No-one has diagnosed me as having prostate cancer yet, however I am very concerned about my rising PSA and have come here looking for advice or comments.
Briefly, I am a 54 year old Caucasian and my father died of Prostate cancer 15 years ago after radiation therapy and about a decade of hormonal therapy. I think he was first diagnosed when he was in his late sixties. My older brother has a nice low PSA of about 1.0 and apparently no problems. I had my first PSA check at age 41 and by age 48 (2003) I could see it steadily climbing. Here is a rundown of my numbers and major events:
3-2-2005 3.9 after 2 weeks cipro Mar 2-2005 12 CORE BIOPSY NEGATIVE
9-1-2005 3.4 (12% free psa)
3-3-2006 3.8 (13% free psa)
8-29-2006 7.35 (12.4% free psa)
9-18-2006 4.75 after 2 weeks cipro
9-22-2006 4.5 Dec 20-2006 26 CORE BIOPSY NEGATIVE, BUT ASAP LEFT APEX
7-3-2007 5.4 (15.9% free)
July 12-2007 PCA3 = 47.4
8-2-2007 6.04 (22.2% free psa)
12-6-2007 5.45 psa / 5.24 psa IMX Feb 27-2008 32 CORE BIOPSY NEGATIVE
8-27-2008 7.04 psa IMX Sept 12, 2008 BEGAN 5MG FINASTERIDE DAILY
1-12-2009 5.67 psa / 6.8 psa IMX (16.6% free psa)
1-21-2009 5.47 after 1 week cipro
1-07-2010 4.06 (42.5% drop in PSA after 18 months) March 3, 2010 STOPPED FINASTERIDE
9-2-2010 8.80 (20.1% free psa)
9-24-2010 9.01 (14.5% free psa) after short course antibiotics
My prostate volume has been estimated 6 times by various doctors and the PSA densities that follow are my own calculations:
Mar 2005 – 51cc PSA density = .077 (3.9/51cc)
Sep 2006 – 52cc PSA density = .086 (4.5/52cc)
Aug 2007 – 66cc PSA density = .091 (6.0/66cc)
Jan 2009 – 48cc (after 4 months finasteride) PSA density = .118 (5.67/48cc)
Mar 2010 – 48cc (18 months of finasteride) PSA density = .084 (4.06/48cc)
Oct 2010 – 51cc (8 months after stopping finasteride) PSA density = .196 (9.01/51cc)
During the first six months on finasteride I had only a 32% drop in the PSA, but after 18 months the total drop increased to 42%. Having stopped the finasteride my number has in six months more than doubled and is now almost 2 points higher than my previous highest reading. Actually, on a chart, my climbing number seems to be rejoining an upward trend line of roughly 1 point per year that was being projected two years ago. Anyone here had similar results going on and off of finasteride? Can benign prostate cells continue to grow or multiply while taking finasteride?
I might add that between September 2006 and March 2010 I have been examined 4 times by an expert in Michigan with Color Doppler Ultrasound – no suspicious areas have been noted. Also, all of my DRE's have been normal so far and I've never experienced prostatitus pain or any difficulties urinating.
I recently heard of a procedure called a trans-perineal mapping biopsy. For men like me having undergone repeat trans-rectal biopsies with negative results, the procedure reportedly finds cancer 39% of the time – mainly in the apex and anterior zones that are apparently either difficult or impossible to sample transrectally.
I wish I had known about this long ago before my PSA ever got anywhere near this high but none of my doctors ever hinted anything to me that transrectal biopsies don't sample the whole gland, or that there is another way to do biopsies.
I am scheduled for another PSA later this week followed by the transperineal mapping procedure in about two weeks (November 9) and plan to pay the necessary ten to fifteen thousand dollars for it out of pocket since my insurance company doesn't want to.
Advice or comments about any or all of the above?
Last edited by DanInWV; 10-27-2010 at 07:39 AM.
Reason: added % free PSA on Aug 2, 2007 was 22.2%
Your history indicates a slow growing PC. PSA leak and benign psa usually level off at some point. Your benign psa should be about 5, so you have 4 points of uexplained psa. I went through the same process as you for 10 years with my psa going from 4 to 40 and getting 13 negative biopsies and a negative MRIS. I assume you used Dr Lee for your CDU. He should have been able to identify anything in the anterior as the CDU is the only scan that can reliably can. Dr Lee is probably only one of two doctors that can sample the anterior Apex through the rectum. I would try one more thing before a mapping biopsy, a dye enhanced MRI with a Telsa 3 mri. Have you had a PCA3 test?
Sorry to hear about those 13 negative biopsies. Is your story posted somewhere on this website?
Yes, I did have a PCA3 test July 2007 before my third biopsy and the number at that time was 47.4. Somewhat higher than the cutoff, but not dramatically so. By the way, I asked my local Dr. for a second PCA3 a few months ago, but he replied that he no longer does them because he was getting too many false negatives and false positives.
Yes I have been seeing Dr. Lee annually. Even if he is capable of reaching the anterior or apex, so far he has never seen a suspicious area to try to sample. The last time he checked me was in March of this year when I was surprised to hear that he now advises his patients to not take finasteride. In his own words: "Our patients who have been on Proscar for a long period of time and when diagnosed with prostate cancer, all had high grade tumors which increased their risk of having extracapsular extension."
Well, up until September, I kept harboring the idea that a growing benign prostate could be the explanation for my numbers, but I believe you are quite right. I have a strong impression that I must have PC somewhere and 4 points of unexplained PSA sounds to me like an already good size tumor could be the reason for it.
Frankly, I am quite worried and my goal is to get diagnosed as promptly as possible. The transperineal mapping biopsy that Dr. Merrick in Wheeling WV does will systematically cover every 5mm of the gland. I'm told that patients who have their cancer discovered via other procedures find that a transperineal mapping biopsy upgrades their PC as much as 70% of the time anyway. They say it gives the most accurate possible evaluation of the size, location, stage and grade of any malignancy(s) and the best info for decision making.
I'm curious why it might be worthwhile to get a dye-enhanced MRI first and who does those anyway? Are there reasons why it might be better not to do the mapping biopsy other than the cost?
The only reason for an MRI is that it is non invasive and costs less. I agree that the transperienural mapping biopsy is the most accurrate in your case. I think that UCLA does the dye enhanced mri. I know the frustration you are going through and getting a mapping biopsy is the best way to get some closure in your case. Please keep us posted on what it turned up. Your knowledge in three years was much better than mine in 10. I wished I had known about this stuff years sooner.
Welcome to the board! However, I still hope that you may not meet our full qualifications as a bona fide prostate cancer patient; if not, we would be glad to have you as an associate member. (Okay so I'm stretching it - there really are no such requirements to be a board member.)
John has made some excellent points, and the preceding exchange has been informative. Among other things, I did not know that Dr. Merrick was doing the 3D-mapping type biopsies in West Virginia. I was also unaware of the cost , though I had suspected in must have been substantial to cover all the pathology for so many cores.
However, I'm thinking there is a better than even chance you do not have prostate cancer, at least not yet. I'm not sure how much the following thoughts would make a difference in whether to have that biopsy, but I'm glad I don't have to make the decision for myself.
You mention your thinking that a growing benign prostate may account for some of the elevated PSA, but don't neglect the possible impact of the infection that appears to be present. The classic pattern of a prostate infection is an up and down PSA pattern, and that is consistent with your case. Some of those declines have been quite substantial after just a short course of Cipro. To me, with no enrolled medical education whatever but with nearly eleven years paying attention to prostate cancer, the evidence is a very strong indication that at least some infection is involved. After all, Cipro does not affect prostate cancer, and you would not have seen those declines after Cipro if all the elevated PSA was due to cancer. Possibly there is some cancer there as well, but possibly not.
As John mentioned, with your prostate at about 50 cc, one rule of thumb would result in an estimate of 50 X .1 = 5 units of PSA, just based on the size of the prostate, assuming healthy cells. The course of finasteride would be expected to reduce that by roughly a third, while you were under the influence of the finasteride. The point is that you would not have to have much of an infection to boost the PSA above that baseline level of 5, or 3 and a fraction for the finasteride period. (A different rule of thumb uses 0.66 times volume or about 3.3 for you based on 50 cc.)
Another indicator is the way your free PSA has behaved. Free PSA is influenced by infection (though PCA3 is not), and the low levels, contrasted with that reading of 20.1% in September, suggest the waxing and waning of chronic infection. The reading of 20.1% in September, probably at a date when the infection was at a low point, is a pretty good clue that prostate cancer is unlikely. In effect, I'm guessing you got a glimpse of what was your true free PSA if uninfluenced by infection - the fog of infection parted briefly. The sudden plunge in free PSA several weeks later also strikes me as what you would see from a flare up of an infection, but not from prostate cancer uninfluenced by an infection.
Your response to "finasteride challenge" was also arguably supportive. Yes, it would have been reassuring to see a drop of more than 32% at the six months point, but that 42% drop by 18 months is pretty impressive, close to the drop of about 50% that experts want to see, especially in the context of a likely chronic infection that would not be influenced by the finasteride and would still be causing an elevation of PSA.
Another clue is that you have had an abundance of cores sampled in the past few years with no prostate cancer detected. At the least, it's very likely that, even if you do have prostate cancer, there is not much of it.
An additional important clue is that you have had one of the experts in color Doppler ultrasound give you four negative reports. It seems safe to say that there is no growth in blood vessels needed to supply a growing tumor or tumors (at least in the areas of the prostate that the CDU can cover); otherwise, Dr. Lee would have seen that.
Regarding the new book "Invasion of the Prostate Snatchers--No More Unnecessary Biopsies, Radical Treatment Or Loss of Sexual Potency," you can find this statement in a section on PCA3 by the medical co-author, Dr. Mark Scholz, on page 84: "Unlike PSA, PCA-3 is unaffected by the size of the prostate. Low amounts of PCA-3 in the urine, say less than 40, send a strong signal that significant amounts of aggressive cancer are unlikely. Levels between 40 and 80 are more consistent with Low-Risk cancer. Levels of 80 to 100 and above suggest more aggressive cancer. PCA-3, like blood pressure, body temperature and even PSA, varies somewhat from test to test. An average of several PCA-3 levels done at six-month intervals provide a more accurate reading than just one test." Your score of 47.4 in July 2007 is fairly close to the lower range, as you are aware, but a follow-up PCA-3 might be informative.
I'm thinking that your unexplained PSA is probably due to a chronic infection or more than one infection due to different bacteria. Prostatitis is known to be difficult to pin down and treat for many patients, with some requiring the right antibiotic given for a very extended period. Finding that right antibiotic seems to rest on luck with a trial and error approach. It appears that Cipro is at least somewhat helpful, but perhaps Cipro does not cover all the bacteria involved. If it were me, with all the evidence you have, I believe, as I sit in my comfortable chair with nothing on the line, that I would work with the doctor to try to pin down and eliminate or treat an infection, while continuing to monitor for cancer with PSAs, DREs, PCA3, and perhaps additional CDUs.
However, it's easy for me to sit back comfortably and speculate. Someone else, like John, can draw on his experience and see this differently. Of course, he may be right.
I'm glad to know that there is at least one doctor other than Dr. Gary Onik who is doing the 5 mm saturation biopsies. Dr. Onik pioneered the procedure, and I believe he described it in a book he co-authored with Dr. Centeno. I know he presented about it at the "International Conference on Prostate Cancer 2006" held in Reston, Virginia, moderated by Dr. Charles "Snuffy" Myers. Dr. Onik's title was "Local Staging of Prostate Cancer--Color Doppler Ultrasound Vs. 3D Mapping Biopsy." A DVD of the talk should still be available from the Foundation for Cancer Research & Education. Dr. Onik reported an extremely low rate of significant complications, about 1%, in 110 patients. You can find his two papers on the technique in www.pubmed.gov with this search string: " onik g [au] AND prostate cancer AND mapping " (without the quotation marks). The most recent paper increases the number of patients from 110 to 180. However, other experts specializing in prostate cancer have some concerns about the side effects/complications from the 3D mapping biopsy, based on seeing men who have had the procedure, perhaps coupled with a concern with cost, leading these experts to prefer the CDU biopsy or CDU without biopsy. One concern is impotence resulting from the 3D mapping biopsy, though I don't know whether that concern is theoretical or based on actual cases. On the other hand, the 3D mapping biopsy is considered the most reliable biopsy method available and extremely thorough.
I don't envy your job in deciding how to cope with your situation. I wish you luck.
Regarding Dr. Lee's comment on finasteride, I'm thinking he's seeing the results of low-grade cancer that has been knocked out by finasteride, leaving just or mostly high-grade cancer if there is any, but not causing it. That is based on what I've read from expert researchers involved with the huge prevention trial involving finasteride. However, my impression is that Dr. Lee is sharp and an excellent observer, and it may turn out that he is right after all. I'll keep his comment in mind. Thank you.
There is some evidence that Cipro may help kill PC cells too, another good reason to get on a long course of it and stick with it.
Recently investigators have been looking at is as adjuvant therapy -- it seems to make hormone resistant PC more susceptible to chemo.
The Following User Says Thank You to Tall Allen For This Useful Post: IADT3since2000 (10-27-2010)
I truly appreciate the helpful info about antibiotics. I know that doctors are being trained nowadays to not prescribe them unneccesarily, but I have to confess that more than a few times I've wondered why none of my doctors has indicated an interest in getting rid of the chronic prostate infections that observable spikes in my PSA and each of my biopsies have indicated are an ongoing problem.
I have just discovered from my records that back on August 2, 2007 my free PSA was briefly calculated as high as 22.2%, so I'm adding that to the data in my original post. I admit I had never considered that prostatitis can deceptively lower the percentage of free PSA so that the occasional higher % readings might be the more accurate numbers. Sounds like the inverse of the way that prostatitus can produce misleading spikes in my total PSA. Thanks.
As for mapping biopsies, I'm told that there are more than a few doctors who can do the procedure across the US now. In Dr. Merrick's case it has become a specialty. He performed all 373 of the trans-perineal mapping biopsies < edited >.
he says that in men (like me) who have had two or more negative biopsies, his cancer detection rate remains high at 38%, but the only areas of the gland where he frequently finds it is in the anterior-most areas. "it appears that disease in the anterior prostate, particularly the anterior apex, is not consistently sampled through a trans-rectal approach."
With that thought in mind, could you please elaborate a little on the words you put in parentheses, "It seems safe to say that there is no growth in blood vessels needed to supply a growing tumor or tumors (at least in the areas of the prostate that the CDU can cover)."
Are there areas of the prostate that CDU has significant problems covering?
Last edited by hb-mod; 10-27-2010 at 11:04 AM.
Reason: Please don't post unapproved websites, per Posting Policy. Thanks.
When Jim says that CDU should pick up major blood flows it means that all agressive tumors need a large blood supply in order to grow, and CDU compares areas of increased blood supply (Doppler) with areas of hyperechotivity (ultrasound) and if there is a match there is a high probability of a tumor present.
Seeing nothing in the CDU doesn't rule out PC, but makes the likely hood that if you do have a tumor it is slow growing and non agressive. Your low psa and low pca3 also indicate this. CDU is one of the only scans that can see the anterior and is better than an MRI in this one regard. My recommendation was more to get some closure for you and so you know what you are dealing with. If PC is found then the decision to treat or not will be a much different matter depending on the gleason and the location. It was much worse for me not knowing and when I was Dxed it was actually a relief as now I could actually address the problem.
On the plus side if you do have a transition zone anterior tumor it is much more likely to be contained and stay contained for a very long time. On the negative side surgery can be very difficult for these types of tumors as it is almost impossible to get all the tissue out and positive margins are highly likely.
Thank you again. I think I've read somewhere that the earliest free PSA percentages I used to get should be ignored because of the test only being useful when total PSA climbs to a certain level. If I look only at my results when my total PSA has been 5 or above, maybe I should be a little encouraged that my % free PSA is usually at least in the teens and sometimes gets into the low twenties.
By the way, I am very confused by some of my PSA numbers and would especially like to be enlightened by anyone who can explain PSA IMX. In December 2006 my "PSA" was reported at 5.4 but "PSA IMX" from the same sample was calculated somewhat lower than that at 5.24. August 07, I was not given a "PSA" but my "PSA IMX" was reported at 7.04. A few months later the PSA was said to be 5.67 with a PSA IMX of 6.8. What is IMX and how can it be higher than my PSA in one sample but lower than my PSA in another? Even my dr. doesn't know what to tell me when I have asked this.
One of the main reasons why I'd like to understand IMX is because I was not given a "PSA" result in August 07 just before I started taking finasteride so the "PSA IMX" number of 7.04 was the one from which I calculated my susequent % drop while on finasteride.
I would also like to learn about transition zone tumors and how it can be said that on the one hand they are more likely to stay contained, but on the other hand they make positive margins highly likely after surgery. I suppose the second factor also tends to make some kind of brachy or other radiation treatment the preferred option?
To be honest, I am suspicious that a transition zone tumor could very well have been the type my father had in the mid 1980's when he was diagnosed. Maybe it could also help now to explain why he had radiation treatments at Hopkins rather than a prostatectomy. I recall that he definitely had a TURP done because of problems urinating, and somewhere in the same general time frame he was diagnosed with PC. I've often conjectured that an analysis of the removed TURP tissue (rather than a needle biopsy) might have been the way his cancer was discovered. Unfortunately I've never seen any of his medical records - I'm told they were thrown away long ago.
Anyone heard of a hereditary element in tumor location?
OK for anyone interested, I just received my latest PSA result of 7.98. That's significantly lower than last month’s 9.01, and encouraging. On the other hand, my % free PSA has somehow plunged to 3.1%. That’s by far the lowest reading I’ve ever had and way down from the 20.1% of just two months ago when my total PSA was up at 8.80.
I am sitting here looking at today’s numbers and wondering what in the world might account for their directions of movement.
I have always tended to assume that unless my total PSA is dropping due to finasteride, lower PSA numbers are more to be trusted than higher ones, since prostatitus will cause transient peaks. By the same logic, maybe I should now be suspicious of plunges in my free PSA, if prostatitus could cause them too.
What I can’t fathom at the moment is how my total PSA could be indicating that an infection is going away or already has, if my % free would seem to be indicating my worst infection ever.
Here is the context again:
3-2-2005 3.9 after 2 weeks cipro
Mar 2-2005 12 CORE BIOPSY NEGATIVE
9-1-2005 3.4 (12% free psa)
3-3-2006 3.8 (13% free psa)
8-29-2006 7.35 (12.4% free psa)
9-18-2006 4.75 after 2 weeks cipro
Dec 20-2006 26 CORE BIOPSY NEGATIVE, BUT ASAP LEFT APEX
7-3-2007 5.4 (15.9% free)
July 12-2007 PCA3 = 47.4
8-2-2007 6.04 (22.2% free psa)
12-6-2007 5.45 psa / 5.24 psa IMX
Feb 27-2008 32 CORE BIOPSY NEGATIVE
8-27-2008 7.04 psa IMX
Sept 12, 2008 BEGAN 5MG FINASTERIDE DAILY
1-12-2009 5.67 psa / 6.8 psa IMX (16.6% free psa)
1-21-2009 5.47 after 1 week cipro
1-07-2010 4.06 (42.5% drop in PSA after 18 months)
March 3, 2010 STOPPED FINASTERIDE
9-2-2010 8.80 (20.1% free psa)
9-24-2010 9.01 (14.5% free psa) after two weeks doxycycline
10-28-2010 7.98 (3.1% free psa)
When I draw a graph and leave out the finasteride period, these are the PSA numbers from which I connect some dots that give me an apparent baseline:
In the past seven years, my “doubling time” was initially about 22 months but somehow has slowed to about 54 months. In the same time frame my velocity has averaged a pretty consistent .89 points per year, but it too might be showing signs of slowing since 2008. I don't know whether or how much my 18 months on finasteride should be factored in.
Anyone’s thoughts, ideas or speculations are welcome. I am pondering whether or not to go through with a fourth biopsy, the mapping one on Nov 9th, postpone or just cancel. I had promised my boss that today’s report will probably be my basis for deciding whether he needs to schedule me time off.
It seems like the finasteride was working for you -- why did you give it up?
Patrik Finne of the University of Helsinki has published a predictive model that predicts the risk of finding PC on biopsy using inputs of PSA, Free PSA, Prostate Volume, and DRE. The model is described here:
He makes the model freely available elsewhere as an Excel spreadsheet.
I will be interested to compare my numbers to Patrick Finne's model. Thank you.
As for the finasteride, I was planning to keep taking it indefinitely until Dr. Lee strongly advised me last March to stop. A couple of days ago I quoted in this string a part of his written warning to me, but maybe I could also elaborate a bit on the conversation we had.
If I recall correctly, he is concerned that even though finasteride may slow down or even halt milder forms of prostate cancer, long term use seems to also make men more likely to develop an aggressive cancer. I have seen articles in which Walsh, Catalona and others express a similar concern.
But in Dr. Lee's case, I think he is also concerned that the cancer becomes harder for him to find in a timely manner with his Color Doppler Ultrasound so long as finasteride is shrinking both the gland and its tumor(s) and keeping them smaller than they would otherwise be.
After reading some articles on free PSA, I noticed one saying: “In chronic prostatitis, it has been shown that the total PSA, free PSA and pro-PSA are all significantly higher in patients with infection.” Another article said that both free and total PSA increase dramatically when there is manipulation of the gland, such as from a DRE.
A month ago I was walking as much as 3 to 6 miles a day, but in the past few days prior to today’s check I was careful to cut out the walks, just in case it might make a difference.
I am suspicious that either my avoidance of the walks, or a reduction in chronic infection, or both, could account for my simultaneous drop in total and free PSA, and that my current 3.1% fPSA reading could be more accurate than the previous higher readings.
I think Dr Lee is expressing an "urban myth" that has become associated with the Finasteride Prostate Cancer Prevention Trial. The following analysis of that trial concluded that finasteride had both treatment and prevention effects in all risk categories:
The following study finds that finasteride is least effective with the most aggressive cancers, they note that this is the cause of the detection bias that has led to that urban myth. Because it is better at stopping low grade tumors, there were more high grade tumors observed in men on finasteride therapy. Even so, that effect was small - high grade tumors were found in 6.4% of those on finasteride therapy, vs. 5.1% in the placebo group. There has been absolutely no evidence that longterm finasteride use causes low grade tumors to become high grade.
Since you do not have runaway PSA results and your biopsies have been negative, it is hard for me to understand your doctor's position. Clearly, finasteride has not caused a more aggressive disease for you. More importantly, you seemed to have done better with it than without it. Perhaps it was treating an incipient disease.
As for the color doppler -- if there is a tumor there and it is shrinking with finasteride therapy, who cares if it can be visualized? The goal is to shrink any possible tumor, not to encourage it to grow to a point where it can be seen. I don't follow his logic.
My doctor here in WV who prescibed my finasteride agrees pretty strongly with the position you’re expressing. Ironically, only a couple of years ago, he preferred not to prescribe it because of “the myth” as you call it. At the same time I recall Dr. Lee saying that he would have been glad to prescribe it for me. So they both changed their minds, but in opposite directions.
Dr Lee did advise me to read a couple of articles written by men advising against taking finasteride, but I have the impression that his own change of mind has been more influenced by a series of observations with his patients rather than published studies such as the ones we can read online. If it’s hard for you to understand his point of view, maybe part of the reason is because you haven’t seen what he has personally seen.
I’ll readily admit that even if my finasteride trial didn’t give me the desired 50% drop, it did feel good to see a gradual decline in my PSA numbers over 18 months. I also was anticipating that it might help prevent me from needing a TURP or something like that down the road. Yes, maybe it was even treating some incipient disease. I also see your logic that one’s goal should be to shrink any possible tumor.
But to begin with, if the gland shrinks along with its tumor, I imagine that the distance from the capsule wall is decreased at the same rate. And when you say, “Clearly, finasteride has not caused a more aggressive disease for you”, some would tell me to add the word “yet.”
Well, my less than 50% drop left me more suspicious that I do have cancer, and if I do, I think there can be a definite advantage in being diagnosed as early as possible. Just think of how many times we’ve all heard it said that prostate cancer can be cured if it’s diagnosed early enough. If there is a tumor, I guess the bottom line is that I’d rather see it and pursue one of the conventional treatments rather than wonder what might be there and pursue a course of watchful / wishful waiting and questionable chemotherapy.
I realized later that I could have given you the reference to the full text study:
Here's what the authors say: "Initially, concern over the higher number of high grade prostate cancers detected in the men who received finasteride led to little interest in using this medication for this purpose. Since the time of the trial’s initial report, analyses have demonstrated that at least three biases were operational in increasing the detection of high grade cancers including (1) improved performance of PSA [greater sensitivity] for detection of cancer and high grade cancer with finasteride, (2) improved performance of digital rectal examination in men receiving finasteride, and (3) better sampling and grading of biopsies performed in men receiving finasteride due to the drug’s reduction of gland volume."
According to the third argument above, one is better off having a biopsy while on finasteride because a greater proportion of the gland's volume is sampled.
The gland volume/distance to capsule wall argument is not particularly apt here. One can take a low grade tumor, and bring it completely outside the capsule wall -- with no effect. The low grade means the cells are still highly specialized to life within the prostate and are unfit to survive outside the prostate. A high grade tumor is unspecialized, more like a stem cell, and can survive outside. Only higher grade tumors metastasize.
When one shrinks the tumors, one is managing the disease without incurring all the side-effects of radical treatment. In the study below, among men who had RP, finasteride did not just prevent PC, it actually slowed tumor growth.
Personally, I decided to take it as a precaution against more aggressive disease until the day I went for treatment. Unlike you, my biopsy showed a lot of (low grade) cancer, so active surveillance was not a good option for me. If I didn't have as much tumor volume, I definitely would have opted for living completely symptom free for a few more years, but we're all different in how we deal with risk and the relative importance to us of treatment effects.
The low grade means the cells are still highly specialized to life within the prostate and are unfit to survive outside the prostate. A high grade tumor is unspecialized, more like a stem cell, and can survive outside. Only higher grade tumors metastasize.
Thanks for this little nugget. It brought some sense to the technical jargon for me!
UPDATE - I went ahead with the mapping biopsy on Tuesday Nov 9, and got the results yesterday. No cancer was found, no ASAP and no PIN. I don't have the written report yet, but if I understand correctly, there was not even any sign of chronic infection this time - something that used to appear in the writeup of each of my previous three biopsies.
In Dr. Merrick's judgment, I do not need another biopsy for ten years unless my PSA would double from its present level. He attributes my annually rising PSA to growth of the gland itself.
I am scratching my head because my prostate size has been measured several times by different doctors in the past seven years. Admittedly, they may have been off with the measurements, but supposedly it was 51cc in 2003 at my first biopsy when my PSA used to be around 3.5 and it measured 51cc again last month when my PSA is around 8 or 9! Dr Merrick is confident that during the mapping biopsy procedure, he got a precise measurement of my current prostate volume at 62cc.
If anyone is interested in the procedure itself, I was put under general anesthesia and 64 template guided needles through the perineum sampled the entire gland from end to end with a 5mm spacing between the needles. That's twice as many needles than were used in my last trans-rectal biopsy, but I woke up with the same mild discomfort in the prostate area that I've had from all 3 previous procedures. On a scale of 1-10 with 10 being the worst, I'd rate it a 1 or 1.5, which is apparently in line with what other men have reported.
The main difference this time was being put under general anesthesia and being discharged from the hospital with a foley catheter in place. That was uncomfortable at first and it took a few hours to start getting used to it, but they removed it the next morning in the doctor's office anyway.
I was not urinating freely, so they showed me how to catheterize myself with temporary catheters before sending me home. I used the catheters a couple of times while waiting for the swelling to go down and returned to work on a midnight shift about 39 hours after the biopsy. I have not needed a catheter since then.
I want to thank anyone who has been thinking about me.