– Physicians often downplay the risks

by Howard Wolinsky, Contributing Writer, MedPage Today

August 19, 2018

Ferdinand “Ferd” Becker Jr., MD, a retired facial plastic surgeon who lives in New Orleans, has one of the scariest biopsy/prostate cancer stories I’ve ever heard.

Initially, Becker was diagnosed low-risk, low-volume Gleason 6. But his MRI records were switched. And he was temporarily diagnosed with extensive prostate cancer. False alarm.

He also was hospitalized for potentially deadly sepsis from an infection caused by a transrectal biopsy. A nightmare.

Becker’s experience is a call for urologists to re-evaluate what they are doing to tens of thousands of men — and for men to question their urologists about biopsies.

Becker has spent much of his adult life on the watch for prostate cancer.

His father Ferdinand Becker Sr. died from metastatic prostate cancer at age 85. The elder Becker’s brother Walter died from prostate cancer in his 60s after extensive radiation treatment that burned his bladder and rectum. He was in severe pain. “It was a horrible death,” Becker Jr. recalled.

Another of the elder Becker’s brothers, Victor, died from heart disease in his 80s, but he also had metastatic prostate cancer.

Now 78, Becker Jr. practiced facial plastic surgery in Vero Beach, Florida, for more than 45 years. He stopped performing surgery in 2009 after he was diagnosed with Parkinson’s disease.

Meanwhile, his prostate specific antigen scores had been on the rise. His PSA went over 5 ng/mL in 2011, up from 4.25 in 2010. His urologist — and friend — in Vero Beach ordered a random transrectal needle biopsy, the commonly used tool to sample a small portion of the gland to try to ferret out prostate cancer.

The urologist had good news: Out of 12 cores, 11 were negative. A single core taken in the left base had a Gleason 6, with only 10% of the core being affected. That’s the sort of cancer that likely will never become a threat.

But 6 days later, on Easter Sunday, Becker spiked a fever of 103.5. “That’s pretty high for someone my age,” he said. He had chills and fever and was delirious.

He met the urologist at the hospital, where he was diagnosed with sepsis.

As a patient on AS for prostate cancer, I can attest to the fact that urologists generally downplay the risk of infection from transrectal biopsy. The rate for all types of infection following a biopsy varies from doctor to doctor, but is roughly 5%.

Becker suggests that infection rates from prostate biopsies are grossly underreported. “Most of these studies on sepsis/infection come from major universities where they report everything. All these doctors in community practice doing random biopsies get infections, but they don’t report them. I know my urologist had some trouble with infections.”

The Sepsis Alliance, a voluntary health organization dedicated to raising awareness of sepsis in general, reports that about 30% of patients die from “severe sepsis.”

Fortunately, antibiotics knocked down Becker’s infection.

He consulted with his urologist and they opted to delay the decisions on whether to treat the cancer or for Becker to formally to go on an active surveillance program.

Two months later, Becker decided he wanted to have a color Doppler ultrasound and an MRI to check on his condition.

He saw a South Florida radiation oncologist, who had shocking news. Becker’s original report said he had a Gleason 6 tumor in a single core with virtually no chance for metastatic cancer.

But the radiation oncologist said: “Looks like you’ve got a big problem here. The MRI report shows that you have extensive tumor on the left side involving in the neurovascular bundle near the left seminal vesicle and extension outside the capsule. You have a tumor on the right side extending almost to the rectum.” The doctor then performed a color Doppler ultrasound and claimed he saw the same findings as in the MRI, Becker said.

The doctor said Becker had “extensive treatment” in store for him. “Looks like what you’re going to need to do is go on hormone therapy first and then we can do external-beam radiation and then we implant radiation seeds,” Becker recalls the radiation oncologist saying.

Becker later learned his MRI report had been switched with another patient’s.

The next week he saw a Virginia medical oncologist who specializes exclusively in prostate cancer. He said the findings made no sense so he referred Becker to a California expert in color Doppler ultrasound. Two weeks later, the California doctor concluded that Becker had a 7-millimeter Gleason 6 in the center of the left base, nowhere near the capsule or any other vital structures, and added that Becker was an excellent candidate for active surveillance.

The doctor repeated the color Doppler ultrasounds twice over the next year and had the same findings.

One year after the initial diagnosis, Becker underwent an multiparametric MRI at Johns Hopkins Hospital in Baltimore that confirmed the color Doppler results. But the mpMRI at Hopkins showed a couple of other suspicious areas.

So 6 months later, Becker had a direct MRI-guided biopsy at Brigham and Women’s Hospital in Boston. Becker said the Harvard group uses a transperineal approach in the skin between the scrotum and the rectum to drastically decrease the chances of infection. Their infection rate is an incredibly low 0.5 percent.

The radiologist found six suspicious areas on the mpMRI and then honed in on them using a direct MRI-guided biopsy system. The only positive biopsy was a small Gleason 6 tumor in the left base, the same results everywhere except in his second opinion in Florida.

Becker noted that random biopsies of the prostate gland miss up to 30% of tumors, which are found in the anterior portion of the gland.

For his part, following his misadventure with sepsis, Becker plans to avoid random biopsies and only have MRI-guided biopsies if needed to investigate suspicious areas.

I’ve had five biopsies without incident since 2010. Prior to my last biopsy, I had a rectal swab to check the status of the microbes and took some extra precautions with antibiotics.

I feel lucky. But, along with many other patients on AS, I am increasingly skeptical about random transrectal biopsies. It’s been 2 years since my last one and expect my urologist will recommend another biopsy next year.

When my time comes, if an mpMRI finds some suspicious areas, I’ll ask about an MRI-guided biopsy.

Howard Wolinsky is a medical journalist and prostate cancer patient based in the Chicago area. Previous installments in his “A Patient’s Journey” blog series can be found here.

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