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Wait time for template biopsy

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User
Posted 29 Nov 2019 at 17:03

Hi Everone,


This is my first post so please be gentle with me 😘


My husband's journey so far:-


Feb  - first PSA blood test = 5.4 by gp


GP wanted 2nd blood test prior to referral


April - 2nd PSA blood test = 8 - referred to urology


May - TRUS biopsy, followed by admission for sepsis


June - follow up - negative result - 6 month follow up


October - Follow up PSA bloods = 20 - referred for MRI


14/10/19 - MRI


22/11/19 - Follow up..........


In our follow up appointment, 5 weeks after MRI, the Dr was blunt and told us the results were PIRADs 5, highly likely that he has T3bN0 PC.  He said he needed a template biopsy to confirm.  He took less than 5 minutes for the whole appointment, would not discuss any timescales for biopsy or enter into any discussion about cancer until diagnosis confirmed.


We were floored.  I asked him to confirm that it was highly likely that this was cancer but you cant give us any other information.  He was defensive about timescales not being in his control.


We then received a patient information leaflet in the post, no letter or appointment, just the leaflet so he called to enquire if it he had an appointment.  We were told the minimum waiting time for biopsy is 6 weeks but likely to be 3 months.


We know that prostate cancer can be slow but we are just in complete shock at the lack of support, information or compassion in the handling of this.  


Is it usual to wait 6 weeks to 3 months for a biopsy when MRI shows PIRAD 5 and PSA is 20?  


Hope someone can help as we are really worried and a bit shell shocked to be honest.


Thank you


Mandy xxx 


 


 

User
Posted 29 Nov 2019 at 18:50
That's shocking, in your situation I would:-
- check whether the hospital is 'failing' in inspections - you can check the CQC website
- go back to the GP to request referral to a different hospital
- contact PALS at the original hospital to complain
- if you have money, ask how much it would cost for a private template biopsy (be prepared for it to be quite a high cost as most do use a general anaesthetic for template biopsy so you would have to pay for theatre time, etc)

I would also seriously consider asking the consultant why he can't do another TRUS biopsy targeting the PIRADS 5 area; I assume that would be rather sooner than 6 weeks
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 29 Nov 2019 at 19:10

I had to wait 8 weeks - it's waiting for theatre time which is usually the issue. I was already on hormone therapy so the wait didn't matter (the HT would stop the cancer progression for a while).


You might ask to go on HT (150mg bicalutamide daily), because a T3b with likely some gleason 5 (which is basically what the PIRADS 5 suggests) isn't something you want to sit on for too long, and it's likely you will need radiotherapy for it. If it turns out you don't need RT after the biopsy and hence didn't need the HT, 3 months on HT isn't going to have any major impact.

Edited by member 29 Nov 2019 at 20:15  | Reason: Not specified

User
Posted 29 Nov 2019 at 21:11
Whoah, PIRADS 5 doesn’t predict elements of Gleason 5!
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 29 Nov 2019 at 21:31

I know that's not the definition, but the consultant radiologist who regularly does one of the support groups explains it's the radiographer's estimate of the highest Gleason present. When that's not found by biopsy, it usually means the biopsy missed it.


So although it doesn't mean that, it does predict that.

User
Posted 30 Nov 2019 at 02:51

You have been unlucky, as ‘best practice’ is to undergo an MRI scan (preferably mpMRI) BEFORE any biopsy.


When I was diagnosed with prostate cancer, two friends advised me to avoid a TRUS biopsy as they both had one and then had to undergo a second template biopsy. I was offered a TRUS biopsy there and then when they told me they thought I had cancer, but I declined and insisted on a template instead. The urologist was a bit flustered, and told me there was a ‘long’ waiting list, but the appointment for the template came through within two or three weeks.


Sepsis is a not uncommon complication of the TRUS biopsy, and together with its inherent inaccuracy, as in your husband’s case, is why more and more hospitals are abandoning it altogether in favour of the template procedure, under either a general or local anaesthetic.


It will do you no harm at all to rattle the cage of the PALS department, and I would expect his template appointment to come through in short order.


Best of luck.


Cheers, John.

Edited by member 30 Nov 2019 at 02:56  | Reason: Not specified

User
Posted 30 Nov 2019 at 03:07

Originally Posted by: Online Community Member
why more and more hospitals are abandoning it altogether in favour of the template procedure, under either a general or local anaesthetic.


TRUS is being abandoned for a local anesthetic transperineal targeted biopsy, but it's not a template biopsy. This new procedure has also replaced some transperineal template biopsies.


Unfortunately, this new procedure doesn't have a uniform name - every place calls it something different.

User
Posted 30 Nov 2019 at 05:22

So is the procedure you describe similar to a TRUS biopsy, the same ‘needle in a haystack’ approach with limited, say, twelve cores sampled, but without intestinal invasion? I had 42 cores sampled with my template biopsy, but the irony is Tommy the Tumour would have been detected by any biopsy, as he was so big, the b******!


I guess they still insert a rectal ultrasound probe, and try not to perforate the bowel which is done repeatedly during a TRUS.


Cheers, John.

Edited by member 30 Nov 2019 at 09:21  | Reason: Not specified

User
Posted 30 Nov 2019 at 07:39

Yes, exactly, except it's not needle in a haystack.


It must be targeted by an mpMRI scan image (PROMIS trial findings). Actually, what's usually done is something like 50-75% are targeted at the suspected tumor area, and the rest are distributed in other areas.


Two needle holes are made in the perineum and through pelvic floor, one on each side, and the needles are angled to aim as required. Also, unlike TRUS, samples can be taken from any part of the prostate (TRUS cannot reach the anterior, and is very difficult to sample the apex).


This was made possible by developing techniques for local anesthetic of the perineum and the pelvic floor area. PCUK was involved in funding this work.


WIth TRUS or this new procedure now being targeted (PROMIS trial findings), there's less requirement for template biopsies than there was before PROMIS.

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User
Posted 29 Nov 2019 at 18:50
That's shocking, in your situation I would:-
- check whether the hospital is 'failing' in inspections - you can check the CQC website
- go back to the GP to request referral to a different hospital
- contact PALS at the original hospital to complain
- if you have money, ask how much it would cost for a private template biopsy (be prepared for it to be quite a high cost as most do use a general anaesthetic for template biopsy so you would have to pay for theatre time, etc)

I would also seriously consider asking the consultant why he can't do another TRUS biopsy targeting the PIRADS 5 area; I assume that would be rather sooner than 6 weeks
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 29 Nov 2019 at 19:10

I had to wait 8 weeks - it's waiting for theatre time which is usually the issue. I was already on hormone therapy so the wait didn't matter (the HT would stop the cancer progression for a while).


You might ask to go on HT (150mg bicalutamide daily), because a T3b with likely some gleason 5 (which is basically what the PIRADS 5 suggests) isn't something you want to sit on for too long, and it's likely you will need radiotherapy for it. If it turns out you don't need RT after the biopsy and hence didn't need the HT, 3 months on HT isn't going to have any major impact.

Edited by member 29 Nov 2019 at 20:15  | Reason: Not specified

User
Posted 29 Nov 2019 at 19:52

Thank you both.  We're going to send a query through PALS and try to contact the consultant next week.  Really appreciate your comments.

User
Posted 29 Nov 2019 at 21:11
Whoah, PIRADS 5 doesn’t predict elements of Gleason 5!
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 29 Nov 2019 at 21:31

I know that's not the definition, but the consultant radiologist who regularly does one of the support groups explains it's the radiographer's estimate of the highest Gleason present. When that's not found by biopsy, it usually means the biopsy missed it.


So although it doesn't mean that, it does predict that.

User
Posted 29 Nov 2019 at 22:54
I don't think all radiologists would agree with the one you have been speaking to. If that was the case, PIRADS 3 would indicate a G3/4 and that is definitely not how PI-RADS was developed or rolled out. mpMRI identifies patterns; the PIRADS score indicates a sliding scale of likelihood of finding cancer of G7 or above, plus the size of the area of concern (e.g. PI-RADS 5 is >2.5cm or whatever) rather than a sliding scale of how poorly differentiated the cells are. If it was the case that a PIRADS 5 indicates a component pattern of 5, there would be no way to explain the recent situation where a new member was judged to be P5 and then given the all clear following template biopsy.

Is it possible that he was simplifying for the benefit of group members not as engaged as you?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 30 Nov 2019 at 00:30

I'll quiz him some more on it. However, he only claimed it's a prediction, not that it would always match. I have to say that it usually has been a good match when men tell me their full diagnosis.

User
Posted 30 Nov 2019 at 01:07
👍🏼
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 30 Nov 2019 at 02:51

You have been unlucky, as ‘best practice’ is to undergo an MRI scan (preferably mpMRI) BEFORE any biopsy.


When I was diagnosed with prostate cancer, two friends advised me to avoid a TRUS biopsy as they both had one and then had to undergo a second template biopsy. I was offered a TRUS biopsy there and then when they told me they thought I had cancer, but I declined and insisted on a template instead. The urologist was a bit flustered, and told me there was a ‘long’ waiting list, but the appointment for the template came through within two or three weeks.


Sepsis is a not uncommon complication of the TRUS biopsy, and together with its inherent inaccuracy, as in your husband’s case, is why more and more hospitals are abandoning it altogether in favour of the template procedure, under either a general or local anaesthetic.


It will do you no harm at all to rattle the cage of the PALS department, and I would expect his template appointment to come through in short order.


Best of luck.


Cheers, John.

Edited by member 30 Nov 2019 at 02:56  | Reason: Not specified

User
Posted 30 Nov 2019 at 03:07

Originally Posted by: Online Community Member
why more and more hospitals are abandoning it altogether in favour of the template procedure, under either a general or local anaesthetic.


TRUS is being abandoned for a local anesthetic transperineal targeted biopsy, but it's not a template biopsy. This new procedure has also replaced some transperineal template biopsies.


Unfortunately, this new procedure doesn't have a uniform name - every place calls it something different.

User
Posted 30 Nov 2019 at 05:22

So is the procedure you describe similar to a TRUS biopsy, the same ‘needle in a haystack’ approach with limited, say, twelve cores sampled, but without intestinal invasion? I had 42 cores sampled with my template biopsy, but the irony is Tommy the Tumour would have been detected by any biopsy, as he was so big, the b******!


I guess they still insert a rectal ultrasound probe, and try not to perforate the bowel which is done repeatedly during a TRUS.


Cheers, John.

Edited by member 30 Nov 2019 at 09:21  | Reason: Not specified

User
Posted 30 Nov 2019 at 07:39

Yes, exactly, except it's not needle in a haystack.


It must be targeted by an mpMRI scan image (PROMIS trial findings). Actually, what's usually done is something like 50-75% are targeted at the suspected tumor area, and the rest are distributed in other areas.


Two needle holes are made in the perineum and through pelvic floor, one on each side, and the needles are angled to aim as required. Also, unlike TRUS, samples can be taken from any part of the prostate (TRUS cannot reach the anterior, and is very difficult to sample the apex).


This was made possible by developing techniques for local anesthetic of the perineum and the pelvic floor area. PCUK was involved in funding this work.


WIth TRUS or this new procedure now being targeted (PROMIS trial findings), there's less requirement for template biopsies than there was before PROMIS.

 
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