Shammai Rockove, MD, FACS  

Founder and senior surgeon, 

Center for Urology, Oregon

“All you need in this life is ignorance and confidence,

and then success is sure.” 

― Mark Twain

Was she right?? Are prostate biopsies… bad?

It’s a recurring theme: The longer I practice, the more I realize how uninformed I’ve been along the way. Though it was years ago, I vividly remember the angry spouse of a man I had just diagnosed with prostate cancer. She had watched a YouTube video where someone poked holes in an apple, supposedly recreating the prostate biopsy process, with fluids oozing out. She was livid, convinced that the biopsies I had performed would cause the cancer to spread. It was difficult for me to conceal my sheer distaste for her ignorance. I responded, "The prostate is not an apple, and the needles I use are not the same as those used in that video." I was a soldier in the belief that our prostate biopsies were completely safe.

So... how do I reconcile my response with a letter to the editor in a recent JAMA article? The authors, discussing PSA screening and prostate cancer mortality, stated: “Prostate biopsies may lead to mechanical shedding of prostate cancer cells into circulation and bone marrow, and the presence of these cells could be associated with biochemical recurrence following prostatectomy. However, there is no clinical evidence that shedding cancer cells during biopsy leads to progressive or lethal disease.” What?! In essence the authors are concurring that we have no clear understanding of the iatrogenic impact biopsies might have on cancer progression. This is particularly unnerving since to date almost all cancers have been diagnosed with biopsy.

How do I give informed consent now?

Who was the ignorant one? (Her approach was simplistic, but she wasn’t necessarily completely wrong. And I certainly wasn’t entirely right.)
 
Here’s what I do know: Like many topics, prostate cancer screening and treatment are often divided among physicians, with adherence to a particular belief or philosophy almost religious in nature. A primary care physician recently referred a patient to me, describing me as "cautious and conservative." I looked at the patient and said, "No, with experience, I’ve simply become more informed — which often means doing less, rather than more." 

For better or worse, I’m relying more on MRIs, doing fewer biopsies, and looking forward to newer, non-invasive diagnostics.