encouraging, it still begs the question: what about the other 40%?

The American Urological Association (#aua ) has Guidelines (navigate to GUIDELINES tab in this blog) for urologists, which advise their membership to recommend as "preferred" AS for patients with low-risk or what's known as Gleason 6 tumors. For intermediate favorable risk- which involves slightly higher grading, their "preferred" extends to all three: Active Surveillance, Radiation, or Surgery.

I'm sure the Guidelines will be revised, but it is not a legal document, and urologists are free to tell patients whatever they want. As a patient and patient advocate with my blog, I aim to inform patients of facts based on data and science. I do not provide medical advice, only information so patients can make informed choices. Another issue is that of "shared decision-making" with doctors. Some men (and women) prefer to listen to their doctor, trusting 100% in their recommendations. However, more are researching (preferably being discerning with Dr. Google!) Therefore, I have selected the information outlets as my go-to for facts only. But back to my point - you, the patient, are the only one who makes a choice. And it should be based on discussions with doctors and getting second opinions after doing your research. That's the essence of shared decision-making, at least for me. I have been invited to make a presentation at the AUA conference in Chicago at the end of April. I'm looking forward to it!

Why am I so passionate about this?

Because many men in America are either not aware of prostate issues until they are older and are uninformed about data and science, or others talk to friends or colleagues or read stories in the media about persons "cured" of cancer. Some celebrities and sports figures often announce their PCa in the media just as they announce they have a great doctor, are undergoing treatment, and will be back on the job soon! Sadly, these men or their spokespeople don't give the public the whole story -- re their diagnosis, thus leaving the reader or viewer with the impression that "surgery" is the only "cure" for PCa. This is false and misleading. First, there is no cure for cancer; unfortunately, the word is bandied about with even supporting cancer-related organizations. The correct terminology is NED or "no evidence of disease." This can last for the rest of one's life or a short while until an unfortunate recurrence. But, again, there is no cure. However, I'll give a little rope to people who still want to use the word.

Men must become AWARE - even at young ages, of prostate issues and what prostate cancer entails.  Right now, screening procedures vary - there is debate within the PCA community as to where the lines are drawn - some recommending as early as 40 yo, beginning with what I call  the "check engine lights" of the PSA and accompanying 4-K blood test (screenings can be a chapter in a book!) However, I know of several cases where prostate cancer tragically hit much younger men, such as the son of a dear friend.  It was also discovered in a 35-year-old man who had spent all his years previously eating junk food and suffering from mental distress while maintaining a high-profile job.  He, fortunately, was diagnosed with low-grade cancer, so he, as well, is on AS with a healthy, nutritional, and exercise lifestyle.  He's also become a big advocate in the PCa world.  Anyone wanting the URL for his advocacy organization, let me know.  And there are support groups; the only issue is a myriad of problematic conflicts of interest, which I won't get into here.

Suffice it to say; I am for the patient.  Period. I am also for educating men who may know peripherally about prostate issues but need to pay attention.  Some eat unhealthily; some are overweight; others don't seek to be informed. Unfortunately, I can't do anything about the latter - it takes someone who wants to be proactive with their health.

This study moves the needle and helps those of us who want to help men and newly diagnosed patients sort through the scientific terminology, ratios, and percentages to the bottom line. The good news is that the curve of reliable information is rising!

So, if you're a man out there (or know someone else) and a doctor gives you a #prostatecancer diagnosis, and you become anxious or depressed, know that it is not a death sentence by any stretch of the imagination.  If you're tempted to tell your doctor to "get it out" (your prostate), fuggedaboutit  (as it said in the Bronx in my current hometown of New York City) before you've done your research ), again, not medical advice, just a suggestion.

Please do your research, have someone do it for you, or contact me.  If there's something I cannot help you with, I have a vast network.  Hopefully, one day I can get on the airwaves and spread the message with a medical team supporting me with their MEDICAL advice.

Be well, and stay healthy and happy!  And if you’re a first-timer, please scroll below and SUBSCRIBE!

Stacy Loeb, MD | Prostate Cancer Podcast

Dr. Stacy Loeb (@LoebStacy on Twitter) hosted a Podcast “The Prostate Health Show” which aired @SIRIUSXM's Doctor Radio Channel. Click on the program information here: https://www.pcf.org/c/prostate-health-radio-series/

Dr. Loeb presented the latest news and science of prostate health, from the very basic (where the prostate is) to the complex (the latest research on treatments for advanced prostate cancer).

Dr. Peter Pinto discussed many facets of prostate biopsies and Dr. Matthew Cooperberg discussed Active Surveillance as an approach to #prostatecancer. Learn more about Dr. Stacy Loeb at https://stacyloeb.com , Dr. Peter Pinto at https://grandroundsinurology.com/author/ppinto/ and Dr. Matthew Cooperberg at https://profiles.ucsf.edu/matthew.cooperberg.

For anyone who missed the podcast, the show replays a few times later in the week and is also available on demand through the siriusXM app for listeners to enjoy at their leisure.

IN BETWEEN POSTS:

i Hope that all of you enjoyed your Thanksgiving and wish you all good health throughout the holiday season! - AND BEYOND!

Never become so much of an expert that you stop gaining expertise. View life as a continuous learning experience – Denis Waitley, Author, and Motivational Speaker

As a patient on Active Surveillance, I have found disparate opinions in the prostate cancer medical community, from screenings and biomarkers to Gleason scores to protocols and everything in between. I have seen other patients in quandaries as well.

I have often been frustrated by the amount of contradictory information I have received and the differences in "best practices," so I am motivated to stay on top of the latest clinical research and studies. I include, but don't limit myself to, seeking and reviewing expert opinions from doctors and specialists who adopt their best practices in caring for their patients. If you're a discerning researcher, you'll use Google and other reference vehicles to your advantage in choosing your sources wisely. I recommend seeking out studies and articles from the NIH, often corresponding to trials conducted (go to clinicaltrials.gov), and reports from centers of excellence such as Johns Hopkins, Brigham, Cleveland Clinic, Mayo Clinic, and several others.  And then there is the data from outside the U.S. – Europe, and other continents.   You may often find videos on YouTube containing interviews and presentations. You can find these videos featuring your targeted doctor or specialist. If you're on Active Surveillance, there is no shortage of information zeroing in on particular aspects of AS protocols.

Support groups - virtual and in-person - remain a comfortable and safe format for many – places to exchange ideas and gain information – as long as you verify facts afterward. Support groups come in many forms.  Frequently, however, facts and opinions in patients' posts in forums - especially, for instance, on Facebook, can have the effect of confusing the reader.  Any support platform usually contains disclaimers regarding offering medical advice - as I often do in reminding readers not to take what I offer here as medical advice, as I am not qualified to do so.  That said, you may hear a "disclaimer," but what follows is someone who gives you medical advice. It can be tricky.

After my initial diagnosis of prostate cancer in April 2018 (two Gleason 6 cores),  I was determined to do my research,  approaching those I thought would offer me educated opinions. Initially, they were from New York University to Weill Cornell, Memorial Sloan Kettering to Johns Hopkins, and Brigham and Women's Hospital (which collaborates with the Dana Farber Cancer Institute). Now, almost five years later, I know of more resources across the country.

What I’ve written above is all a preamble to how I gradually gravitated towards patient advocacy as a Board Director of the 501c3 Active Surveillance Patients International and volunteer for CancerABCs.  I have attended virtual webinars and conferences (some in-person), read dozens of abstracts, watched videos, and kept on top of news alerts from medical and scientific sources.  As a peer reviewer for the American Urological Association Prostate Cancer guidelines in April 2022,  I learned what the doctors and specialists refer to when wanting to update themselves on specific management recommendations and preferences.  In other words, I’ve immersed myself in research; however, I would never call myself an expert; there will always be a learning curve, especially when some research leads to different opinions.

I have found that many patients do not avail themselves of opportunities to research their particular diagnosis and determine the next steps.   Understandably, it is a daunting task, especially if you want to live your life either with your family, work, hobbies, or other interests.  Self-advocacy is not easy; it was not for me in the several months following my diagnosis.  Consulting an advocate during that period helped me organize everything I needed to do with doctors' appointments, lists of questions, understanding my medical records, and more. 

As these almost five years have gone by,  men (and their caretakers) began contacting me as a source for where to obtain the latest information and, most importantly, how to glean from that data what they needed to know to make informed decisions.  As I often state, one size doesn't fit all.

Due to this increase in volunteering my time to patients who sometimes faced immediate choices, I decided to hit the books and discover the nuances of patient advocacy.

Since my last blog post, I studied for, and passed, a 125-question core competency exam administered by the PATIENT ADVOCACY CERTIFICATION BOARD (PACB) to achieve certification for my patient advocacy. Here are the requirements for achieving certification (from the PACB website):

“The Domains of Patient Advocacy:

1. Scope of Practice and Transparency

2. Empowerment, Autonomy, Rights, and Equity

3. Communication and Interpersonal Relationships

4. Healthcare Access, Finance, and Management

5. Medical Knowledge and the Healthcare System

6. Professionalism, Professional Development, and Practice”

“Patient Advocates will:

1. Provide to potential clients clear, accurate, and complete information about training, education, experience, credentials, and limitations, as well as any possible fees and areas of potential conflict of interest;

2. Inform clients about the limits of their scope of practice and advise clients strictly within their defined area of proficiency;

3. Develop clear and achievable expectations with the client to encourage a strong working relationship and productive advocacy;

4. Obtain, maintain, and protect the privacy of any and all medical records required to serve the client’s needs, sharing them with the client and anyone designated by the client;

5. Abide by all relevant laws and regulations related to confidentiality of medical and identity information including, but not limited to, HIPAA;

6. Avoid making any decision for, or on behalf of, a client;

7. Avoid diagnosing or prescribing any medical/mental health treatment for clients, even if the advocate has additional licensure or training;

8. Refer clients to qualified alternate professionals if a client’s needs are outside the scope of the advocate’s knowledge or training;

9. Adhere at all times to the Ethical Standards defined by the Patient Advocate Certification Board (PACB);

10. Provide a written service agreement to each guarantor and client, both paid and pro bono, that clearly sets forth the nature and scope of services, fee schedule, terms, projected length of the relationship, and the criteria for appropriate termination of the relationship.”

I have posted this not only as an achievement but also to inform patients who may have engaged or are thinking about engaging a Patient Advocate to understand the Patient Advocate’s protocol.

During this period between blog posts, I also attended Cancer ABCs in-person conference in Florida in early November 2022 and found it an extraordinarily valuable experience. While volunteering as an “Active Surveillance specialist,” I also attended breakout sessions on treatment decisions and other subjects and mingled with patients and presenters across the spectrum. I’ve attended only one other in-person conference, and that was before Covid hit. The Fall 2019 PCRI (Prostate Cancer Research Institute) conference was my first in-person event. It was a valuable tool in moving the needle in my education on PCa.

As a patient advocate, I aim to contribute to patients’ knowledge, empower them in their journeys, and help them navigate the healthcare system. As for me, I plan to continue to serve patients who have been diagnosed with prostate cancer and their families and caretakers. My focus includes helping those with rising PSAs (who have not undergone biopsies) during the shared decision-making process with doctors.  In addition, I listen to newly diagnosed patients who are either considering or already on the management protocol of Active Surveillance.  Many need assistance with or are in the process of analyzing and decision-making regarding their tests, procedures, reports, and protocols.   I hope I can assist them in deciding what (and how) to compose questions to doctors and specialists and how to follow up when they still don’t understand something.

At this writing, I am still exploring how best I can help others.

WEIGHING IN ON THE GLEASON DEBATE…

In this post, I am addressing those of you who have been diagnosed with low-risk PCa (Gleason 3+3 (6) tumors who may have come upon a debate in the PCa medical community around the classification of Gleason 6 [1] as cancer. This debate has been ongoing for more than a decade.

I hadn’t planned to broach this ongoing debate if it were not for AS patients becoming aware, through support groups and surveys, of this discussion among doctors and specialists.

Some History

Know that, for those of you not particularly attuned to PCa in the 1990s and before, it was the norm for urologists to recommend, or patients to request, a radical prostatectomy, even with the lowest Gleason grade – upon hearing the "c" word, they just wanted it out. In the late 1990s, we know that doctors Klotz, Carter, Carroll, and Holloway, among others (please, no letters if I left anyone out!), were instrumental, either on their own or in sync with each other, in introducing the concept of Active Surveillance as an alternative to overtreatment of Gleason 6 diagnoses – mostly, removal of prostates.

Authors Mark Scholz, M.D. and patient Ralph H, Blum illuminated the push to eradicate these over treatments, or surgeries, in the MUST-READ book Invasion of the Prostate Snatchers.

“An indispensable map through the medical minefield of prostate cancer revised and updated with the latest developments in treatment options.” Make it stand out

Every year almost a quarter of a million confused and frightened American men are tossed into a prostate cancer cauldron stirred by salespeople representing a multibillion-dollar industry. Patients are too often rushed into a radical prostatectomy, a major operation that rarely prolongs life and more than half the time leaves them impotent. Invasion of the Prostate Snatchers argues that close monitoring—active surveillance rather than surgery or radiation—should be the initial treatment approach for many men at the low- and intermediate-risk stages.”

Fast forwarding to today, those newly diagnosed with PCa are now in the 60 percentile of choosing AS over treatment (it is purportedly 80% in Sweden and 90% in Michigan).  As a patient, advocate, and activist for AS patients, I know that some doctors continue to recommend treatment (when the pathology points to low to favorable intermediate risk), often in the form of surgery – playing upon patients’ fears. We continue to hope that these doctors will become relics of the past.

And as a doctor recently remarked, it's all well and good that Active Surveillance is on the rise. However, he pointed out the stark reality that 40% of those diagnosed either choose not to pursue AS or, by being diagnosed with higher-grade cancer, must choose treatment from the outset. And, again, it’s still a daunting task to prevent some remaining percentage of newly diagnosed men with low-risk grade tumors from opting for or being led to overtreatment.

The American Urological Association made a slight course correction this past May 2022 in recommending to MDs to counsel patients diagnosed with "low to intermediate favorable risk" PCa to consider Active Surveillance as a first option instead of any treatments (Navigate to "Guidelines" in the Menu)  A game changer? Perhaps.  But, one can argue that doctors don't need to follow those guidelines. Comprende?

So, why, you may be thinking, am I bringing this Gleason 6 reclassification debate up in the first place? Why should you, as a patient who may already have been diagnosed with cancer with the lowest Gleason score possible – indolent and not likely to metastasize – be interested in an argument about re-classifying Gleason 6 to a non-cancer or one of several proposed labels floating out there?

Patients are becoming aware of the debate through support groups and online forums. Many — who may not be in on the history of the Gleason score or paying attention to reasoned arguments for and against reclassification (which I’ve provided below) —- are now being asked for their feelings and opinions on the matter. I, as another patient, don’t understand what my opinion would be used for, or why it would matter. If I had been told in 2018 that I had some pre-cancerous biopsy cores, I wonder how certain procedures in Active Surveillance’s monitoring costs would be covered by my health insurance. Would health insurers cover biomarker tests such as MRIs, or even genomic tests, to name a few?

Frankly, I’d love to hear more from those patients who have their opinions and feelings on various other topics, some of which I talk to men about daily - ranging from confusing and conflicting protocols to “does BPH equal cancer?”; “why should I consult with an oncologist?” to “is this new machine called a MicroUltrasound going to replace the MRI?”; or “should I be getting a biopsy every two years or five years - and is a systematic biopsy the same as a random?”; or, “why isn’t my health insurance covering…?” [this or that].

Again, what do you, the patient, care about the most?

Is it cancer or a non-cancer? [“Is she your sister or your daughter” (visual: Jack Nicholson slapping Faye Dunaway for those old enough to have seen Chinatown.)]

I have spoken with - and continue to ask - those in the Prostate Cancer medical community their thoughts on the matter. I have also read various reporters’ interviews of doctors on both sides - some of whom are PCa “familiar” names - Laurence Klotz, Peter Carroll, and William Catalona, among others. I believe the unanswered question is: how do doctors frame their patients’ diagnoses to them? Do they use the “c” word with the same severity in talking about Gleason 6s as they do with Gleason 8s or 9s? Or, heaven forbid, metastatic disease? How can doctors play a role in managing their patients’ anxieties and fears with ANY diagnoses? A welcome addition to guidelines, in my opinion, would be an addendum that would instruct providers to carefully explain in layman’s language, which patients can easily understand, the nature of their Gleason scores, whether they be Gleason 6, 7, 8, or 9. Grade 1- that it does NOT metastasize and that diligent monitoring on Active Surveillance for such a low-risk diagnosis is considered a preferred management protocol; Grade 4 - that needs attention - more likely than not - soon.

Please give them the science and proven statistics. Why scare them, or say something you know creates fear? Because it’s a great motivator? What, to live? Gimme a break. I’m not positing that MDs need to play shrinks when they don't specifically have that training, but how about learning some plain old-fashioned communication skills which give patients the truth to make informed decisions without projecting what they think on their patients? I sure as hell didn’t appreciate my mom’s doctor over ten tears ago giving her an exact date by which she’d be dead. She ended up living several months past that and enjoyed life one day at a time. Folks, that’s how it goes.

I encourage patients to read as much as possible to be fully informed about this discussion. One size does not fit all - meaning that one person’s diagnosis at, let’s say, a young age may not equal that of someone older. Or other factors may come into play, such as family history, genetic testing (if recommended), race (percentages of African American men who might be at higher risk for PCa than others), and so on. Stay informed, and ask questions. Because I still do!

Here are some resources which may enlighten you on this debate. I selected them from a variety of articles and studies - feel free to seek others. I hope, though, that these will begin to adequately represent both sides of the issue.

Click on this link to read a 2012 study with former Johns Hopkins MD Ballantine Carter weighing in as an author. Laurence Klotz and Jonathan Epstein also opined on opposite sides of the aisle in 2013:

More recently, in this past year, arguments for and against reclassification:

Low-Grade Prostate Cancer: Time to Stop Calling It Cancer

v.

Renaming Gleason Score 6 Prostate to Noncancer: A Flawed Idea Scientifically and for Patient Care

Last month, I communicated with a pathologist about some verbiage put out to some AS patients: “those who say it should be called cancer reference that Gleason 6 cancer can become Gleason 7 or higher in some cases….” This statement struck me as a bit misleading - we’ve known for a while that if you have a Gleason 6 tumor, that tumor will not grow nor metastasize. AS has always been about monitoring for more aggressive cancers if suspicious lesions appear in a regularly scheduled MRI and cancer is ultimately found in subsequent biopsies. Gleason 6s don’t suddenly morph into 7s or higher; yes, there is a small percentage of Gleason 6 scores misclassified. But that’s why you get second, even third opinions.

The pathologist who I referenced above sent me the following note:

“That statement [Gleason 6 cancer can become Gleason 7} is poorly phrased from the pathology point of view. When you biopsy a lesion, only [a] small proportion of it is sampled; it may or may not represent the entire grade. After prostatectomy, when the entire tumor is out, we see everything, and that’s why we may see higher grade tumor that was not sampled on biopsy.”

I think Dan Sperling in Florida puts it best on his website. Citing various studies, he writes: “….. it becomes obvious that conclusive evidence as to whether Gleason 3+3 cancer behaves like cancer is not yet to be had.”

Even though AUA guidelines call for Active Surveillance to be preferred for low and intermediately favorable cancer, as I discussed above, there remain urologists - many, though not all, in small practices in rural communities who convey ambivalence or straight out advise patients that if they don’t want to think about it, they can have their prostate removed. Again, as I said above, much of the debate lies in how the diagnosis is currently communicated to the patient and how even the mention of the “c” word can cause instant anxiety when one is facing a low-risk, Grade 1 diagnosis, which is easily monitored with AS and a change in nutritional and exercise lifestyle.

One of the concerns voiced by those who maintain that Gleason 6 has all the hallmarks of cancer (for the reasons you can listen to and read about) is that men will tend not to monitor themselves, perhaps risking aggressive cancers later on, which would have been identified if some surveillance were in place. This is a question that indeed needs to be discussed.

Please watch for any developments on this matter.

In the end, my goal always is to be on the patient's side and to give you the data to make informed decisions. So now you have links to the debate arguments if you want to ponder the question if faced with it.  “In case of dissension, never dare to judge till you've heard the other side.”
― Euripides.

Until next time,

Stay well, eat healthily, and don't forget to exercise!

Glossary:

[1] Gleason 6  “The definition and clinical relevance of Gleason 6 prostate cancer have changed substantially since its introduction nearly 50 years ago. A high proportion of screen-detected cancers are Gleason 6, and the metastatic potential is negligible. Dramatically reducing the diagnosis and treatment of Gleason 6 disease is likely to have a favorable impact on the net benefit of prostate cancer screening.”

https://www.auajournals.org/doi/10.1016/j.juro.2015.01.126

Coming soon:  the latest on transperineal biopsies!

To poke or not to poke, or rather, where to poke, that is THE question.

Martin Gewirtz, BCPA

Being Alive

“In three words I can sum up everything I’ve learned about life: it goes on.”

― Robert Frost

As I continue on my life journey and meet or talk with other prostate cancer patients, including those who’ve been newly diagnosed, I remind myself of how grateful I am that, to date, I have low-grade PCa, and am on an AS protocol. While anxiety creeps in when I’m awaiting the results of an MRI or biopsy, I wake up in the morning increasingly focused on how I can be creative and make the most of my day. I am keenly aware of men with more aggressive cancer who juggle treatments with different outcomes.

For now, I find fulfillment in listening to newly diagnosed and AS patient stories and questions, keeping up with the latest studies, and discovering new research outlets. And again, while I do not dispense medical advice, I concentrate on how I can provide reliable resources to men who may just need a guide that will empower them to make decisions with their doctors and specialists.

And, at the risk of repeating myself with statements from other posts, I always encourage patients to seek out second or even third opinions (should they need to break a tie!) if the decision involves a test or procedure. And I try to remember to impart a mantra that:

Being Alive, one day at a time, is a gift.

I do have some good news to report. At the end of my last Blog (#2), I spoke of my plan to have a transperineal biopsy at Brigham Women's Faulkner Hospital in Boston. Through contact I made with Adam Kibel, MD, Chief of Urology at Brigham, he referred me to Brigham urologist James Rosoff, MD. I had my confirming TP MRI-guided in-bore biopsy at Brigham four years ago, reporting nine benign samples – after which I could officially continue my AS.   This time, I could have repeated an in-bore transperineal biopsy (inside the MRI tube). The in-bore technique has long been a gold standard as the medical specialist can see any suspicious areas the MRI picks up. However, my urologist does not perform in-bore biopsies but would have been happy for me to revisit with an interventional radiologist who had conducted my confirming biopsy four years earlier

I double-checked with Dr. Kemal Tuncali at Brigham, who elaborated on elements of the in-bore biopsy. However, he didn't have the newest transperineal equipment – the Precision Point System.  (<---recommended reading).  Given what I knew about Precision Point – specifically that other centers such as Johns Hopkins uses the system - I decided to go with a TP MR-Guided/fusion biopsy this go-around. Again, I had an MRI report graded Pirads-4 with a "stable" lesion. In a telehealth appointment, my doctor and I discussed what he would target and explained the fusion process at length. While I could have had the biopsy in his office with a local anesthetic, I chose to have a general anesthetic which moved my procedure to the hospital. A quick note about general anesthesia: one doctor on my team advised me of recent studies that general anesthesia carries a risk for older adults in memory loss. I looked up several studies – you can read one here – and I found that they were inconclusive. Everything with Prostate Cancer carries risk. Put that in your file. I have found that I have had to make many decisions based on risk assessment. They include uses of gadolinium contrast for imaging, the antibiotic ciprofloxacin,  and risks of infection in transrectal vs. transperineal biopsies. Only with the latter issue is definitive science that backs up the claim that transperineal biopsies are less riskier for infection or sepsis. Although I cited it in my last Blog, read this article by Jeremy Grummet and others as to why transperineal biopsies are now considered the standard over TRUS biopsies. There is an effort to lobby the American Urological Association to add it to their guidelines in 2023. Arvin George, MD, in Michigan, is an excellent source of information about transperineal biopsies, as well as Michael Gorin, MD, and Australian Jeremy Grummet, MD(among others). Look for my Transperineal Analysis soon, including interviews with expert knowledge of the procedure.

Did I say that I consider Brigham a significant center of excellence among several throughout the US? If I didn’t, let me iterate it now. They have a stellar staff and are thorough in gathering pertinent patient information and informing patients of prerequisites before a biopsy.

THE RESULTS ARE IN…!

The pathology report arrived less than a week after my procedure, and I reviewed the results with Dr. Rosoff. The lab analyzed the samples the doctor had taken: all benign with three Gleason Grade 6s  (3+3), which allowed me back on the yellow brick road of Active Surveillance and my monitoring protocol. 

I felt relieved that pathologists did not find any aggressive tumors. It is a familiar feeling among all patients on the AS protocol when pathology results do not change their status of harboring low or intermediate favorable risk PCa.

MOVING RIGHT ALONG ….BIOMARKERS & SCREENING

(This section is for those on Active Surveillance, the newly diagnosed, and for those men who have not yet begun screening for Prostate Cancer , so PLEASE SHARE and copy and paste the link for your friends or loved ones: https://www.ASProstateCancer.blog

For those who wish to know – before you screen for Prostate Cancer – there are standard initial screening procedures. They include what age men should begin the screening process, and these guidelines are available from centers of excellence and scientific studies. Watch this short video from the CDC.  Although it is a bit dated, it contains some good information - below I update the numbers for you. You’ll also see below a second reference on screening recommendations from Johns Hopkins.

Since this CDC video, many in the prostate cancer medical community are recommending screening at earlier ages, especially for men with family history or positive genetic test results, and African American men. It is also a fact that, although it is rare, there are men as young as 35 (and perhaps younger) who begin to develop issues with their prostate.

I have previously emphasized the importance of shared decision-making (SDM) among patients, doctors, and caregivers. SDM begins at screening, and the following link is from the annual AUA meeting in 2022, surveying disparities in the shared decision-making process.

It's an excellent informative article for your research toolbox.

https://www.urotoday.com/conference-highlights/2022-annual-meeting/aua-2022-prostate-cancer/137136-aua-2022-disparities-regarding-shared-decision-making-in-prostate-cancer-screening.html

Again, while I do not provide medical advice, first questions about PCa screening are usually discussed with a urologist you trust. If you do not have one, you may want to ask your primary care provider and seek out a couple of other recommendations in your community. You can always have a consultation with one and get a second opinion from another. Suppose you belong to one medical center where all the medical staff knows each other. In that case, you may want to consider finding your second opinion from outside that medical enclave. Although this is not absolute, doctors and specialists affiliated with one practice tend to stick together and not contradict their colleagues. 

LET'S TOUCH UPON THE PSA, DRE, AND 4-K BLOOD TEST

After eight years of experience with the PSA test, attending countless webinars with medical "experts" and leaders of support groups, here is what I have gleaned from many points of view.

PSA is a check engine light. It's the first in a series of screening tools that can – WITH OTHER SCREENING TOOLS -  give you an indication of whether or not you should proceed with further tests – BEFORE considering a biopsy. There are multiple reasons which have nothing to do with prostate cancer for a PSA number to fluctuate or spike. For this reason,  the PSA test is never directly linked to a prostate cancer diagnosis. Only a biopsy can do that. Again, and it bears repeating, a high PSA, as a sole check-engine light, does not equal Prostate Cancer. Remember that if anyone suggests otherwise.

Some reasons for a false PSA reading include, but are not limited to the following:

Many men do not know (or are never advised) to refrain from ejaculation for up to 48 hours before having a PSA test, nor do they know to refrain from bike riding or unusual physical exertion for the same period. See this simple review, which provides for other conditions that could affect one's PSA numbers.

Again, while some guidelines call for screening to begin at age 55, other factors could lower that number significantly to age 40 and even before. (When to start screening is a hot oft-debated topic in the PCa world so expect changes). Several conditions can affect the PSA number: family history, genetic testing, ethnicity, and other ailments around your prostate (i.e., enlarged glands, prostatitis, and BPH). Certain medications, as well, can affect the PSA number, and this factor, as well, should be discussed with your doctor(s).

Currently, as of this writing, I have an enlarged prostate of around 80cc. Given this fact, when I monitor my PSA every six months, my doctor and I consider my enlarged gland if I obtain a high PSA reading. The PSA density test then comes in handy, and it is a calculation with which you should be familiar, although, as you will read here, guidelines do not commonly include it in guidelines.   Read more here.  

THE 4K BLOOD TEST

The 4K test has been a source of confusion for some. Only those who have not been diagnosed with PCa are eligible for this test (if you've had a biopsy, the results would have had to be benign). However, the company that manufactures the test has not conducted the requisite research or trials to have any predictive value for those diagnosed with PCa, even with low risk.

It is an excellent test (and hopefully, your insurance will pay for it) to have as a comparison to your PSA score. Some urologists do not mention this test, so should you be in the position of NOT being diagnosed with PCa and you're just in the middle of a screening process, surprise your doctor and ask for the test if he doesn't suggest it to you. A low score on this test and a low PSA reduce the risk of a false negative result on the latter. Click here for test details and read this STUDY from the NIH, which supports its use as a biomarker.

- From The National Cancer Institute

The Digital Rectal Exam (DRE)

A urologist usually performs the DRE; however, a primary care physician during an annual physical can do the same. The doc can tell from this exam whether you have an enlarged prostate gland, and they will also be able to know if there could be any abnormal growths. It's another check engine light to accompany the PSA test when considering what, if anything, you may need to investigate further whether you should consider additional testing.

HOLD ON ….THERE’S ANOTHER TEST YOU MAY WANT TO CONSIDER WITH YOUR DR

THE SELECT DMX TEST

(Click above for link to MDXHealth)

The National Comprehensive Cancer Network (NCCN) in its latest guidelines, has approved this test as a biomarker which can be used along with blood tests as another check engine light which might lead you to, again, talk to your doctor about additional testing for Prostate Cancer which may include a 3T-MRI and/or prostate biopsy.

Excerpted from the NCCN Guidelines

Download a full PDF of NCCN’s guidelines.

I want to make it clear that the American Urological Association, in its 2022 guidelines, stops short of recommending an MRI before a biopsy (mentioned in earlier blogs only for risk stratification.) It may not preclude a confirming biopsy within the next year, but the disparity in opinions about an MRI following a PSA is unhelpful for the patient. It is why some urologists do not suggest an MRI for men who present rising PSAs. They tend to go straight for a biopsy. I'll add more about this in upcoming blog posts since patients question why doctors recommend an MRI after a patient's biopsy and a possible diagnosis. Or, to put it another way, why couldn't their FIRST procedure be an MRI-guided biopsy?

"Clinical use of the SelectMDx urinary-biomarker test with or without mpMRI in prostate cancer diagnosis: a prospective, multicenter study in biopsy-naïve men." -

Read this May 21 study here.

I've endeavored to lay out a "starter kit," if you will, for what one can do before ever considering having their first biopsy: PSA - DRE - 4K Blood Test - Select DMX. At the time of this writing, I am omitting information about the ExoDx test, as I’m in the midst of researching its efficacy - and use by urologists or specialists - as a biomarker. Stay tuned. These screening tests are essential information to share with friends who have fortunately not been diagnosed with any prostate cancer grade. And, again, work with your doctor. And do your research. You'll be better off succeeding with your shared decision-making process.  

—————

Finally, I would like to conclude with my assessment (and my opinion only) of the Prostate Cancer medical community. For certain, there are excellent and competent doctors and specialists across the board, and across this country. Many work tirelessly on behalf of their patients. And there are those, like in many other professions, who may not make the grade insofar as being attuned to the latest studies or guidelines, or may have affiliations with companies - manufacturers of equipment or pharmaceutical companies - which hopefully they disclose. You’ll find them across the board and this country as well, including those who work in locations far away from metropolitan areas or major centers of excellence. Ergo, even though there are guidelines from both the NCCN and AUA (and some of these guidelines, in my opinion, don’t go far enough in keeping up with new developments in the field) doctors will disagree with doctors, or other specialists. It’s the nature of the Prostate Cancer medical community. So, again, as a patient, make sure you’re informed, and that you be discerning when you come upon contradictory information and opinions. As the saying goes:

TRUST BUT VERIFY

I have planned some extra special posts coming up: Healthcare and Health Insurance; (Reminder: the October 15 open enrollment date for Medicare and the ACA (for both Federal assistance and individual state plans) is fast approaching; clearing up questions and confusion about the Transperineal Biopsy; an overview of the nature of support groups; “Your Prostate and Nutrition and Exercise”, and separating out facts from fiction - straight medical news reporting and editorial articles and posts in social media. Healthcare and Insurance play a prominent role in many patients’ lives - I’ll offer a guide to navigating a complex system; many patients who may need to face confirming biopsies or for those following a protocol of having biopsies every 2-5 years have questions with the emerging support for Transperineal biopsies; Support groups are essential to one’s education on Prostate Cancer, and saying that, there are many. You want to be heard, and you want to hear facts. The subject of nutrition, diets, what foods to avoid and what’s best to consume, including supplements, are becoming forefront in discussions, as well as exercise. And let’s discuss “news” vs. “opinions” and, to paraphrase the New York Times: “everything that’s fit to know.”

And, again, I’m a patient, not a doctor nor a scientist. But you can count on me on where and how you can source the best information for your particular situation.

If you haven’t already, please SUBSCRIBE. Simply scroll down to the very end of the blog page to the subscription field in the slightly grey footer section. And feel free to email me with any questions, insights, or even feedback on what I write.

Martin Gewirtz, BCPA

WE INTERRUPT THIS BLOG TO BRING YOU …

I had planned to move on to what I consider essential subject matter relevant to AS, but I interrupted that plan to bring you some news of my own.

If you read my first blog post, I ended with the decision to go on Active Surveillance after my confirmatory biopsy, which yielded nine benign samples, including those targeted by a Pirads 4/5 interpretation of an MRI I had had that year. My AS protocol consisted of PSA tests every six months, annual MRIS, a Color Doppler (1) (see glossary of terms at the bottom) thrown in. and embracing a whole food plant based diet. I cut out meat, dairy, and eggs, and I buy organic produce when I can. I have researched various nutritional regimes - most notably the Hippocrates and Gerson (2) protocols. I attended the Optimum Health Institute in San Diego where, for three weeks, a schedule consisted of tasty raw food meals, intermittent juice fasts, many classes, wheatgrass, and more. Look for my entry on nutrition soon. At the moment, the ptrostate cancer medical community embraces a “heart healthy” Mediterranean diet for cancer patients although recently there has been activity from doctors encouraging patients to explore plant-based diets. My go-to is Dr. Greger nutritionfacts.org. For now, before tomatoes disappear from farmers markets since we’re close to end of season, make your own tomato sauce and soak up that lycopene!

My Farmer’s Market

My farmer’s market at the Union Square Greenmarket in NYC operates year-round, but when summer comes, I know I get the great stuff: heirloom tomatoes, fresh organic basil for a vegan pesto, excellent prostate friendly cruciferous vegetables such as cauliflower and broccoli. Instead of pasta, I’ll by yellow and green squash and put it through my spiralizer to have it as spaghetti! Amazingly delicious, healthy, and none of the carbs of regular pasta.

Throw in nutrient rich mushrooms and top the dish with your own marinara sauce or pesto!

Farmer’s market prices are usually higher than supermarket prices; the tradeoff is that you know you’re getting produce freshly harvested!

Back to My News

While I am in charge of my own AS, I should emphasize that I currently have a small team of doctors and specialists who help me monitor my AS on PCa. and my attendant BPH issues. 

So it came to pass in August 2022, my annual MRI results were the same as the previous two years, with a small lesion, though this latest report added the word "stable" as it was comparing it to my earlier imaging. However, because I had chosen to have a form of Gadolinium contrast, (3) the MRI was graded a Pirads 4. There was some disagreement on my team as to whether I should follow up with a biopsy. Again, I remind you, the reader, that we, the patients, make the choice – considering shared decision-making and research. Often, the decisions come down to risk assessment, and after I weighed the risks (and benefits), my need for peace of mind was the big decider. Weighing the pros and cons of disparate suggestions among prostate cancer specialists, I chose to go with guidelines from the American Urological Association (4), which recommend a biopsy every 2-5 years for men on AS, no matter the results of an MRI - NOT mandated as part of the AS protocol.   The revised AUA guidelines (see Guidelines in the navigation bar) recognize the importance of MRIs in "risk stratification." The AUA, however, does not recommend MRIs when determining whether or not to biopsy. Many men on AS opt for the MRI to determine if they should go for an MRI-guided biopsy. After all, who loves getting poked with needles? I certainly don't! And for the last several years, I accepted the advice of one doctor who felt it unnecessary, with my MRI results, to go for a biopsy. However, there was something different this time – and I had also just engaged a new PCa urological specialist who definitely follows the AUA guidelines. This choice can be a dilemma for men – mainly when their medical team disagrees. Ergo, my research studies came in handy.

The type of biopsy I would have was now forefront. I chose the same transperineal approach that I had four years ago. For me, that was a no-brainer. And although the AUA has not changed its guidelines from recommending the transperineal approach over transrectal – the Association is getting a good deal of feedback to consider a change. So look for next year to see what they might consider. I will also be writing a blog about transperineal vs. transrectal biopsies soon.

However, the question now was whether to have an MRI-guided biopsy only, based on the one lesion on the report or to have a combination MRI-guided fusion/systematic biopsy. (5) Several recent studies point to the efficacy of having a combination biopsy over solely one that is MRI-guided.

Another PCa issue. Still pretty inconclusive. However, Johns Hopkins in Baltimore, MD, which has a large cohort of men on Active Surveillance, has a protocol of mandating a combination MRI-guided/systematic biopsy for every patient every TWO years. I learned of this a couple of weeks ago, in a conversation with someone in the cohort for awhile - and before Ballantine Carter, MD left. If this changes or already has changed, I’ll certainly update the numbers.

I again wanted to have my biopsy at Brigham Women's in Boston., although I live in New York. However, I needed to make one more decision: would I choose a TP MRI-guided in-bore (in the MRI tube receiving live images during the biopsy) as I had previously indergone, or the combination of MRI-guided/fusion/systematic/? I found out that the difference would be that, with the latter, the urologist could use the Precision Point (6)  transperineal equipment; it was not available for the in-bore. So I chose a combination TP-MRI-guided/fusion/systematic biopsy.   I also decided to have general anesthesia, which required my procedure to take place in the OR in the hospital.

I am awaiting the results from the pathology lab. From the preliminary notes and subsequent talk with the urologist who performed the biopsy, there were 16 samples taken. He targeted the area designated as a lesion in my MRI, including where my first random samples of Gleason 6 were found in 2018 and used a template to take samples from the remaining quadrants. At least, that's what I understood from a phone call fading in and out on an Amtrak train ride back to New York. I'll have more details in my next post – plus the preliminary results before I get a second opinion from Dr. Jonathan Epstein at Johns Hopkins, a world class pathologist …. and a mensch, to boot. Stay tuned!

One more item…..

Embracing Active Surveillance (AS) is to expect things to change—changes in your tests or news from the outside. The information could be coming from within the U.S. or anywhere, i.e., findings from studies on almost any aspect of prostate cancer. This blog site has a dropdown "In The News"; however, I might sometimes add a "breaking" headline to a post. Today, it concerns a study containing a Swedish cohort, a study published on September 14. 2022, with the findings that "suggest that men older than 65 years with low-risk P.C. had a high proportion of treatment-free years (53%-70%) and a low risk of P.C. death (6%-8%); hence AS was indicated among men in this subgroup. In contrast, in men younger than 65 years, AS appeared to be indicated only in those with very low-risk P.C… " Tead this study in full HERE. And, note that this is a study out of Europe where guidelines differ from the AUA. There will no doubt be disagreement with the study’s premise. And it’s still relevant to place into your Active Surveillance research library.

Some studies will sound absolute and conclusive; some, in fine print in their conclusions, will often state that more studies are needed to bolster the findings reached here. As Active Surveillance pioneers grow (up to 60% in the U.S.; 90% in the state of Michigan), it is, by its very nature, a protocol that warrants your staying on top of new studies, discovering the development of new biomarkers, and changes in organizational guidelines.

This blogger advises all on Active Surveillance to stay involved and vigilant – through support groups, your medical providers, peers, and this blog site! As I cannot possibly monitor all news coming down the pike, I certainly welcome you to email me with anything you feel relevant and “fit to publish.”

And remember – scroll down and subscribe to this blog so you'll receive notifications of my new posts. And always a good idea to refresh your browser! Until next time,

I wish you good health always!

Glossary of Terms:

(1) Color Doppler Ultrasound This type of ultrasound, with the practitioner gently inserting a probe into your rectum has been utilized for awhile. I had been referred to the specialist Ethan Halpern at Jefferson University in Philadelphia. Read more about it here. A new type of test, the Microultrasound developed by Exact Imaging has made its way to the states. Laurence Klotz in Canada uses it regularly in tandem with the MRI for periodic checks on AS patients. Currently, the equipment is located in various centers around the country. I have not taken advantage of this newer imaging to date. I’ll explain more as part of a blog post on AS protocols.

(2) Hippocrates and Gerson protocols. Click the names for sources of information. Above, I told of my stay at San Diego’s Optimum Health Institute. They follow the Hippocrates protocol. Remember the Hippocrates saying: “Let Food Be Thy Medicine?”More on this in my nutritional and healthy lifestyle blog post.

(3) Gadolinium Contrast

So there’s no shortage of controversy, questions and debate when it comes to receiving contrast for a 3-T MRI. Webinars from PCa support groups have presented the subject - slanted a bit towards risks and long term side effects. Most radiologists will say that there is no definitive science on dangers of Gadolinium - that it is safe and leaves the body quickly. Other drs either shrug their shoulders and defer to their colleagues. Many cite anecdotal stories of brain and other sordid damage. Given that the latter may exist, the exact risk percentage is not known. I know of one major cancer center, MSKCC, whose radiology department specifically has not used contrast at all for several years. And I spoke at length with one prominent radiologist oncologist who dismisses MRIs without contrast, calling them “useless.” Again, a divide. I found one rather easy to read definition of the contrast, its use and safety, from Yale University. You have every opportunity to consult Dr. Google for other sources. There are plenty of them. Have fun exploring. I personally went for the contrast as I understood it to be a necessary agent for highlighting areas important for radiologists to examine. And again, to counter that, I’ve spoken to a Dr. who calls it hogwash, maintaining that, without contrast, the readers of the imaging have to “work harder - the contrast makes them lazy.” You decide!

(4) American Urological Association

Have a look at AUA’s website. I’ve also posted their 2022 Prostate Cancer Guidelines which you can find in the navigation bar. Note that in their revisions in 2022, they have gone farther than before in recommending that the “preferred” option for low risk (usually Gleason 6 tumors) and favorable intermediate risk (may include 3-4 tumors with no more than 10% involvement in the “4” - but, that can vary from dr to dr). As I said above, the AUA has stopped short of recommending MRIs as part of an AS protocol except in cases of Risk Stratification, and the jury is still out on opining on Transperinneal biopsies vs. TRUS. And don’t even THINK about other biomarkers you’ve heard about. But, not to worry. We’ll get to all the news that’s fit to print about everything from the Microultrasound to Select DMX urine tests to the 4K blood test to measuring a blade of grass. (the latter suggestion being tongue in cheek…)

(5) MRI-guided fusion/systematic biopsy

Take a look at this February 2022 study from PubMed.gov, also known as NIH. Examine previous studies cited. And put the general PubMed/NIH URL in your browser “Favorites.” It is an excellent research tool. Also: clinicaltrials.gov - a go-to tool for finding out about completed studies and those that are still recruiting. Simply type in prostate cancer in the search bar, and, presto! You’ll probably find more than you bargained for. Of course. you can insert specific terms - studies are continuous on all facets of PCa.

(6) Precision Point

Everything you need to know: Precision Point was developed by a company called Perineologic Know that, currently, not everyone performing Transperineal biopsies has this system. An excellent source for support of the Transperineal Biopsy can be found here. Follow several of the proponents of the Transperineal Biopsy on TWITTER. Jeremy Grummet Michael A. Gorin Rick Popert Arvin K. George Matthew Allaway.

Just a Note ON ABOVE LINK TO DR. KLOTZ’S VIDEO:

As much as I have complete respect for Dr. Klotz as a pioneer and for his accomplishments in positively affecting the lives of thousands of men with the advent of Active Surveillance, I disagree with his views on nutritional lifestyle (at the end of the video) - more on that in an upcoming post!

! 

QUESTIONS?

WANT MORE INFO? NEED TO CHAT? LET ME KNOW!

Martin Gewirtz, BCPA