Transperineal Biopsy and Advancements in Screening for Prostate Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances a Cleveland Clinic Podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of cancer advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase 1 and Sarcoma Programs. Today I'm happy to be joined by Dr. Zeyad Schwen a urologic oncologist in the Glickman Urological and Kidney Institute. Dr. Schwen is here today to talk to us about transperineal biopsy of the prostate and advances in screening for prostate cancer, so welcome Zed.

Zeyad Schwen, MD: Thanks for having me on.

Dale Shepard, MD, PhD: Absolutely. So maybe just start, give us a little bit of a background. What's your role here at Cleveland Clinic?

Zeyad Schwen, MD: Yeah, I'm a urologic oncologist here, primarily treating prostate kidney, bladder cancer, as well as testicular cancer surgically, that's my clinical focus. I do have also a research focus and prostate cancer biomarkers detection, including the transperineal prostate biopsy, which we're going to be talking about today and finding ways to better detect and better identify prostate cancer.

Dale Shepard, MD, PhD: So when we talk about better detect and better identify, let's start with that. So there's, anytime we have a platform to talk about screening. There's a lot of confusion about prostate cancer screening. So kind of what's our position on screening and maybe give us a little background on that right now.

Zeyad Schwen, MD: Yeah, absolutely. Prostate cancer screening saves lives. We know that from many studies that have been showing a reduction in mortality and prostate cancer with screening, we do know that people typically want to be starting screening around age 50 and typically going yearly until age 70, some men with higher risks of prostate cancer, like African Americans or those with a high strong family history should probably start screening sooner. It's a blood test that you should be getting either through your primary care doctor or your urologist.

We know that people aren't getting their screening on time. And a lot of times, particularly in the COVID era where people have kind of put their screening to the wayside, understandably. So we've seen a greater proportion of people presenting late after the cancer has already spread outside of the prostate. And by then, we're not talking about cure, not curing the prostate cancer, but we're talking about just trying to control it. And that's something that we know that when we can detect it early, we can, if it needs treatment, treat it and try to prevent the development of metastatic disease. So that's important.

Dale Shepard, MD, PhD: And another thing you mentioned was better diagnosis. And part of that is diagnosing patients that actually need biopsies actually need to be treated, right?

Zeyad Schwen, MD: Absolutely, absolutely.

Dale Shepard, MD, PhD: Are we actually treating the right people?

Zeyad Schwen, MD: Prostate cancer is common. It about one and eight men would develop it in their lifetime. And it's probably greater than that because we know that a lot of men die with prostate cancer and of natural causes so that we know that there's a lot of indolent prostate cancers out there. And we don't actually want to find those types of prostate cancers. We want to find the kinds that are potentially life-threatening those that need treatment because we don't want to overtreat patients. And that's why it's important to kind of identify those who are at higher risk of having more aggressive prostate cancers. And that's with blood tests, also imaging and other biopsy techniques like the transperineal prostate biopsy to try to identify the type of cancer that requires treatment rather than the kind that would likely not cause you any harm.

Dale Shepard, MD, PhD: And then we're going to turn our attention to the biopsy itself. But Dr. Eric Klein was a guest on this podcast series in the past and talked about a test called IsoPSA. So tell me a little bit about where we are with that.

Zeyad Schwen, MD: Yeah, IsoPSA is a really great blood test biomarker for prostate cancer. It's really good at differentiating those who have more aggressive cancer that require biopsy and potentially treatment. It's a way that really is a smarter PSA test. It's a PSA like biomarker and there's a few others like it IsoPSA is a very fantastic one. Another one is called the prostate health index. That is a very similar type of a blood test. And we use these to get more information on the likelihood that there could be more aggressive prostate cancer. We are routinely using that here at the Cleveland Clinic for determining who needs to go on for a biopsy.

Dale Shepard, MD, PhD: All right. So patient gets screening. They have an elevated PSA. We may or may not have a situation where they have an IsoPSA to guide biopsy, it's time for a biopsy. Tell us about the options from a biopsy standpoint.

Zeyad Schwen, MD: Yeah, it's very interesting kind. I'm very interested in medical history and kind of identifying where things started from. The first biopsies were actually done with a finger guidance. You try to feel the lump with your finger. Then you can guide the needle into the prostate and identify the prostate cancer tissue that way.

Dale Shepard, MD, PhD: That doesn't even sound a little bit dangerous.

Zeyad Schwen, MD: It sound terrible. Nowadays we have ultrasound and guidance and we can actually do MRI and ultrasound fusion. And we can identify these lesions in real time. The most common type of prostate biopsies, the transrectal biopsy, where the needle actually goes through the rectum and into the prostate. That's the way over 95% of prostate biopsies are done in the United States. We do know that there is actually high risk and not surprisingly of developing an infection about 7% of men can get an infection even with giving antibiotics beforehand. And that's something that in 3% of patients actually can develop a severe life threatening sepsis infection, which requires admission to the hospital.

And people have dedicated their whole careers in trying to prevent these types of infections. And no matter what type of antibiotic we use or what other cleaning devices that we use when we do a transrectal biopsy, we you know that there's going to be a risk of an infection. A newer approach, which is actually kind of a blast from the past too, that people were doing back in the day, but that's kind of fallen out of favor, but now is coming back to the forefront is the transperineal prostate biopsy it's instead the needle goes through the skin into the prostate, and that is greatly the risk of an infection.

And also does not need antibiotics routinely to give beforehand. So we're doing better, what's best for patients in reducing the risk of an infection. And also studies are showing that it's better for cancer detection as well, that the transrectal approach typically could not sample. So you get better cancer detection, lower risk of an infection, and it's well tolerated by patients.

Dale Shepard, MD, PhD: So from the sampling of the prostate that has to do with the fact that there's portions of the prostate that are further away and you're not able to adequately sample?

Zeyad Schwen, MD: Yep, the top of the prostate, the anterior zone of the prostate traditionally is very difficult to sample through the transrectal approach. But with the transperineal approach, you got a straight shot to it. And as a result, you can have better detection of cancers that could be lurking and hiding in that part of the prostate. So better sampling of the gland in its entirety, and it's safer. So it's a no brainer.

Dale Shepard, MD, PhD: I'm going to, what might be a naive question is, why didn't people adapt that approach instead of the transrectal approach?

Zeyad Schwen, MD: It's a very good question. A lot of it has to do with training, because as I had mentioned that back in the day, people would do the transrectal approach because they could feel the prostate gland with their finger. But now that we have ultrasound and better imaging techniques, really, it's just a matter of time before this is going to be the primary form of prostate biopsy, moving forward. As people buy the instruments and also have the training to start to do them, thankfully here at the Cleveland Clinic, we're a leader in that. And we've been able to offer that to patients and not just at the main campus, but also in the region. So people come from far away actually to get this type of prostate biopsy here. And that's because it's getting out there that patients would prefer the safer biopsy approach.

Dale Shepard, MD, PhD: And so is this something that's primarily being done only at academic centers or the large urology practices, or?

Zeyad Schwen, MD: Yeah, that's a great question. In general, it is only being offered at the larger academic centers. Few urologists do this type of prostate biopsy. In other parts of the world in Europe, it's actually become the dominant form of prostate biopsy. And so most folks overseas can get that approach, but in the United States, it's really just a handful of centers, but it's growing rapidly in terms of where people can get this type of prostate biopsy.

Dale Shepard, MD, PhD: From a patient perspective. Is this about the same in terms of time recovery? Certainly the infection risk is lower, pain, things like that.

Zeyad Schwen, MD: Patients tolerate it really well. And that's something that can be done either under local sedation, just a lidocaine like the normal prostate biopsies are done, but also we offer sedation for those folks who may have a lower pain threshold, but it's well tolerated. The cost is the same for patients because it's billed the same as a regular prostate biopsy. And so it is just a matter of being able to offer patients that service.

Dale Shepard, MD, PhD: And is there anytime you mention cost, of course insurance comes to mind. Are there any issues with coverage?

Zeyad Schwen, MD: Generally not, it's the exact same cost for patients and in general for the healthcare system, it cheaper because we're not having to pay for people going to the hospital for severe infections. Also, we don't have to pay for antibiotics beforehand. So in general, it should be a cheaper form of prostate biopsy for the healthcare system.

Dale Shepard, MD, PhD: Are there any downsides?

Zeyad Schwen, MD: Well, it's really just a matter of finding the places that can offer them. It can be in some patients that don't have access to them may have a hard time getting that type of prostate biopsy, but really the national organizations that create guidelines for prostate cancer and prostate cancer detection, they're even starting to adjust the wording of those to say that the transperineal biopsy should preferred, the European urologic guidelines have already changed saying that the transperineal biopsy should definitely be the primary form. So it's really a few downsides, it's something that really is just a matter of finding the right places that can offer them and doing what's right for patients.

Dale Shepard, MD, PhD: Is there anything regarding patients themselves? Are there any patient selection factors? Are there any times when you might see a patient and they better suited for one type than another?

Zeyad Schwen, MD: Well, really we always offer both approaches for patients and we say, we've got the transrectal approach or the transperineal approach. And we do talk to patients about the pros and cons and it's a very easy sell for patients. They generally think intuitively and correctly so that when you stick a needle through the rectum where there's bacteria stool, and then that goes into your prostate, there can be very easily seeding of bacteria into the prostate.

And that's where infections originate. So it's an easy sell for patients. Patients are driving this as well. They're coming from far away to try to get this approach. And I expect in the next five years that this will be probably the more dominant biopsy in the United States. So this is a growing and shifting phenomenon. And it's something that, it's great to be part of a great team here at the Cleveland Clinic to be able to have the support, to do that and offer that to patients.

Dale Shepard, MD, PhD: Excellent. So we've talked a little bit about screening. We've talked about biopsies. We're going to talk in a minute a little bit about more the now you know you have prostates, what you do, but I guess just really quickly, is there anything that is kind of on the horizon that you find particularly interesting either from a diagnosis standpoint? We mentioned IsoPSA and some things, anything from imaging, anything in that arena that you find particularly exciting right now?

Zeyad Schwen, MD: It's great, there's such a boom and new technology and new research and prostate cancer detection. You mentioned Dr. Klein, he's part of a growing initiative to do kind of a liquid biomarker where you can detect DNA and tumor DNA in the blood. And that includes for prostate cancer. So you can screen for dozens of types of prostate cancer, just with a single blood test. And that's something that, is on the horizon, but still not quite there yet, but from the imaging standpoint for prostate cancer, there's another type of PET and a PSMA PET scan that we offer here at the Cleveland Clinic that can detect prostate cancer. And those men who may have a concern for spread, and it's a better way to identify who may have metastatic prostate cancer.

And I anticipate that's going to be on the forefront for localized cancer as well. And we can do fusion biopsies with also the PSMA PET scans in addition to MRI, which is another great new technology to detect prostate cancer. So yeah, there's a lot of great technologies on the forefront. Also another great growing area of interest in is active surveillance for prostate cancer. As you mentioned, what do you do once you have the diagnosis? Well, we know that a lot of people can be safely watched and that's where active surveillance comes into play.

And that's another major interest of mine finding ways to avoid overtreating prostate cancer and finding ways to make sure that we're not missing a window of a cure and also not having to over biopsy those people, because they'll need to be on surveillance. Sometimes you need to check in and finding ways to not turn the prostate into a pincushion is another good way to help patients quality of life.

Dale Shepard, MD, PhD: When you think about PSMA scans, certainly as a medical oncologist, I'm usually thinking them as someone who has had a definitive therapy, they've had radiation, they've had surgery now their PSA's going up and it's much more sensitive and we're able to detect metastatic disease far earlier than we could have in the past. But from your standpoint, as a urologist, you have someone comes in, they had an elevated PSA, they have a biopsy, you know they have prostate cancer. Now, how's that being incorporated into decisions to go forward with a surgery rather than maybe think of as a systemic disease, because we can find it now.

Zeyad Schwen, MD: Absolutely, and that's helped us get patients to the right treatment because before we were limited with just maybe a bone scan and a CT scan, which aren't very smart imaging tests, they would miss a lot of metastatic prostate cancer. So we were treating a systemic disease and a lot of men with a local therapy. And when the cat is out of the bag already, there's a different type of treatment that they would be a better candidate for. So for people who are very high risk or high risk prostate cancer, we're starting to make sure that they don't have metastatic disease before we consider them a candidate for local therapy like surgery or radiation. So it's something that as it's becoming more widely available, and this is kind of another area where it's an availability and a cost thing as that problem's addressed, it's going to be more commonly used, kind of to find out if you're a good candidate for a local therapy before pulling the trigger.

Dale Shepard, MD, PhD: And then when we think about how's the world these days from a urology standpoint, in terms of thoughts with taking out of prostate, even in a setting with, low volume metastatic disease, sort of that control of a primary and a metastatic setting. There seems to be a sort of resurgence of what do we do in that situation.

Zeyad Schwen, MD: It is going to continue. I expect because there's always studies showing even when it's metastatic that treating the primary source of the cancer, where it originated from may have a survival benefit. And then there's other studies that show the exact opposite. So there's a lot, there's a disagreement in the field right now. And I think most people are probably in the camp of, well, if it's metastatic, maybe the better is not to treat the primary source of the cancer and the prostate, because there is a morbidity associated with it, whether it's radiation or surgery, there's side effects associated with treating the prostate and whether or not we're going to be helping patients, that's something that's still to be determined.

Dale Shepard, MD, PhD: In terms of making that surgery as uncomplicated for the patient as possible. Tell me a little bit about what we're doing with minimally invasive surgery.

Zeyad Schwen, MD: You know that's one of the great things of being here at the Cleveland Clinic. We've been leaders in the field of robotic surgery for prostate cancer. Started with some of the giants here, Dr. Kaouk ho's very well known and Dr. Haber, who's our chairman. Both are at the forefront of that robotic surgery treatment for prostate cancer. And the minimally invasive surgery is getting even more minimal with the single port robotic surgery where we can do the entire surgery through a single incision. So it's a very key whole surgery, it's practically an outpatient surgery now.

Zeyad Schwen, MD: So back in, not so distant past people were in the hospital for a week, a lot of pain, a lot of discomfort. And now we're getting to a point where we can send people home the same day through a single incision, pain is well controlled to the point, or we don't need to send people home with any narcotics, Tylenol, and ibuprofen is pretty much all they need. So we're taking a surgery that was once kind of a bigger deal and making it more of an outpatient approach. And again, better tolerated, better for patients and good cancer outcomes. So it's something that we're seeing a lot of patients excited about that as well.

Dale Shepard, MD, PhD: That's great, anything else from a surgical side that looks promising in prostate cancer?

Zeyad Schwen, MD: There's a lot of people pushing the limits in terms of finding ways to make the surgery better make the surgery safer, make the surgery painful. And so there's some people who are considering doing more focal therapies for prostate cancer, which is a growing field. And we offer a few focal approaches. One of them is the HIFU, which is the ultrasound ablation of the prostate, where we can target just the air area where the cancer was found and leave the rest of the prostate behind.

And that does a few things. Well, one, it minimizes the side effects, so lower risk of urine issues, lower risk of having erectile issues after surgery. And it's also less painful and better tolerated. So it's one way that we could, in certain patients who are good candidates for it, where it's just focused in a one spot, we can sometimes just ablate that small area or just surgically remove that small area of your prostate. So that's something that we're doing more of, we're having better experience with it. Not surprisingly when you only treat one part of the prostate, you're still at risk of developing cancer in the other parts of your prostate.

So it still requires close surveillance afterwards, but in general, people would have fewer side effects. And that's something that we're always trying to find ways to cure the cancer and do what's better for the patients in terms of a recovery.

Dale Shepard, MD, PhD: Well, that's outstanding Zeyad, you've taken us from screening through biopsies and diagnosis to treatment and giving us some great updates and insights.

Zeyad Schwen, MD: Yeah, thank you. Thanks for having me on prostate cancer is still the second leading cause of cancer death in men. And that's something that we have a lot of work to do to bring that down. And we've seen it with screening a reduction in death and metastatic prostate cancer, but once it's detected also finding ways to get better cures in better results.

Dale Shepard, MD, PhD: Very good. Well, thank you very much.

Zeyad Schwen, MD: All right, thank you so much for having me on.

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