Matthew Fowler:
Welcome to the latest episode of the “Oncology Peer Review On-The-Go” podcast. I’m your host Matthew Fowler, and today is Monday, January 31st. This week I spoke with Dr. Matthew Allaway, founder and CEO of “Perineologic” about a new prostate cancer biopsy technique that uses the transperineal approach to detect cancer in harder-to-reach areas of the prostate. We discussed the American Cancer Society’s annual report that shows the rate of advanced stage prostate cancer cases are increasing in recent years. We also examined a companion study to that report and Dr. Allaway walked me through the specific details and benefits of this new biopsy technique. Take a listen to our conversation!

Matthew Fowler:
Dr. Allaway, Thank you so much for taking some time out of your day to speak with me. I want to first set this baseline understanding, and talk a bit about this annual report that came out from the American Cancer Society. Could you just give a brief overview of “what that is” and “why it’s significant”?

Dr. Matthew Allaway, DO:
Well, every year we attempt to track the number of cases of each particular cancer: not only the incidents, but also the mortality. For different cancers, the incidents and the mortality rates do change over time, so it’s really important to have a pulse on that. Although it’s a little bit interesting too, because we’ve been in COVID for the last two years and I was very interested to see how the numbers we are seeing can be affected by the fact that for prostate cancer, this is a cancer that requires a sort of “screening pathway” and that “screening pathway” has been obviously disjointed during the times we’re living in, but prostate cancer in general is really pretty consistent as far as incidents and mortality. And of course the most important highlight, which we’re seeing again with the annual report is the fact that prostate cancer is the most common cancer in American men, but it’s the second most common cancer killer, second to lung. And women, it follows the same trend: you know, common cancer, second, most common cancer killer. So there’s a lot of similarities between this cancer of a man and the breast for a woman.

Matthew Fowler:
Right. And with this report, there was a companion study that was released and it touched on a number of cancers, including lung, breast, and prostate. But I want to specifically focus on prostate with you: would you talk a little bit about what you saw with prostate cancer trends in that study, and what your main takeaway was from that research?

Dr. Matthew Allaway, DO:
Some of the important takeaways is that we’re now… well…. it gets a little bit deeper than some of the findings in the study, but some of the important take home messages that now “screening” is not just “screening, doing a digital rectal exam and a PSA”. We are much more savvy in our use of prosthetic MRI scanning to help screen and select patients even more carefully before the decision to biopsy. Of course, biopsy is the actual way that we establish the true diagnosis, and which type of prostate cancer that the patient has. Mortality rates from prostate cancer is actually if you track them historically, (and you see this in the report) is that mortality rates are beginning to drop. I mean, it’s not a dramatic, like fall-off -the-cliff drop, but there are improvements in survival, certainly. And that’s a very encouraging sign! I think sometimes the incidents is affected, again, I think the factors of the COVID world we’ve been living in is certainly a reason, I think the incidents is truly much higher than we’re seeing in the report. And I think it’s going to have to sort of flush itself out over the coming years. So I think what you’re going to see in further annual reports is that the incidence is actually going up, but that may not be truly an indication of prostate cancer being more likely, but rather picking up those individuals that have been kind of lost in the weeds with screening that hasn’t really been taking place over the last two years.

Matthew Fowler:
Right. That definitely makes sense. So if I understand correctly, there’s a new biopsy technique that you invented for detecting prostate cancer. Could you just kind of give us an overview of that and talk a little bit about how that works?

Dr. Matthew Allaway, DO:
Well, this is really such an exciting time of change, and let me kind of paint this picture of “what has happened historically” so you have a sort of a basis for why this is an exciting change in what we’re providing. Historically, the prostate biopsy was performed by placing an ultrasound probe in the patient’s rectum, so you could actually see the prostate and then with the probe in that position, you slide a biopsy needle within a needle guide that then passes through the rectal wall to get into the prostate. The rectum contains an abundance of bacteria: it’s contaminated field and there’s no way to sterilize the rectum before placing the needles through it. Normal surgeries or biopsies anywhere else in the body, we’re able to put an antiseptic on the tissue and then go in with the needle. This is the only example where we’re actually putting a biopsy instrument through a completely fecally contaminated organ into another organ. So essentially you’re putting the patient’s own fecal material, injecting it into their bloodstream, via the prostate. Now, unfortunately, this has been the reality we faced for last 37 years because engineering and the physics of what we were trying to do only truly allowed us to do it this way and be easy and repeatable and done under local anesthesia in an office setting. So to mitigate this risk of sepsis and infection, which by the way, occurs in up to 6% of patients, I mean, it could be as low as 1%, but realistically it’s probably around 2% to 3% on average around the world, but as high as 6% or 7%. So to get around this, we just keep throwing new and more antibiotics at the patient, because what happens when you overuse antibiotics, they suddenly don’t work because the bacteria develop what’s called “resistance”, based on their exposure to the antibiotics. So now we’re reaching what we’re calling “the post-antibiotic era”, where the antibiotics that we have actually will not treat certain bacteria that have grown a multi drug-resistant pattern. So this came front and center in about 2010. Now this is where we stepped in. I, as a urologist who has been practicing for 20 years, realized that this biopsy technique should no longer be performed because of the safety issues, but also missing cancers. Because if you look at the physics of the prostate, sitting there with an ultrasound probe and at this other angle to reach the top portion, or what we call “the anterior apical portion” of the prostate, getting there is rather challenging. So these were the two problems, and one day I just decided: I’m no longer going to perform this procedure, but I’ve got to come up with a better technique. And so this concept of “freehand transperineal biopsy” originated. So the perineum is the anatomy, between the scrotum and the anus. It’s also referred to as “the taint”, if you will. So I realized that the perineum was the perfect anatomical landscape. One: we could actually clean the skin and remove bacteria so that when we pierce in through it to get to the prostate, we’ve now entered in a sterile fashion. That way we don’t even need to use antibiotics, and the risk of infection should drop to essentially zero, which is what we are able to do. Next most important point is that if you’ve got the prostate sitting here and you’re entering the prostate, we’re able to enter the top prostate or the anterior prostate, we can equally enter the prostate posterior. And even more importantly, the biopsy capture gets into the relevant portions of the prostate, because the prostate has different zones. It’s not just one spongy object: there’s actually distinguishable zones within the prostate and cancers happen to occur in a couple of those zones, but not in others. The way we enter into the prostate, every millimeter of biopsy tissue sample includes that relevant tissue. So we accomplished the complication issue, and we’ve been able to now sample the entirety of the prostate and improve our cancer detection. And we do this…. and this is the exciting part of it: imagine being able to do something so thorough, but only through two punctures in the patient’s anatomy! So with the methodology, there’s only two punctures, placed like a little snake bite: one the right, one on the left, but through this common access point, we can shift and move our position and our angle of biopsy in innumerable ways so that we can biopsy as many areas of the prostate through that single puncture. This you can actually offer to the patient even under local anesthesia, just like the old fashioned transrectal approach. So really we’ve checked off all these important boxes. The patients are very, very excited about this because now the patient doesn’t have to go through bowel preparation, they don’t have to take antibiotics, they don’t have to worry about infection. And when we give them a clean report that says you don’t have cancer, we can take that to the bank with a lot more confidence than we ever could before. And if you also combine this method and pathway with the introduction of prostate MRI scanning, we make the experience even better. And so I can now sit in a room with a patient and I can actually get excited about the fact that I can do something so well, and patients key in on this and they start to spread the word and suddenly this process of “screening and biopsy” is not one that they have to fear like they would in the past. And so I think we’re going to do a much better job in assessing the population, reducing the risk of unnecessary complications and improving the accuracy and diagnosis.

Matthew Fowler:
So you’ve mentioned here a number of really benefits for patients with this new technique, but I’m wondering what this will do, or what caregivers would stand to gain from incorporating this new technique into their prostate cancer related practices.

Dr. Matthew Allaway, DO:
Well, I’ll tell you one of the most interesting findings that we’ve noted over the last four years, since implementing this method: that is that when we discuss what we’re doing now with the primary care physician, (because the primary care physician is the screening gatekeeper) patients go to their primary care, getting a PSA test, getting a digital rectal exam. It’s them referring the patient to the urologist where we get an opportunity to further the process of screening and diagnosis. So when we talk about what we’re doing, we’ve suddenly inspired the primary care physicians to actually get more involved in screening. Because if you look back to like 2000, when we were having all these problems and complications, the primary care hears about it, the patient goes back and says, “Boy, that was a horrible experience! It was painful. I got infected, they didn’t find cancer.” And the enthusiasm the primary care had for screening had dipped. Now, once we educate the primary care about what we’re doing suddenly they’re enthusiastic and they want to start screening better again. And truly like all cancer, “screening is key, early detection makes a difference”.

Matthew Fowler:
Absolutely. And, so looking at this technique, I know you’ve mentioned like you are utilizing it in your practice. Have you seen this new technique, you know, expanding outside of your, your clinic?

Dr. Matthew Allaway, DO:
Yes. As a matter of fact, it’s now become kind of a household name: this idea of “freehand transperineal biopsy”. It’s actually it’s more than a method. It’s actually a specialized device that is used to perform the procedure and this device is “an access system”. So this is the instrument that allows you to accomplish all these feats through the two punctures. So what we’ve seen now is that it’s spreading globally. In fact, we just got a report back from the United Kingdom and currently 70% of the biopsies performed now in the UK are performed with this method and this access system. And that’s over a period of just a little over two years. So from a very small sort of scratch-the-surface to 70% penetration: that’s what’s happening! So we see that trend also occurring in Australia, New Zealand and other parts of the European Union. And in the US or North America, it’s equally spreading rapidly. Now you could pack stadiums with men who have had biopsies done in this fashion. And that’s so exciting because at the end of the day, we’re taught as Doctors, “first do no harm”. Okay. Unfortunately we violate that principle with old techniques. Now we’re actually giving tools and skills to our urologists to respect the fact that “first do no harm” and then “do a great job”. So it’s really, it’s expected to be the new standard of care as far as biopsy of the prostate.

Matthew Fowler:
I think helps me transition into into my last question for you, to wrap things up: “How do you see this technique really impacting the way prostate cancer is treated, managed, found, or otherwise cared for in the coming years?”

Dr. Matthew Allaway, DO:
Well, this is where it gets even more exciting! So clearly the foundation is built on the biopsy. So once we do a better biopsy with MRI scanning to help us really map out the patient’s prostate. Now, we suddenly realize that there are cancers that may be isolated to just one area of the prostate, and the remainder of the prostate being completely normal. So think about this for a minute. If suddenly we know with confidence, “this is the only area of concern”, now it opens the door to better treatment and alternative treatments. For example, “focal therapy”. Focal therapy is the concept where, instead of destroying the whole prostate via radiation or removal, now we can actually target just the area of concern. For example, with breasts, we used to take the entire breast off or do a mastectomy, but now we do basically an extended lumpectomy. And we can do something quite similar to the prostate. But without this technique, it was very hard to be confident that you’ve really adequately sampled the entire prostate. So if you thought there was only a lesion here, but in fact, you missed the disease in another area of the prostate, you would be doing a great disservice to the patient with focal therapy because prostate cancer is unique in the fact that it often is multifocal. So there may be a focus on the right side. There may be a focus on the left side. So the positive for the patient is now they may have more options for treatment, and with a more limited treatment, like focal therapy, we don’t have to worry quite as much about the risks of urinary incontinence, erectile dysfunction, and other downsides to full gland treatment that happens after surgery or radiation.

Matthew Fowler:
Perfect. Well, Dr. Allaway, those are all the questions I had for you. Was there anything that you wanted to add to this conversation that we haven’t already touched on yet?

Dr. Matthew Allaway, DO:
I would only add that we’re now undergoing a multi-generational shift in “how we do what we do”, and it’s really exciting to be part of that process, to help and educate and train and move the field forward. I get so thrilled when I can actually have a patient go through these experiences and they come back saying, “Wow, I mean, that was easy. That was smooth. And I have confidence. I know what I am dealing with!”. There’s much more to say as, as time goes on. So stay tuned!

Matthew Fowler:
Absolutely. I will. Well, thank you so much for your time, Dr. Allaway: I really appreciate this insight.

Matthew Fowler:
Don’t forget to subscribe to the Oncology Peer Review On-The-Go podcast on Apple Podcast, Spotify, or wherever you get your podcasts. Or listen online at Cancernetwork.com/resources/podcasts. The Oncology Peer Review On-The-Go podcast is the official podcast of Cancer Network, the home of the Journal Oncology. For more information, visit us at www.cancernetwork.com and find us on Twitter at Cancer Network, (without the “O”) or on Facebook and LinkedIn at Cancer Network. Thanks so much for tuning in! We’ll see you again. Next time.

Listen to the interview on cancernetwork.com.