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Old 10-14-2009, 07:15 PM   #1
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clem752 HB User
wait six months for next psa test?

Just got the results from my last psa test and the message I got from the urologist was to wait and retest again in 6 months. Both my father and his father died from an aggressive prostate cancer. I'm 57 years old and here is a history of my psa tests:
4-96 1.9
7-97 1.4
9-99 1.9
5-01 1.8
12-02 2.0
7-04 1.5
1-06 1.52
6-07 1.5
10-08 2.4
4-09 4.3 subsequent biopsy found nothing
7-09 3.13 free psa was 13.4%
10-09 3.90

Anyone see any concerns with waiting 6 months before another psa test? The last 2 were after 3 months.

 
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Old 10-15-2009, 11:08 AM   #2
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Re: wait six months for next psa test?

Hi Clem,

Welcome to the board!

You and I share that worrisome family background, though I did not know that the cancer that got my paternal grandfather was prostate cancer until after my own diagnosis at age 56 as 1999 drew to a close. At least you have good family communication on that score, and you have an excellent PSA track record for comparison and trend watching. I'll insert some thoughts in green. I am a now savvy survivor, but I've had no enrolled medical education; I'm passing on what I have learned.


Quote:
Originally Posted by clem752 View Post
Just got the results from my last psa test and the message I got from the urologist was to wait and retest again in 6 months. Both my father and his father died from an aggressive prostate cancer. I'm 57 years old and here is a history of my psa tests:
4-96 1.9
7-97 1.4
9-99 1.9
5-01 1.8
12-02 2.0
7-04 1.5
1-06 1.52
6-07 1.5

That's a nice, enviable patter to this point. Although it is somewhat higher than the median PSA of 0.9 for men in their fifties who do not have prostate cancer (per Dr. William Catalona, MD, arguably the "dean" of American urologists), the trend is clearly basically stable and not indicative of prostate cancer.

10-08 2.4
4-09 4.3 subsequent biopsy found nothing
7-09 3.13 free psa was 13.4%
10-09 3.90

Anyone see any concerns with waiting 6 months before another psa test? The last 2 were after 3 months.

I too, knowing what I do now, would be quite concerned, both with that increasing PSA trend and with that fairly low free PSA result, though I can see why your urologist is taking a more relaxed view. My bottom line: I would insist on another look at three months.

I'm thinking the urologist's concern decreased when he saw that PSA of 4.3 in April drop back more than a point to 3.13 three months later. That kind of up and down pattern is typical of infection, so when he sees the increase to 3.90 in October, he's likely thinking that an infection is behind the pattern, and he could easily be right. Also, checking in six months is not a lax move, fairly prudent. He's probably thinking that, even if you do have prostate cancer, based on the trend your PSA will very likely not increase by more than 2 in six months, and diagnosis at that point would very likely be quite timely.

Here's the "other hand". Suppose you did or still do have some infection that is driving some of the PSA, especially that rise to 4.3, but that you also have underlying prostate cancer that is causing part of the increase in PSA. I'm thinking that, if you throw out that 4.3 but look at the trend using other scores, it could hint whether there is that tell-tale "exponentially" increasing PSA - suggestive of prostate cancer. The Memorial Sloan Kettering Cancer Center has published tools for calculating PSA doubling time (PSADT), and I just checked them. Essentially, depending on what values you keep in the mix of scores for calculating PSADT, your scores are consistent with that tell-tale pattern, with doubling times ranging from 17.12 months to 21.40 months, the latter if you use the June 2007 score in the mix. (As I did not know the exact dates, I chose the 15th of each month so that I would not be more than 16 days off for each score.) The trend line does vary a bit, depending on which mix of scores you use, but it is fairly robust. It's important to keep in mind that being "consistent" with the tell-tale pattern is only suggestive, not conclusive. Even with this probing look at the trend, infection still could be the main cause of the variation. There might also be a little BPH involved, which would increase the PSA result but not exponentially.

To me, that's enough of a concern to get another score in three months. It would give me greater peace of mind, and a whole lot of peace of mind if the score declined, or even if it were stable or just a slight increase. But I feel the urologist's preference is well within the bounds of sound practice, and I don't see that you would put yourself at that much greater risk by waiting six months.

Another detection tactic you could use would be to have a PCA3Plus test done. The doctor gives you an "attentive" DRE for about a minute, causing prostate cells to be shed into the urine. After a short time a sample of the urine is collected and shipped to one of the few labs that can analyze the results. The lab I hear most frequently for that test is Bostwick Laboratories. The PCA3Plus test is not influenced by infection, unlike the PSA and free PSA tests. It is not as sensitive as the PSA test (meaning that it takes a stronger "signal" to boost results into the range that indicates cancer), but it is far more selective: if your score is above a certain threshold, the odds are high that you have cancer. You can check the board archives to find several posts about the PCA3Plus test. Certain other and older versions of the technology are also available.

Here's another perspective altogether: using tactics to help prevent or minimize prostate cancer, especially the lethal kind that did in your father and grandfather. We now have gold-standard type medical research proof that the fairly mild drug finasteride (now generic, also available as brand name Proscar) reduces the risk of prostate cancer by 25% to perhaps as high as 30%, and does it safely, with a previous safety concern virtually resolved. In fact, the American Urological Association and the American Society for Clinical Oncology came out with a statement encouraging doctors to talk to their patients about finasteride for prevention. It's sister drug (both are "5-alpha reductase inhibitors" - 5-ARI) Avodart also recently successfully completed a prevention trial, though results have only been reported at a medical conference and have not yet been formally published. It too reduced the incidence of prostate cancer by about 25% and did it safely. A fairly small minority of patients on these drugs experience some reduction in libido and some ED, while the rest of us do just fine or even do better. The other concern is that they can affect pregnancy likelihood (somewhat decreased volume of ejaculate for one thing) and the fetus, so men still interested in reproduction are urged to bank sperm. Research has demonstrated that these drugs also enhance the usefulness of both PSA and DRE results, making them more reliable, once allowance is made for the likely halving of PSA in the first six months of use, resetting the trend line. (If the PSA falls by significantly less, that too is a clue there may be prostate cancer.)

The statin class of drugs is also a mild (for most of us) insurance policy as it sharply cuts the odds that prostate cancer will be lethal. The protection is substantially better when the patient has been on a statin for at least three years. (I've been advised that patients should take some Co-Q10 when on a statin drug; I take 50 mg daily.)

No lifestyle tactics have a similarly impressive pedigree as the drugs, but results for a number of the tactics are quite encouraging, though not conclusive. Some key facts and leads for these nutritional, exercise and stress reduction tactics are in a thread started 3/6/2008, "Nutrition & lifestyle tactics - books, resources and a quick summary." There are other stand alone threads on the board covering elements in these tactics such as pomegranate, vitamin D3, selenium, vitamin E, avoiding red meat (and pork), avoiding flaxseed oil, etc.

I can provide more detail, leads and background if you would like it.

I hope this helps, and good luck!

Take care,

Jim

 
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