Prostate biopsy can be risky: More men getting ill from drug-resistant infections

Shane Greenstein only vaguely recalls being told that a prostate biopsy he had in June was negative for cancer. That's because within two days of the exam he was in the hospital with a potentially deadly blood infection.

'It was the worst illness I have ever felt in my life,' said Greenstein, 50, an economics professor at Northwestern University who sought emergency-room treatment in Evanston, Ill., 10 hours after feeling 'mild flu-like symptoms.'

Doctors gave him intravenous fluids to maintain blood pressure and prevent shock, a complication that could lead to a cascade of symptoms including organ failure and death. Greenstein was saved when the third antibiotic he was prescribed, an intravenous one, managed to kill the bacteria.

Among the millions of men tested for prostate cancer around the world each year, doctors are detecting an alarming trend: An increasing number of patients are getting sick from potentially lethal, drug-resistant infections.

Studies emerging during the past year have uncovered that a small yet growing percentage of those undergoing routine needle biopsy tests are becoming critically ill and dying from bacterial infections. Infectious complications including sepsis, the condition Greenstein had, from prostate biopsies have more than doubled in less than a decade, studies from three countries show. Nine out of 10,000 men whose tests were negative died within a month, researchers in Toronto reported in the Journal of Urology in March last year.

The new reports, by urologists from Baltimore to Singapore, are forcing doctors to rethink their approach to screening for prostate cancer, the most common malignancy in men. The newly uncovered risk of dangerous infections is adding to concern that the tests are being overused, leading to aggressive treatment that may cause some men more harm than good.

The studies also are exposing another deadly risk attributed to the global rise of infections that can't be readily treated by existing antibiotics.

'We're all beginning to see more and more sepsis as a result of resistant bacteria after prostate biopsies,' said Peter T. Scardino, chief of surgery at the Memorial Sloan- Kettering Cancer Center in New York, which does about 2,000 of the tests annually. 'This is an extremely worrisome problem.'

Doing a tissue biopsy of the prostate to detect cancer typically entails sending an ultrasound-guided needle about a dozen times through the rectum to collect specimens from the walnut-sized gland that sits under the bladder. The test carries an infection risk because the needle can take bacteria from the bowel into the prostate, bladder and bloodstream. The 15-minute procedure, usually performed in a doctor's office, can be dangerous if the bacteria are resistant to antibiotics given at the time of the biopsy.

'It's a significant threat,' said Florian Wagenlehner, head of urology at University Hospital Giessen, near Frankfurt, who is researching infectious complications from prostate biopsies in Europe. 'If you have 1 million procedures a year in Europe and you have a 1-to-5 percent infectious complication rate, it's unacceptable.'

More than 1 million transrectal prostate biopsies are done in the U.S. each year to diagnose cancers in men whose screening blood tests suggest they may have the disease. No studies have examined the risk of sepsis globally. Instead doctors are trying to gauge the scope of the problem from studies beginning to emerge from North America, Europe and Asia.

'The fact that there is a mortality rate associated with the procedure, that's concerning,' said Robert Nam, head of genitourinary cancer at Toronto's Odette Cancer Centre, who led the largest study to date of hospitalizations after biopsy.

Nam helped uncover the emerging infection risk last year after he trawled through more than 75,000 electronic records of biopsy patients treated in Ontario between 1996 and 2005. When he looked at hospital admissions among patients whose biopsy was negative for cancer, Nam discovered the chance of being hospitalized within a month of the procedure had increased fourfold in less than a decade, reaching 4.1 percent in 2005 from 1 percent in 1996, according to the Journal of Urology report.

'There's not just smoke, there is a fire. No question,' said Gilbert J. Wise, 78, clinical professor of urology at New York's Weill Cornell Medical Center, who has practiced urology since 1969. 'I'm personally aware of two deaths — they're not mine, thank God — in patients following biopsy. So it can happen. It's a shame. You do something, there is no cancer, and they die of the procedure.'

Infectious complications are adding to debate over so- called PSA screening, a blood test for a protein produced by prostate cells known as prostate-specific antigen. About 30 million American men get the test annually, costing at least $3 billion, said Richard J. Ablin, the scientist who discovered PSA. Still, the exam can't detect prostate cancer nor distinguish between the 'type that will kill you and the one that won't,' he wrote in a March 2010 opinion piece in the New York Times.

'The test's popularity has led to a hugely expensive public health disaster,' wrote Ablin, a research professor of pathology at the University of Arizona College of Medicine in Tucson. 'The medical community must confront reality and stop the inappropriate use of PSA screening.'

Men most susceptible to harboring resistant bacteria include those who have taken antibiotics in the year before the procedure; who have recently visited countries where resistance is common in the community; and those who work in a hospital or live with someone who does, said David Bell, a urologist in Halifax, Nova Scotia.

Bell, who is head of the urology department at Dalhousie University, and colleagues reported three cases of sepsis from multidrug-resistant bacteria in doctors who underwent prostate biopsy in the Canadian Journal of Urology in April last year. One of the physicians, a 44-year-old whose biopsy was negative for cancer, died.

Prostate biopsies also are controversial because a cancer diagnosis doesn't necessarily save lives. A two-decade-long study led by Gabriel Sandblom of the Karolinska Institute in Stockholm found that PSA tests and digital rectal exams helped detect cancer but didn't reduce deaths. A separate study from Sweden last year showed that 293 men needed to be invited for a cancer screening and 12 had to be treated to prevent one death.

An estimated 217,730 men were diagnosed with prostate cancer and 32,050 men died of the disease in the United States last year. U.S. medical costs linked to prostate cancer care were estimated at $9.9 billion in 2006.

Michael Liss, a chief resident in his final year of urology training at the University of California, Irvine is researching a test that will help doctors predict the best antibiotic for preventing infections. Liss was prompted to look for ways to make the procedure safer after almost losing a patient to sepsis three years ago.

Biopsy candidates who recently traveled to India, China and other parts of Asia should wait six months after their return before having the procedure, said Anthony Costello, who does about 200 biopsies a year at prostate cancer clinics at the Royal Melbourne and Epworth hospitals in Melbourne. He estimates two of every 100 biopsy patients will develop sepsis. About 26,000 procedures were done in Australia last year, more than double the number a decade earlier, government statistics show.

One in six men in the U.S. will be diagnosed with prostate cancer during their lifetime, according to the National Cancer Institute in Bethesda, Md. Even so, fewer than 3 percent of men will die from the malignancy.The American Cancer Society changed its guidelines in 2010 to reflect a growing body of research suggesting screening tests may do more harm than good in some men. The cancer group said patients should be warned of the risk of misleading tests results and treatment side effects, which might in some cases cause more damage than the slow-growing disease.

'There has been this huge enthusiasm for everyone getting their PSA checked, which has led to a lot of prostate biopsies that have not benefited anyone,' said James R. Johnson, an infectious diseases physician at the Veterans Affairs Medical Center in Minneapolis. 'The more dangerous the biopsy becomes because of infection risk, the more likely it is that the balance is shifting toward harm, rather than benefit.'

Sepsis survivor Greenstein said the desire to get an early jump on prostate cancer is such that it wouldn't dissuade him from a repeat biopsy if it's recommended.

'The risks are too high,' the father of four said. 'You've got to do what you can to avoid it.' But at the first sign of a problem, he said he would seek medical help. 'I would go to the hospital at 8 o'clock, rather than wait until the next morning.'