Prostate Biopsies — Rate of Serious Infections Has Risen — Another Example of the Need to Be Aware of Medical Risks

© 2011 Peter Free

 

30 September 2011

 

 

Choosing a sensible course with prostates was already challenging — this new finding further complicates decision-making

 

Prostates are money-maker for urologists, but a sensible person’s cancer screening conundrum.

 

Many men are unwittingly taken down a prostate cancer screening and treatment road that is based on surprisingly little scientific evidence.  I have written about this before: here, here, and here.

 

Last week, Johns Hopkins Medicine added another cautionary note to routine prostate cancer screening.

 

Its study of Medicare records over a period of 16 years found that serious infections due to prostate biopsies more than doubled between 2000 and 2007, presumably as a result of the rise of antibiotic-resistant bacteria:

 

In their study, the researchers examined the frequency of biopsy related complications that required hospitalization in more than 17,400 men age 65 and older from 1991 to 2007.

 

They compared these rates to a cohort of 134,977 men during the same time period with similar characteristics who did not undergo a prostate biopsy. The researchers only looked at hospital admissions, not men whose complications were treated in an emergency department or outpatient setting.

 

While the rate of hospitalization following prostate biopsy has declined steadily since 1991, the researchers found that the rate of hospitalization during the time period was still two-fold higher among the men who had a biopsy (6.9 percent compared to 2.9 percent).

 

There was also a steady rise in the rate of serious infection-related complications.

 

At the onset of the study in 1991, fewer than 0.5 percent of men were admitted to the hospital because of an infection diagnosed following a prostate biopsy.

 

This rate remained stable until 2000, when rates of infection-related complications began to increase to more than 1.2 percent in 2007.

 

Those hospitalized had a range of complications, such as bleeding and infection, as well as flare-ups of underlying medical conditions, such as heart failure or breathing disorders.

 

Overall, mortality rates in men undergoing prostate biopsies did not increase.

 

However, men hospitalized with biopsy-related infections had a 12-fold higher risk of death compared to men who did not have a biopsy.

 

© 2011 Press Office, Johns Hopkins Study Reveals Significant Rise in Prostate Biopsy Complications and High Post-Procedure Hospitalization Rate, Johns Hopkins Medicine (22 September 2011) (paragraphs split, reordered, and emphasis added)

 

Senior author, Dr. Edward Schaeffer, hypothesized that antibiotic resistance accounted for the rise in hospital admissions.

 

The article also only looked at hospitalizations.  Presumably, if one includes non-hospitalized infections, the post-biopsy infection rate was significantly higher than the study reported.

 

 

Caveat

 

Because this study is not yet available at the Journal of Urology website — where it is apparently due to appear in the November issue — we do not know whether the researchers tried to equalize (normalize) medical conditions between the biopsied/hospitalized group and the control/un-biopsied patients.

 

It is medically probable that the biopsied/hospitalized group was actually sicker to begin with than the not-biopsied group.

 

If that’s so, the 12-fold higher risk of death in the hospitalized group is less meaningful than it might first appear.  Really sick people always die at a higher rate than comparatively healthy people.

 

 

The take-away message — prostatic biopsy is not a trivial procedure

 

Dr. Schaeffer put the study’s finding in perspective:

 

“Prostate biopsy is an essential procedure for detecting prostate cancers,” says Edward Schaeffer, M.D., Ph.D., a Johns Hopkins urologist and oncologist and the study’s senior investigator.

 

“Coupled with appropriate screening, prostate biopsies save lives. However, it is important for men to be aware of the possible risks of prostate biopsies, which are often described as simple outpatient procedures” . . . .

 

© 2011 Press Office, Johns Hopkins Study Reveals Significant Rise in Prostate Biopsy Complications and High Post-Procedure Hospitalization Rate, Johns Hopkins Medicine (22 September 2011) (paragraph split)

 

 

Why is there such a noticeable risk of infection?

 

Invasive procedures risk infections.  Always.

 

Biopsy needle access to the prostate is through the rectum, perineum (between anus and scrotum), or penile urethra.  The trans-rectal approach is most common.  Obviously none of these methods is completely sterile, which explains why patients are put on an antibiotic after the procedure.

 

In the pre-antibiotic resistance era, people assumed that infections could easily be treated.  In the resistance era, this is less true.  And patients now need to be aware that infections are dangerous, even in comparatively healthy patients.

 

 

In low and normal risk patients — weighing biopsy risks often involves large amounts of uncertainty as to whether the procedure itself is actually necessary

 

Medical screenings for prostate (and breast cancer) are loaded with uncertainty-related booby traps for the unwary.

 

Medical practitioners face a disappointing lack of proven science in regard to which screening tests and procedures actually work to reduce overall mortality.  Physicians, understandably, tend to use whatever they can — thoroughly proven or not — in hopes that using even weak tools will promote their patients’ longevity and quality of life.

 

For patients, aspects of the “screen or not to screen” dilemma are made more difficult because medical professionals are often strong in promoting screening (for the above reasons), but somewhat weaker on thoroughly explaining the physical and psychological risks to doing it.

 

The patients’ “risks-balancing” conundrum comes down to the facts that: (a) the science underlying recommended screening procedures is often significantly less persuasive than practitioners recognize and (b) the risks to screening larger.  This is particularly true with screening for prostate cancer in low and normal risk patients.

 

There is another subtlety to the assessment of risk.  This is the fact that, once the “train” of detection and treatment leaves the medical “station,” a patient is pretty much stuck on seeing it through all its stops, psychologically speaking — even when no cancer is actually present.

 

The medical train may make multiple stops/interventions along the way.  These stops can result in accumulated intervention-caused risks.

 

For example, it is not uncommon to find oneself undergoing a “routine” screen — like a digital rectal exam or PSA (prostate specific antigen) level check  — and winding up submitting to multiple biopsies, and even unnecessary surgery, as a result of suspicious findings or false positives.

 

If the frequency of suspicious results — loosely called “false positives” — were low, boarding the medical train would not matter.  The overwhelming majority of its passengers would be en route to dealing with actual cancer(s).

 

But with prostate cancer screening, the combined rate of (i) suspicious findings, (ii) false positives, and (iii) true positives for non-aggressive cancers is comparatively high.

 

As a result, a disturbingly large proportion of the prostate trains’ passengers undergo arguably unnecessary financial, physical, and psychological costs during their journey.

 

For example, 65 to 75 percent of men who undergo prostate biopsies as a result of high levels of PSA levels do not have cancer.

 

And that is why it is important to weigh the very real risk of infection (after biopsy) against the difficult-to-quantify risks of foregoing the biopsy and even the initial screening.

 

 

The moral? — Fully participate in medical decisions that affect you

 

Everything has risks.  Everything has costs.  Weighing them is difficult, especially in medicine.

 

The more you know, the better off you are when it comes to making satisfying decisions in regard to your health care.  Formulating your medical philosophy is best done by researching your ailments and making a habit of speaking honestly with your physicians and surgeons.

 

In this regard, a surprising number of patients actively conceal information, ignorance, and philosophical inclinations from their doctors.  This helps no one.  It makes coping with medical uncertainty more difficult for the practitioners involved in our care.