Understanding Prostate Biopsy

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Those with an elevated prostate-specific antigen test are referred for a biopsy of their prostate to help diagnose prostate cancer or other prostate concerns. This can bring anxiety and discomfort for the patient.  

Dr. Chad Ellimoottil, a urologist and division chief of men’s health and reconstruction at Michigan Medicine, shares information on prostate biopsies. He discusses those who need it, forms of biopsy, and the latest in performing them. 

Cancer Aware is a part of the Michigan Medicine Podcast Network.

Participant:
Chad Ellimoottil, MD

Resources: 

Prostate-specific antigen test

Prostate cancer

Transcript

Scott Redding:

Welcome to the Cancer Aware Podcast, where we'll discuss cancer prevention, treatments, the latest in research and important news around cancer, brought to you by the University of Michigan Health, Rogel Cancer Center.

We're here with Dr. Chad Ellimoottil, Urologist-in-Chief of the Division of Men's Health and Reconstruction in the Department of Urology at Michigan Medicine to discuss prostate cancer biopsies and how improvements made over time is helping patients feel less anxious. Welcome, Chad.

Dr. Chad Ellimoottil:

Thanks for having me, Scott. Happy to be here.

Scott Redding:

Before we kind of get into what is and how prostate biopsies perform, can you tell us about why or when a patient would need to have a biopsy of their prostate?

Dr. Chad Ellimoottil:

Sure. Yeah. There's a lot of reasons why men come to us to have prostate biopsy performed. I'd probably say the most common reason is because they'll have a blood test called PSA, which stands for prostate-specific antigen that may be drawn by their primary care doctor or maybe drawn by a urologist, that comes back abnormal. In most cases it comes back elevated.

And so, in order to have that evaluated, that test is essentially a test, a screening test for prostate cancer. And so, many of those men who have an elevated PSA will ultimately end up getting a biopsy of their prostate to look for prostate cancer. But there's other reasons why men will have biopsies. For example, their physician may perform a rectal exam, a normal prostate feels smooth, an abnormal prostate may have bumps on it, and if it has bumps, those men may end up getting a biopsy.

A lot of men these days will get an MRI done of their prostate for various reasons, including having an elevated PSA. And in that case, if there's an abnormality that's found on that MRI, then those men will get a biopsy as well too. There's other risk factors. For example, if you have a family history of prostate cancer, if you're African-American, you're at greater risk for prostate cancer or if you have a genetic mutation that makes you at a greater risk for prostate cancer, those men are also evaluated for biopsy as well too.

And so, a lot of different reasons why people end up coming to us for biopsies. And then, even after they have a biopsy or they have a diagnosis of prostate cancer, some of those men are watched on something called active surveillance. Those men will also periodically get biopsies too. So, a lot of different reasons.

Scott Redding:

So, if someone has an elevated PSA and they get a biopsy, it doesn't always necessarily lead to cancer. Can it lead to other urologic diseases?

Dr. Chad Ellimoottil:

Yeah, certainly. I mean, the elevated PSA itself, it may not be necessarily a sign of cancer. In fact, they could have an abnormal PSA for three main reasons, I'll say. One, is as men get older, their PSA number tends to go up. So, that's a reason why PSA can be elevated. Two, if they have a very large prostate, their PSA may be outside of the reference range.

Three, I guess, there's four reasons, but if their prostate's inflamed, that's something called prostatitis that can cause the PSA number to go up. And then four, which is the main reason we're doing the PSA test, is to look for prostate cancer. And having an elevated PSA doesn't necessarily mean that you have prostate cancer. We do diagnose other things like you asked about enlarged prostate while we're doing the evaluation for elevated PSA.

Scott Redding:

So, if someone does have an elevated PSA, do they always have to have a biopsy?

Dr. Chad Ellimoottil:

Yeah, that's a great question and that's something a lot of patients ask. So, I have this number, do I need to get a biopsy? And actually, I'll tell you that our thinking on doing prostate biopsies and diagnosing prostate cancer has greatly evolved over the last 10 years. There was a time when you had an abnormal PSA that you would automatically get a biopsy done, and that's still okay. And there's a lot of men that go down that route because biopsy is really the only way to actually diagnose prostate cancer.

But these days we do a lot of alternative testing to sort of build the case for doing the biopsy. And the reason for that is because, and we understand the biopsies are invasive, they're awkward for men to have, they can be painful. So, try to leave that as the last resort and we'll try to do alternative testing to build a case.

For example, I often when I see a man who has an elevated PSA, first off the bat, will repeat the PSA, if it's the only one that they have elevated. About 40% of PSAs when you recheck it actually come back normal. So, that's usually my first step.

Now, if it's still abnormal, then I'm a little bit more concerned, especially if they have other risk factors for prostate cancer. And if that's the case, I'll usually order an MRI of the prostate. So, MRIs are very useful and used very frequently now. The MRI gives us three pieces of information that are critical.

So, one is it tells us the size of the prostate. And the reason that's important is because it helps us put your PSA into context. There's men that have very large prostates that may always have an elevated PSA, and we work them up for prostate cancer, but after a certain point, we can be content that they have an elevated PSA.

And then, the MRI also tells us the probability of having prostate cancer. And then finally, if there is a suspicion of prostate cancer on the MRI, the radiologist will mark that area so that we end up doing a targeted biopsy of that area. So, that's one alternative test.

Another alternative test to biopsy is using a biomarker. So, a biomarker is either a blood test or a urine test that again, tells us the probability of prostate cancer. The one that we use very frequently here is a MyProstateScore, which is a at-home test that comes back with a score from 0 to 100, which essentially tells you what's the chance that you're going to have a prostate cancer if you do a biopsy. So, these days we use alternative tests. Biopsy is still definitive, but these tests help us build the case to go ahead and do the biopsy.

Scott Redding:

So, obviously you talked about the prebiopsies here with the PSA, MyProstateScore, MRI. When a biopsy is actually performed, how is it done? What would patients expect?

Dr. Chad Ellimoottil:

That's a good question. Patients have a variety of experiences when they do biopsies, but I'll give you the high level. In general, it's a relatively short procedure. A biopsy of a prostate should take no longer than 20 minutes the whole procedure itself, even though the time that you're in clinic may vary between one hour to two hours.

There's really two approaches to biopsy that are done across the country. I'll say the more traditional approach is called transrectal, which means that you come to clinic, you're awake, you lay on your side, the doctor will put an ultrasound probe into your rectum to see the prostate and then take 12 samples or use an MRI to take samples of the prostate through the rectum. That's kind of the traditional way that's called transrectal.

About four or five years ago, we switched over to doing something called transperineal, which means that you come in, you lay down on a clinic bed, you have your legs up, and we take the samples from underneath the scrotum. And we started to do that about four or five years ago for men that were at high risk for infection because that approach, where you're going through the skin, instead of going through the rectum, actually has a much lower risk of infection.

And then, at some point, we had a discussion about, well, why are we only doing this for men that are high risk? Why don't we expand it and just lower the risk for everyone? And so, that's actually become our default biopsy, and that's what we do most commonly transperineal.

And so, you come in, you're positioned, we use local anesthetic to numb that area. There's two pokes that you feel on the skin, and then there's a poke that you feel as we're numbing the muscles around the prostate. And then, we take 12 samples of the prostate or more if you have an MRI. And if you have an MRI, we also use that MRI for guidance.

And afterwards, usually you may have blood in the urine, semen, stool that can last up to two weeks after the procedure. You go home right after that procedure, and then your results usually come back in about five to seven days or so.

Scott Redding:

When you describe this to a patient, what is their reaction to? Is there anxiety? Is there anxiousness or what does a patient feel like? And then, how is that addressed to make them feel more comfortable?

Dr. Chad Ellimoottil:

Yeah, so I think a lot of patients are anxious about biopsies. I mean, they have friends that have had biopsies. Those biopsies may have been done at a time where we weren't offering some of the things that we do now for biopsy. There's different types of biopsies, and that's why I mentioned that everyone's journey through a biopsy can be a bit different.

So, in general, patients are anxious about biopsy. It is an uncomfortable procedure. It's in the sensitive area, so you're usually not used to it. Particularly if you don't have any other health conditions, you're not used to getting probed and prodded and so forth. So, I think that that can be an uncomfortable experience, but a lot of men will, after the biopsy is over, we'll hear a lot of them say that it's not as bad as I thought it would be. And oftentimes, that anxiety leading up to the biopsy is the worst part.

Scott Redding:

So, is there something being done to help with some of that anxiety?

Dr. Chad Ellimoottil:

Yeah, definitely. So, I think one of the biggest innovations that we've done recently was to centralize where we have our prostate biopsies. So, we previously had biopsies at multiple different sites at Michigan Medicine, all biopsies being done slightly differently. And what we did was actually move them all to a central area in Brighton, Michigan in a medical procedure unit, which is not quite an operating room, but it's not quite a clinic, it's kind of a hybrid.

And one of the reasons for that is that, number one, standardizes the experience. So, we took the best lessons learned from all the doctors that were doing these biopsies, and we combined them all together. We had discussions about what are the best practices. So, we created this centralized, focused standard procedure.

And then, on top of that, by being in the medical procedures unit, we were actually able to offer these men something called conscious sedation. So, conscious sedation is when you're having a biopsy, you're still awake, you're conscious, I can talk to you during the procedure, but you are relaxed because you have an IV in and you have medicines going through your body that are relaxing you and also providing additional pain relief.

So, we still do the prostate block to make sure that that prostate area is numb, but the conscious sedation has really transformed the biopsy experience, making it much better for men. And I think that's a massive improvement on the patient experience with biopsy.

Scott Redding:

Is that something that's unique here for offering this for that, or is it common for most urologists to offer conscious sedation?

Dr. Chad Ellimoottil:

Yeah, I would say it's actually pretty unique. And so, there are some areas that we'll do biopsies under full anesthesia where you're going in into the operating room, you meet an anesthesiologist, you're asleep. That usually often takes up your entire day and the recovery is a little bit more rough when you have a biopsy like that.

So, this idea of conscious sedation is not widely used, but I think that it's gaining traction particularly as places like this are not only showing the success with it, but also letting others know this is a great way to do a biopsy and tracking patient experience and doing patient feedback surveys and so forth.

Scott Redding:

You talked about it being more comfortable for the patient. Are there other advantages for conscious sedation with biopsies?

Dr. Chad Ellimoottil:

Yeah, the patient is much more comfortable, which actually makes the biopsy a bit easier too. So, if there's certain factors, for example, if you have a very large prostate, often getting to that region to do a targeted biopsy can be difficult. So, if the patient is lightly sedated, then it makes that easier, so it makes the procedure actually easier, it makes the patient more comfortable. And so, overall, it's a win-win.

Scott Redding:

When you do biopsies, how do you make sure it's as accurate as possible, especially if you're going in through the skin where you're not necessarily seeing everything?

Dr. Chad Ellimoottil:

So, we do have, just off the bat, pretty good accuracy. Even though we are going through the skin to do the biopsy, we have an ultrasound that shows us the prostate. We're linking it with an MRI, giving us a targeted area to go after.

So, the biopsy itself is fairly accurate, but the conscious sedation, for example, I think does help because when you're doing a biopsy, often there's going to be some movement and that's just natural whether you're willing or it may be completely involuntary, it's just your body reacting to having a procedure done. So, that really helps us ensure that the area we're trying to reach with the needle we actually get to. So, in that way, it improves that experience.

Scott Redding:

With this more centralized program and being able to offer pretty much the same experience for patients, is every patient a candidate for conscious sedation?

Dr. Chad Ellimoottil:

Unfortunately, not. Not every patient is a candidate for conscious sedation. So, that's a discussion to have with the doctor that's making the referral for the biopsy. We do have some exclusion criteria for conscious sedation. For example, if your kidney function isn't great or if you have severe anxiety, if you have very severe anxiety, it's hard to give you a safe amount of conscious sedation to make you feel relaxed.

And then, also if there's other medical conditions like severe heart and lung conditions, if you have trouble breathing, if you're on home oxygen, those types of things may disqualify you for conscious sedation because we want to be able to do this in a way that makes you feel comfortable, but also keeps you very safe.

And so, I think that it certainly, in my opinion, does improve the experience, but we're not going to do that at a cost of potentially hurting you. So, that's why we have exclusion criteria that are written out that our doctors can refer to when we're setting someone up for conscious sedation for their biopsy.

Scott Redding:

I'm sure we've covered some here, but are there any myths that patients get concerned about that talk to you when they're getting their biopsies?

Dr. Chad Ellimoottil:

Oh yeah, for sure. I think I'm busting myths all the time related to biopsy. That's pretty common. I think one myth that men often have is that, and this adds to the anxiety that they have before a biopsy, is that if they're getting a biopsy, they have cancer. And so, in some cases where in other parts of the body where you have a CT or an MRI that shows a tumor, you go in and you take a sample to understand what type of tumor it is, that's the purpose of the biopsy.

In prostate cancer, where actually the biopsy is used for diagnosis. So, even if you have an MRI that shows an area of concern, it's just an area that the radiologist is concerned about. And so, you can't diagnose prostate cancer using an MRI. So, the radiologist gives us a probability and we have to actually take a sample to look underneath.

And I tell some men that your probability of prostate cancer, for example, if they had an MRI, we use a scoring system called PI-RADS for the MRI. And if they have a PI-RADS 3, that means there's about a 15% chance that they have a prostate cancer that would be concerning.

And so, I tell them that you actually have 85% chance that this is going to be benign or be one of those prostate cancers that you don't need to act on. So, I think that understanding is super important that if you're getting a biopsy, it doesn't mean you have cancer. It's actually just part of the journey to diagnose that prostate cancer.

I think another big myth that comes up and leads to a lot of hesitation to get a prostate biopsy done is that if you have a biopsy, the prostate cancer is going to spread, and I want to be crystal clear that there's no evidence of that. There has been some concern for biopsies in other parts of the body, but for prostate cancer, there's really been no evidence of that. And we do biopsies on men that have prostate cancer are on active surveillance, and they stay on active surveillance for decades even after all those biopsies because the risk of spread with the biopsy is essentially zero.

There is a myth, and if you go to patient forums and so forth, that the biopsy is extremely painful. And I'll just say that I think that the biopsy experience is a personal experience, and for some men will feel that their biopsy was painful, it was extremely anxiety-provoking and so forth, and I'm completely empathetic towards that. But I will say that's not kind of a blanket statement.

So, I think it does produce a lot of unnecessary fear, particularly for men that have their biopsy done and then finish it by saying, "I don't know what I was worried about. That was not that bad." So, I think that's somewhat of a myth, but for some men, that was reality. But I think that in general, I don't think that's the experience for everyone.

The other thing is that there's a worry about biopsies causing severe infections and biopsies can lead to an infection, that is certainly a complication, known complication of prostate biopsy. But it's also the area of where the most research has gone into where people have really tried to optimize and minimize infections. And particularly at University of Michigan, there's been a lot of work done to help reduce biopsy-related infections.

And also, across the state through a program called music, they've made a lot of advancements in reducing biopsy infections. And I think one of the greatest advancements has actually been the move from transrectal to transperineal where, and the last time I checked, I think our data shows that the risk of a severe infection is about 0.25%. So, it's actually pretty low. That is certainly a fear that you think patients it's real because people do get sick from biopsies, but I think that the rate might be much lower than people actually think.

The other myth that often comes up is we talked about these alternative tests. And so, when a man has an MRI, for example, and their MRI comes back negative, they often think, "Well, I don't need a biopsy anymore because I have a negative MRI." That may be true with the scoring system. Some radiologists can say with about 90% confidence that you don't have a clinically significant prostate cancer, but it may not always be the case.

I think it's up to the patients and the physician to look at the negative MRI and also look at other risk factors and decide whether to still pursue a biopsy. I often couple a negative MRI with a second test that's negative like a biomarker test. And if both of those are negative, you may say, "Okay, there's probably enough evidence here that we can avoid the biopsy." But if they have a very high PSA with a family history and a negative MRI, you still want to pursue a biopsy. So, those are probably some of the top myths. There's a lot of others, but I think that would probably cover most of them.

Scott Redding:

Do patients who decide not to have a biopsy, could that potentially increase their risk down the road of getting a more advanced prostate cancer?

Dr. Chad Ellimoottil:

Yeah, that's a good point. So, men that forego biopsy for a number of different reasons, it's a possibility that if they do have a prostate cancer and it's undiagnosed, that prostate cancer could get worse. And so, connecting to the myths, I think there's some misunderstanding about prostate cancer, that all prostate cancers are indolent. You're going to die from something else as opposed to prostate cancer, and that's not true.

I think that there's a spectrum of prostate cancers. There are some prostate cancers that will never hurt you, less than 1% chance it's going to hurt you in your lifetime. And honestly, we're not really looking for those prostate cancers anymore. What we do is focus on prostate cancers that may hurt you in your lifetime.

And so, particularly here with our group, if we're recommending a biopsy, it's most likely because given your age, your life expectancy, other factors, your family history, your findings on MRI, maybe your findings on your biomarker test, all of that is pointing towards the fact that you may have something in your prostate that could cause you harm. You have what's called a clinically significant prostate cancer.

So, if that's the case, then it's best to just get the biopsy done because the biopsy is not treatment. That's just the first step is just to actually see if it's there. So, you get the biopsy done, you look at what type of cancer it is, and then, then you can make the decision to treat, to not to treat. All those doors are open, but actually knowing what's in there is really important because you could be missing something that's actually aggressive.

Scott Redding:

Have there been improvements for prostate biopsies?

Dr. Chad Ellimoottil:

Yes. There have been a lot of improvements in prostate biopsies over the years. Believe it or not, when our field was first starting to do prostate biopsies, we would use an ultrasound and just take six samples of the prostate, and that was it. And so, as a result, detection rate was very low, not surprising, and a lot of men would end up having to, they would either miss prostate cancer or end up having to get a repeat biopsy.

So then, years went down the line and then the major advancement was to take more samples. So, we started taking 12 samples of the prostate, which of course, improved detection rates, but still we're missing cancers. Repeat biopsies were pretty common, but I think the biggest transformation probably a bit more than a decade ago was the development of imaging-guided biopsy.

So, the prostate MRI came into development, which allows us to actually not just take random samples of the prostate, but actually focus in on a region. So, we still do the sampling around the prostate, like we traditionally do those 12 samples, but the radiologist will often mark an area for us to additional samples. So, the MRI guidance, the fusion biopsy that many people have heard of was probably the biggest transformation in biopsy care.

Then, I think the second biggest transformation is the move from transrectal to transperineal, which at our system, we started doing about five years ago, because that approach does reduce the risk of infection, and there's some advantages in terms of reaching areas of the prostate that are harder to reach with transrectal. And I think a lot of my efforts in the recent years have actually been focused on improving the patient experience.

And I think that's the other big improvement over the years is really focusing on the fact that this is a challenging procedure for men. It can be painful for men, it's anxiety provoking. And so, what can we do to prevent that? And some of it begins with all the teaching that we do beforehand. There's approaches in the actual procedure room like playing music and other strategies that we use.

But probably the biggest thing that we focused on is the introduction of conscious sedation to essentially help patients relax right before their biopsy to give them a much better experience. And so, our recent focus has really been on improving the patient experience, which I think we've successfully done.

Scott Redding:

Chad, I think this has been really great, good information. There's one thing you want to make sure people know about biopsies in particular, prostate biopsies, what would that be?

Dr. Chad Ellimoottil:

That's a great question. So, I think my big take-home point would be that over the years, we've really developed a thoughtful approach to biopsy. It's no longer here's an abnormal test, get a biopsy done. We understand that biopsies can be difficult for men. It's an invasive procedure. So, taking a thoughtful approach by using alternative testing to ensure that you need a biopsy is very important.

And then afterwards, if you do need a biopsy, optimizing your experience with biopsy is very important. And so, that's been our major focus and that's my big takeaway is the thoughtful approach to biopsy is very important for prostate cancer care.

Scott Redding:

Thanks for being here today, Chad.

Dr. Chad Ellimoottil:

Thanks a lot. Thank you for having me.

Scott Redding:

Thank you for listening and tell us what you think of this podcast by rating and reviewing us. To stay up to date on what's happening in the cancer world, follow us on X at UM-Rogel Cancer. You can explore additional episodes at www.rogelcancercenter.org/podcasts. Cancer Aware is part of the Michigan Medicine Podcast network.