A Safer, More Precise Way to Diagnose Prostate Cancer with Transperineal Biopsy

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone. And welcome to another Butts and Guts episode. I'm your host, Scott Steel, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Super excited today to have Dr. Zeyad Schwen, a urologic oncologist in the Glickman Urological and Kidney Institute. Zeyad, welcome to Butts And Guts.

Dr. Zeyad Schwen: Thanks for having me on. Really enjoy the name of your podcast by the way.

Dr. Scott Steele: Absolutely.

Dr. Zeyad Schwen: When I figured out how I could be a guest on Butts and Guts I'm like, I'm in.

Dr. Scott Steele: So today we're going to talk about something that we haven't had as much discussion about on this podcast, and that's talking about prostate cancer, and specifically we're going to go into a safer, more precise way to diagnose prostate cancer with transperineal biopsy and innovative treatment options. But before we get there, tell us a little bit, give us the 50,000 foot overview of yourself and where you're from and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Zeyad Schwen: It's kind of come full circle. I'm from Cincinnati, but I did my undergrad training here at the Case Western Reserve University in Cleveland. So, I went around and did some training in Pittsburgh for med school. I did my residency at John's Hopkins, and then I did my fellowship here, back in the Cleveland clinic. So I kind of returned because, well, like you said, it's a beautiful city and it's good to be back. I really enjoy being in Cleveland and here at the Cleveland Clinic where we are kind of at the forefront of urologic oncology and a lot of really innovative treatment options and also diagnosis options that we have available for patients.

Dr. Scott Steele: That's fantastic. And we're glad you're here. So let's just start with prostate cancer in general. I once heard that if you live long enough and you're a male, you're going to get prostate cancer. So, is that true? And tell us a little bit of the maybe statistics about prostate cancer and then, how does it come about?

Dr. Zeyad Schwen: That's a great question. And people will always kind of believe that eventually we will all get prostate cancer. In some ways, there's some truth to that. Prostate cancer is something that we slowly can develop over time and will find it a lot of times after people have died from natural causes that, oh, yep, they may have had prostate cancer.

What we, as urologic oncologists, our goal is to detect it early and detect those types of cancers that can actually be life-threatening. And that's something that, we here in the United States have a big problem of, because prostate cancer, it's common and it's actually the second leading cause of cancer death in men. So it's not just common, but it's also a common cause of death and it can be life-threatening.

One in eight men will be diagnosed with prostate cancer. And we have, as that reason in the United States, a higher problem with it than in other parts of the world. Dietary influences of the Western, diet, high cholesterol, high fat, high red meat diet, these are things that can really influence and increase our risk of developing prostate cancer. So, ways of preventing it, dietary, trying to tie it into kind of what this podcast is all about is kind of dietary influences that you can do.

We as men, we can adopt a more plant-based diet, reduce our red meat, reduce cholesterol, add certain types of vegetables that we know are good at preventing prostate cancer. One of them is cruciferous vegetables like broccoli and cauliflower. Tomato has been associated with a reduced risk of prostate cancer, coffee. But we do know that red meat is a big no-no, obviously you don't have to eliminate it completely, but making meaningful reductions in that can really help our risk. So, in the United States, we do PSA screening, Prostate Cancer Screening, which is a great way that we can diagnose and catch prostate cancer early.

Dr. Scott Steele: So let's talk a little bit about PSA because it wasn't too long ago that there was some controversy about PSA and whether or not that was a specific test and whether men should get the PSA or we should scrap it all together. So tell us a little bit about PSA, and then. what other types of screenings are available for prostate cancer? And if you will, talk a little bit about what age, I just turned 50, what age should men begin that cancer screening?

Dr. Zeyad Schwen: That's a very important thing to talk about because our understanding of the PSA test, which is a blood test, it's called the prostate-specific antigen, it's a blood test that can help detect prostate cancer. There was a lot of controversy about it before, because we weren't using it correctly. But actually, as we kind of understand the way we've started to use it better, it's actually one of the real cancer screening success stories.

In fact, if you compare the cancer mortality for prostate cancer in the 1980s, before PSA screening to now, there's been about a 50% reduction in cancer death as a result of largely prostate cancer screening. The reason why it kind of got a lot of controversy around it is we were using it incorrectly. We know that it's a good screening test, but it's not a very specific test, meaning that there's a lot of false positives.

But if you know how to understand in those people who are at higher risk, if we can do additional testing, find out who needs a biopsy and who needs treatment. So we were kind of using it a little bit over aggressively, biopsying everybody, treating everybody with any type of prostate cancer, even the kind of prostate cancer that won't be life-threatening and that we will die with and not from.

So, as a result, if you look at the curves of prostate cancer mortality, comparing that to say breast cancer before mamography, you can actually see a steep drop in the cancer death as a result of PSA screening. So, like colonoscopy has been for colon cancer, PSA screening has really saved a lot of men.

Dr. Scott Steele: That's fantastic. So is PSA the only screening test? What about the good old fashioned digital record examination and prostate check?

Dr. Zeyad Schwen: The finger exam is important when used in addition to PSA screening. It's not a perfect test. We have a lot smarter blood tests that we use in people who have an elevated PSA to help really hone in on who is at really a higher risk. One of them is the IsoPSA, which is another blood test that we offer here at the Cleveland clinic.

And we actually did a lot of the research and initial research in the development of that biomarker. Another one is the prostate health index, which is actually a combination of other PSA Isoforms, which are kind of like PSA-like proteins that can be used in an equation to calculate your risk. These are kind of more used in people who already have an elevated PSA. So the PSA is still one of the better screening tests, because it will capture most people who have a higher risk of prostate cancer. But then we use the additional testing to really hone in on who's at higher risk for having prostate cancer.

Dr. Scott Steele: I know we're going to get in a little bit about maybe some imaging that may be involved once you have it or suspected of it, but is there any other endoscopic or radiologic test that is a part of screening?

Dr. Zeyad Schwen: Well, we are using the MRI. It's a multi-parametric prostate MRI. That's also really revolutionized our ability to kind of screen people for prostate cancer. It's also one of those that are good used when combined with PSA, but the MRI, having a negative MRI, meaning no lesion seen in your prostate on the MRI, is pretty predictive of not having prostate cancer, but it would still miss by itself around 15 to 20% of what we would call clinically significant prostate cancers.

So, it's another one of those things that we kind of have to use multiple tools together, but you can also avoid a biopsy in a lot of these people who have a normal MRI and a relatively low PSA and maybe other favorable biomarkers.

Dr. Scott Steele: But just to be crystal clear, we're not getting an MRI in the absence of maybe some other indication that you may or may not have an early lesion or an advanced lesion?

Dr. Zeyad Schwen: You know, they keep developing MRIs. They're getting better and better and cheaper and cheaper. If we were to get everybody an MRI, that would be a big cost on our health system. And there have been studies that suggest that using the MRI first or before considering a biopsy can really reduce their likelihood of missing a prostate cancer, and also we can reduce the number of people who would eventually get a biopsy, but by itself, not a good screening test. There's another imaging test called the PSMA PET scan, which is another really great imaging test that we use, but you're really not in the screening indication.

Dr. Scott Steele: So let's just jump ahead now and say that for whatever reason screening results indicate that a biopsy may be needed. What are the options available here at the Cleveland clinic?

Dr. Zeyad Schwen: Well, as we kind of talked about, a lot of times we can look at other blood tests and other imaging tests like the MRI, but if a biopsy is needed, there's the traditional route, which is a transrectal biopsy. So this is an ultrasound probe that's placed in the rectum and then a needle that goes into the ultrasound probe through the rectum, and then into the prostate to get a sample of the prostate, to hopefully rule out prostate cancer or diagnose it.

We are offering now the transperineal prostate biopsy. And that's kind of what I wanted to talk about today, because this is a newer biopsy, but newer in a way that actually it's kind of a blast from the past, because the first biopsy of the prostate ever done was a transperineal biopsy, which is where the needle goes through the skin instead of through the rectum into the prostate.

And that's a safer biopsy approach because it really has dramatically reduced the risk of an infection after the prostate biopsy. So it's a safer biopsy because there's a lot of, as you know, a lot of really dirty bacteria in the rectum and that bacteria can seed its way into the prostate during the biopsy. And to prevent the infection or prevent an infection we have even tried things like doing multiple different antibiotics.

Now, we will do actually two different antibiotics. There's also other antibiotic acrobatics. I like to call them, because we really try to do all these sorts of fancy antibiotic algorithms to help reduce the risk of an infection with the transrectal approach. But still even with all of our efforts about 3% will get a severe enough infection that requires a hospitalization, 7% can get a urinary tract infection.

So, this is something that with the transperineal approach, we can reduce the risk of an infection during a prostate biopsy by less than 1%. So it's very low and that's without antibiotics. So it's also really important that, us not routinely using antibiotics, we've kind of helped stop or limit the amount of multi-drug resistant bacteria that can happen as a result of using antibiotics unnecessarily.

So, really it's something that going through the skin instead of through the rectum and patients actually can understand that, that there's a lot of dirty bacteria in the rectum, that avoiding that route and instead going through the skin has really reduced the amount of infections.

Dr. Scott Steele: So I'm coming into your office. What can I expect? You mentioned the skin and there may be some listeners out there that don't understand what transperineal is. You say skin, they're thinking belly, they're thinking of trans-, what does that mean?

Dr. Zeyad Schwen: The ultrasound probe would still go into the rectum. That's the best way to view the prostate with a transrectal ultrasound probe. But instead of the needle going through the rectum into the prostate, we go through a patch of skin that's actually between your scrotum and your rectum called the peroneum, which is kind of the quickest access point to the prostate.

So we do this procedure in the clinic, just like we would do the traditional prostate biopsy. We would numb up the skin with lidocaine and, making sure that everything's nice and well tolerated. And then we target the prostate in certain areas that prostate cancer can be hiding. And the other advantage of that route is that we can actually target another part of the prostate where prostate cancer can be hiding called the anterior part of the prostate.

And this is actually an area that the transrectal traditional biopsy often under-samples. So there can be a lot of times you get a prostate biopsy and if your tumor is in the anterior part of the prostate, you may miss it, and you may have a delayed diagnosis or a missed diagnosis. So the transperineal approach, going through that patch of skin, helps you target that area a lot better. And as a result, you have a higher cancer detection rate with the transperineal approach. So it's a more accurate biopsy.

Dr. Scott Steele: So we're going to transition to a little bit of truth or myth now, and I know you spoke a little bit about infection, but all things in terms of complications combined. Truth or myth: transperineal biopsies are safer and more precise for patients compared to standard biopsy procedures.

Dr. Zeyad Schwen: That I would say is truth. Not only as we had talked about the risk of an infection is much lower, but rectal bleeding, which is another complication of the transrectal approach, you're poking a needle through the rectal wall. So up to 30% of men after a prostate biopsy with a transrectal approach would get rectal bleeding.

So not surprisingly, we've eliminated that by doing the transperineal approach. So that's one less of a complication. And like I said, it's more precise in that it can target the anterior part of the prostate, the top of the prostate a lot better. And we can still do the fancy fusion techniques where we confuse the ultrasound with the MRI. If there's a lesion on the MRI, we can target that tumor in real time, just like we can do with the transrectal approach. But if the tumor's in the anterior part are in the top of the prostate, we can target a lot more accurately.

Dr. Scott Steele: So let's jump ahead and say now that the patient has a biopsy confirmed cancer, can you talk a little bit about what are the non-surgical options and what are the surgical options for it?

Dr. Zeyad Schwen: Yeah. Being here at the Cleveland Clinic has been really great because this center has revolutionized the minimally invasive surgical techniques for treating prostate cancer. The robotic approach for removal of the prostate, a prostatectomy, if you have a significant prostate cancer, this is an excellent way to treat and cure your prostate cancer in a very minimally invasive way.

In fact, we've kind of developed it to the point where it's largely an outpatient procedure. People can go home the same day compared to the open surgical approach, where you have a bigger incision. The robotic approach, you don't even really need narcotics either. You can just take Tylenol or ibuprofen and you can go home the same day.

So, we've got the multi-port robotic approach, which is where you've got the traditional robot, where you have multiple small, one-centimeter incisions, but we also have the single port robotic approach, which is a single incision. We do the entire procedure through truly one key hole. So you have one scar, which is better pain control, faster recovery, and patients are happier with the results.

So that's from a surgical standpoint, something that has really been revolutionized here at the Cleveland Clinic. Other treatments that are really effective for prostate cancer. Well, there's radiation where you can do radiation for the prostate, usually combined with the androgen deprivation medications. You can either do the external beams or the brachytherapy seeds.

There's another, really, revolution in prostate cancer treatment that's aimed at treating just the area of the cancer: focal therapy. And that's something here at the Cleveland Clinic that we do through the HIFU, which is the high-intensity focused ultrasound. And this is a way that we can just ablate the area of concern in men who have just a small focus of cancer in one part of their prostate.

We can really reduce the side effects associated with treatment by just ablating that area of the prostate. And that's another very effective cancer treatment. There's other ones that are a little bit less commonly done. One is called cryotherapy, where you can freeze the prostate. That's something that's not as commonly done anymore, just because of the higher risk of erectile dysfunction and some other complications that can be a little more devastating. But, yeah, if your cancer needs treatment, those are some very good options. Some cancers can just be watched with active surveillance.

Dr. Scott Steele: So what are the advancements on the horizon in the diagnosis and treatment of prostate cancer?

Dr. Zeyad Schwen: There's been many revolutions lately in the treatment of prostate cancer and the diagnosis of prostate cancer. A lot of that has happened in the space of people who have metastatic prostate cancer, so cancer that has already spread outside of the prostate. There's newer hormonal drugs. There's newer immunotherapy drugs that are incredibly effective at treating prostate cancer that has become metastatic.

Also, our ability to detect metastatic disease has improved. So in people who may get local therapy, meaning treatment of just the prostate, but have already had cancer spread, they may benefit from more systemic therapies like hormonal drugs or the immunotherapy. So our ability to really better detect metastatic cancer has improved with the PSMA PET scan, which is one of the newer pet imaging techniques that really can bind to the prostate cancer cells and light up.

So if there's cancer outside of the prostate, we can detect it a lot better. It's a time, prostate cancer can be very scary, but it's always great to know that there's been some tremendous research advances in the diagnosis and treatment of prostate cancer. So really that's something that the Cleveland Clinic has continued to be on the forefront for.

Dr. Scott Steele: That's fantastic stuff. And it's our time to get to know you just a little bit better and with our quick hitters. So first of all, what's your favorite meal?

Dr. Zeyad Schwen: Ooh, green bean casserole.

Dr. Scott Steele: Whoa.

Dr. Zeyad Schwen: Reminds me of Thanksgiving. My favorite meal.

Dr. Scott Steele: Have not had that before. I was going to ask you, what's your favorite word, but you already told me cruciferous. So we will go with what's your favorite sport?

Dr. Zeyad Schwen: Well, I played soccer growing up. I would say my favorite sport to play is soccer. I actually played at Case Western back in the day, but my favorite sport to watch is Formula 1 racing, hands down.

Dr. Scott Steele: You and my wife. And so what is a bucket list place that you would like to go to?

Dr. Zeyad Schwen: Probably Portugal. That's been on my list, but with how crazy it's been to fly lately, we're going to have to delay that one.

Dr. Scott Steele: Probably not the time. And then, you had said that you've kind of been all around. So tell us one of the things you like about being here in Northeast Ohio.

Dr. Zeyad Schwen: I would say that, well, it's a beautiful city. Right now, it's a beautiful day outside. There's a lot of parks, a lot of great places to be out on the water, too. Last weekend I was just taking a boat out on the Lake Erie, which is incredible. The people are wonderful, Ohioans. They're really special people. It's a city that you've got all four seasons for. So, if you like your summers, if you like your winters, you've got it both. It's great to be back.

Dr. Scott Steele: That's fantastic. So give us a final take home message for our listeners.

Dr. Zeyad Schwen: For people who are really interested in dietary management of things, eat a plant-based diet, cut down on the red meat, help reduce your risk of prostate cancer. Another take home message is get screened for prostate cancer. PSA screening saves lives. If you detect it early, you can cure the prostate cancer and help save your life.

You had mentioned when do you start getting screened before, most people would say screening starts at age 55. There's a yearly PSA screening test until age 69. But those who are at higher risk, meaning those who have either a family history, African Americans, they tend to get prostate cancer earlier, that can start as early as 40. And so that's something that really, you have to just talk to your doctor about your prostate cancer risk, about when to start screening and kind of catch this prostate cancer early if you do have it.

Dr. Scott Steele: Words to live by. And so for more information on how to schedule a prostate cancer screening at the Cleveland clinic, as well as other access to our patient services, please call the Cancer Answer Line at 866-223-8100. That's 866-223-8100. You can also learn more about Cleveland Clinic's advancements in prostate cancer screening, breakthrough biopsies, and more by visiting clevelandclinic.org/prostatecancercare. That's clevelandclinic.org/prostatecancercare. Dr. Schwen, thanks so much for joining us on Butts and Guts.

Dr. Zeyad Schwen: Thanks for having me on.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.