More selective prostate biopsy approaches could greatly reduce health care pollution
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More careful patient selection for prostate biopsy would reduce health care pollution associated with the procedure, according to study results published in European Urology.
In the study, investigators assessed the environmental effects of prostate MRI and prostate biopsy, both of which are part of the diagnostic process for men with known or suspected prostate cancer.
“When we talk about the cost-effectiveness and downstream consequences of doing a biopsy, we believe environmental impact should be part of that conversation,” Michael S. Leapman, MD, MHS, associate professor of urology and clinical program leader of the prostate and urologic cancers program at Yale School of Medicine, told Healio. “It should be part of the conversation for all the things we do in health care. This is actually on a relatively small scale. Most procedures and treatments have a far bigger impact.”
Leapman discussed his study’s findings and explained how more careful patient selection for prostate biopsy can curb environmental impacts, reduce costs and spare patients potentially unnecessary testing.
Healio: What inspired you and your team to conduct this study?
Leapman: Everything we do in life and in health care has an environmental impact. People are often surprised by how much waste we generate in health care. Health care alone is one of the largest producers of carbon emissions and pollution worldwide. The United States is among the largest producers of greenhouse gases in the world.
Of course, this is not to say we shouldn’t deliver health care, but much of the waste is potentially avoidable. We wanted to look into the environmental impact of some common procedures we do. We focused on prostate biopsy because we recognize this procedure is overperformed. It’s an invasive procedure, it can cause complications, and it can be unpleasant. Of course, there are also costs involved.
There has been a long push and a movement toward being more selective in offering prostate biopsy to patients. In our study, we wanted to see what the environmental impact would be if we adopted a more careful approach to selection of men for biopsy.
Healio: How did you conduct your study?
Leapman: Currently, if someone has an elevated PSA level or is suspicious for prostate cancer, the recommendation is to perform an MRI of the prostate. Then, if there is an area that looks suspicious, we perform a biopsy of that area. The MRI can point you in the right direction, but it isn’t adequate to make a diagnosis of prostate cancer.
For our study, we broke down the process into three steps: the MRI, the biopsy and evaluation of the biopsy results. For the MRI step, we did direct observation of all the supplies that are used — the IV, the disposable equipment, and the sheets and linens, which have to be washed and reused. For biopsy, we took into account all the individual components we use, the disposable plastics, the sheets and the other supplies. We used a method called lifecycle assessment — the gold standard for studying this type of thing. We calculated all the waste that would be generated.
Then we looked at our main question: what if we used different techniques or methods to be more selective? One way to do this is if you have an MRI and it doesn’t show anything, you may be able to skip the biopsy. This is the approach that we think would be good for patients. We wanted to see the environmental impact of that.
Healio: What did you find?
Leapman: We estimated that performing 100,000 fewer biopsies would avoid 8.1 kg of carbon dioxide emissions. We also estimated that by using prostate MRI to carefully select patients who would undergo biopsy, we could reduce 1.4 million kg of carbon dioxide equivalent emissions per 100,000 patients. This is the equivalent of 700,000 L of gasoline consumed. That’s a lot. We do approximately 1 million biopsies per year in the United States, so many of these could be avoided if we did an MRI first and stopped there.
Healio: Did skipping the biopsies affect patient outcomes?
Leapman: We didn’t measure that directly in our study — we used evidence from prior studies. Large studies have explored this, and the more careful approach to biopsy is used in many parts of the world, such as in Europe — and particularly in the United Kingdom. If patients have an MRI and it doesn’t show anything, they tend not to biopsy. The tide is turning on this, so we wanted to know whether, in addition to the patient benefits and cost savings, what the environmental impact of a more selective approach would be.
Healio: Is there anything else you’d like to mention about this?
Leapman: There are other ways to stop testing even before the MRI. Some patients are screened with PSA outside of the recommended guidelines based on age and life expectancy. That also takes a toll on patients in terms of invasive testing and overdetection. So, if we can be really in line with the guidelines as far as who gets screened in the first place, we would benefit patients.
I would also like to make sure I highlight all the people on our team. The senior author, Jodi D. Sherman, MD, who leads an environmental research program at Yale, was the driving force behind this. We also had Cassandra L. Thiel, PhD, an environmental engineer at NYU, and Ilyssa Gordon, MD, PhD, a pathologist at Cleveland Clinic who studies sustainability. It was a great team and a wonderful collaboration.
For more information:
Michael S. Leapman, MD, MHS, can be reached at: Yale School of Medicine, 800 Howard Ave. Floor 3, New Haven, CT 06519; email: michael.leapman@yale.edu. Twitter: .
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