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Old 06-14-2010, 04:33 PM   #1
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Should we seek a 3rd opinion for how to proceed after a PSA test?

Hi there:
I am posting this on behalf of my husband. 5 months ago he went to our family practitioner for a routine physical and she ordered a PSA level on his blood test along with all of the other regular assays. He was 38 yrs old at the time, with no immediate family history of prostate cancer. The PSA level came back at 1.7 (high for his age) so she suggested he go see a urologist. The urologist retested him, and came back with the same result (1.7), and suggested that he wait several months to get tested again. Also, neither the family doctor, nor the urologist's DRE found anything abnormal. In May, the result came back at 2.1 (3 months later). He suggested that my husband get a biopsy because of the rapid increase in the PSA level.

We decided to seek a second opinion instead of jumping right into a biopsy, given his age and history. The second doctor has taken a completely different stance, and seems quite fixated on the fact that my husband was too young to be screened in the first place. He says we should wait at least 3 months to retest, and even then the only way you can accurately measure the velocity is over an extended period and several test results.

At this point we feel as if we've opened Pandora's Box! Should we seek a THIRD opinion as to how to proceed??

Any advice would be appreciated!

 
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Old 06-14-2010, 07:34 PM   #2
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Re: Should we seek a 3rd opinion for how to proceed after a PSA test?

Thanks so much for the response and the encouragement to take this slowly and calmly. We did have the tests done in two different labs, so do you think we should go back to the first lab, or just stick with the second lab from now on?

 
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Old 06-15-2010, 10:02 AM   #3
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Re: Should we seek a 3rd opinion for how to proceed after a PSA test?

38 is under the age for screening according to current guidelines. Many Dr's are more aggressive in screening due to the larger number of cases being diagnosed at younger ages. However this could be the result of more widespread screening at younger ages which is a circular dilemma.
Since you've already had the doubt raised, your present inclination to retest in 3 months is quite reasonable.
On the other hand if you both will continue to worry and wonder and feel this is unfinished business, a competent biopsy could resolve the issue. A third opinion would most likely result in another PSA which if ambiguous would simply continue your uncertainty.
A biopsy which is very low risk and needn't be unpleasant with IV sedation will put the matter to rest or avail you of all options for very early stage, low risk P.C. which would almost certainly be cureable.
If you're able to put it out of your mind and go on about your lives without anxiety, then deferring for another 3 months before retesting is probably quite safe and prudent.
I followed a similiar course after my first suspicious rise in PSA (at a much later age,68) and only had a biopsy after the third PSA which had continued its rise from 3.6 to 4.2 and finally 4.8 in 3 month intervals. This was almost 10 years ago. The biopsy was positive with very early stage low risk cancer which was cured by surgery 3 months after the biopsy. I'll admit that I was quite nervous after the second PSA test and changed urologists because the original urologist was too casual for my temperment. The second insisted on a biopsy after the 3rd PSA ending the uncertainty.

Last edited by shs50; 06-15-2010 at 10:05 AM.

 
Old 06-16-2010, 09:33 PM   #4
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Re: Should we seek a 3rd opinion for how to proceed after a PSA test?

Hi nadamlie and welcome to this board!

You've had some helpful replies already, but I'll add a few points in green to an excerpt of your initial post. I'll be second guessing the doctors, but please be aware that I have had no enrolled medical education. I'm just passing on what I have learned from coping with this disease over the past ten years.


Quote:
Originally Posted by nadamlie View Post
Hi there:
I am posting this on behalf of my husband. ... He was 38 yrs old at the time, with no immediate family history of prostate cancer. The PSA level came back at 1.7 (high for his age) so she suggested he go see a urologist.

The median (half lower/half higher) PSA for men in their 40s is .7, so you can see why the doctor was concerned. I've got a hunch your husband's family practitioner is fairly savvy about prostate cancer.

The urologist retested him, and came back with the same result (1.7),

Good practice.

and suggested that he wait several months to get tested again. Also, neither the family doctor, nor the urologist's DRE found anything abnormal.

That DRE finding rules out enlargement as an explanation of the PSA rise. Benign enlargement is a major cause of increasing PSA, but it's quite uncommon to find it in a man as young as 38.

In May, the result came back at 2.1 (3 months later). He suggested that my husband get a biopsy because of the rapid increase in the PSA level.

That rise of .4 in just three months does raise concern. It would project to a rise of 1.2 over a year's time. While benign enlargement seems quite unlikely in view of age and the negative DRE, it's possible a subtle infection could be causing the elevated level and rise. (Benign enlargement, infection, and thirdly prostate cancer are the main causes of elevated PSA.) However, it would be wise to check out cancer as the cause, either soon, or at least by another few months.

We decided to seek a second opinion instead of jumping right into a biopsy, given his age and history. The second doctor has taken a completely different stance, and seems quite fixated on the fact that my husband was too young to be screened in the first place. He says we should wait at least 3 months to retest, and even then the only way you can accurately measure the velocity is over an extended period and several test results.


Doctors who specialize in prostate cancer say they see a surprisingly large number of men in their thirties who have cases needing attention. While it is still quite uncommon to have prostate cancer at that age, it is not rare. It's likely that the typical urologist sees so few of such cases that he does not realize the extent of the threat.

I suggest you both insist that a "free PSA" test - a test that is quite standard - be done now! A high percentage, especially 25% or higher as a result, indicates cancer is quite unlikely, while a low percentage, especially 10% or lower, elevates the likelihood of cancer.

However, infection can also cause a low "free PSA" result. A test known as PCA3 Plus is not affected by infection and can help home in on the likelihood of cancer. Decision making is highly personal, but, if I had to decide this for myself, I would get a free PSA test now. If the result were high, I would wait a few months to check the PSA again. If it were low, I would get a PCA3 Plus test right away, not waiting.


At this point we feel as if we've opened Pandora's Box! Should we seek a THIRD opinion as to how to proceed??

You could call either or both of the two urologists and see if they would be comfortable with the free PSA test and the PCA3 Plus test as a possible follow-up. If one was okay with the PCA3 Plus and the other was not, I would go with the one who was okay with it. The family practitioner might also have an opinion about which would be best at this point. Of course, going to a third doctor is also an option. It would not have to be a urologist; a "medical oncologist" could also help.

Any advice would be appreciated!
Good luck with this. I hope it turns out to be just an infection. But if not, please be confident that there is a lot of fine technology out there to help beat prostate cancer, particularly when it is caught early.

Take care,

Jim

 
Old 06-16-2010, 09:35 PM   #5
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Re: Should we seek a 3rd opinion for how to proceed after a PSA test?

Hi nadamlie,

My take is different many. Prostate cancer is a very complex cancer. Some men can live PCa and never have a symptom, and the number of patients under 40 with PCa is unknown. But there are cases of aggressive PCa in young men. Since the PSA seems to be increasing at a high rate for a young man, it seem very reasonable to keep a close eye. At 60 and younger a velocity if .5 ng/ml per years is a caution signal. At 60 and over a velocity of .75 ng/ml is a caution signal. When the velocity is high and there is a family history of PCA the chances of PCa increase. That is how I found my PCa. My dad had PCa and at 63 my velocity was .75/ng/ml but my PSA was within the normal limits for my age. I requested a biopsy and was treated.

No one can tell which PCa is indolent or which is aggressive.

I favor on the side of early detection and early treatment.

There is a lot to learn for men to make informed decisions. Knowledge is King!

Last edited by viperfred; 06-16-2010 at 09:35 PM.

 
Old 06-19-2010, 09:33 AM   #6
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Re: Should we seek a 3rd opinion for how to proceed after a PSA test?

The first Dr. requested a Free PSA tests at the same time as the PSA tests. Those came back as 12% (1st test) and 10% (3 months later). While we had read that the low free PSA % could indicate a presence of cancer, we also saw on the lab report - and the 2nd Dr highlighted it as well - a free PSA % should only be taken into account if the PSA level is 2.5 or above.

We have made an appointment for a 3rd opinion on July 8th. We figure that if the second doc told us to wait 3 months, we might as well do SOMETHING while we're waiting! I think that what my husband needs is some kind of consensus. So, hopefully, with all of your valuable input and experience combined with the 3rd opinion we'll be able to achieve that.

Thanks to all of you! We will let you know what happens after our July appointment
Natalie

 
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