A Call to Arms

Raoul S. Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

The year was 1989, and I was one year away from finishing six years of residency in general surgery and urology.

After months of soul searching and anguish, I felt it better for me to forgo another 2 to 3 years of urologic oncology fellowship training and instead enter into private practice with an established group in Nashville. My charge, once I arrived the following year, was to advance urologic oncology and lower urinary-tract reconstruction, areas that were of particular interest to me then and still are to this day.

However, a perfect storm was arising in the field during that time. A new blood test, PSA, was gaining traction, as was the expanded role of transrectal prostate ultrasound, to aid in the diagnosis of prostate cancer.

For those of you reading this who trained after 1990, it is doubtful you ever had the joy of the triangulation method to biopsy the prostate: one finger in the rectum to palpate the area of suspicion on the prostate, a blind transperineal approach with a 14-gauge Vim Silverman Tru-Cut needle, and the hope that you did not shave off the top layers of epidermis of your index finger. Because of PSA, more and more biopsies were being performed, with or without an abnormal digital rectal exam. The blind transperineal or transrectal approach was unacceptable and carried a high complication rate. The new approach of ultrasound-guided biopsy was coming of age and gaining popularity across the country.

My future employer felt it wise that, before my employment commenced in 1990, I should attend a course on prostate ultrasound and biopsy, given that I was at the time toiling away at the VA hospital where that technology was nowhere near in sight. It surprised me, however, that the course that nearly everyone was attending to learn this technique was not at a major teaching or academic institution. The destination hub was Mobile, Alabama. A semi-retired urologist had convinced his group to allow him to work on this new technology and bring it to their practice. His name was Dr. William Cooner. He recognized the shortcomings of prostate biopsy and devised a better system.

I recall walking into the procedure room of his office and finding a scene exactly like the one many of us use to perform the biopsy today. Dr. Cooner even had a monitor in front of the patient so that he could watch the ultrasound in real time. My generation of urologists learned this technique, either directly from this southern gentleman or due to his inspiration. And because ultrasound equipment was readily affordable and the number of biopsies was going up dramatically, the rest, as they say, is history. (As many of you may know, because of his work, Dr. Cooner was invited to join the staff at Emory University in Atlanta, where he continued teaching prostate ultrasound until his untimely death of esophageal cancer in the mid-’90s.)

Fast forward 25 years to 2014. For the most part, we are performing prostate biopsies the exact same way that Dr. Cooner described. However, we are all well aware of the current limitations of this sampling and the understaging of those that we diagnose with prostate cancer, not to mention the controversies around negative biopsies and significant/nonsignificant lesions. We need a better system.

The role of multiparametric MRI and ultrasound fusion biopsy of the prostate is looming on the horizon. Is it perfect? No, but it does represent a movement forward with many questions to be answered. PSA was a marked advancement from prostatic acid phosphatase. But like sextant biopsy, it too has probably outlived its usefulness as the prime driver to determine who needs biopsy. The burgeoning role of biomolecular testing will surely have a significant impact. But the costs and clinical utility are yet to be determined, especially as we move into the era of value-based medicine.

The lines between academic and community urologists are becoming more blurred. Those who practice in larger groups, just like our brethren in teaching institutions, have the ability, should they so choose, to be on the forefront of cutting-edge technology, and in helping to advance science and medicine. Working cooperatively with our academic colleagues and industry, the opportunities are abundant. We have made significant headway in the management of castration-resistant prostate cancer. In an area that heretofore was never thought to be part of the traditional practice of community urology, many of us have embraced the newer therapies by working in conjunction with our friends in the ivory towers, and have created centers of excellence to better manage these difficult patients.

Developing trials that will utilize both multiparametric MRI and next-generation sequencing/biomolecular markers requires this joint effort in order for us to maintain our stronghold on prostate cancer. We owe it to ourselves and the field of urology. More importantly, we owe it to our patients and their families.