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Old 02-14-2011, 01:59 PM   #1
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Enlarged prostate, 4.5 PSA

I am 52. Family has prostate cancer history. My father was diagnosed with it at age 60 and passed away 10 years later. His father had it also.

4 years ago my PSA was 1.5. Last week during the DRE my doctor was concerned about an enlarged prostate. I did not get a size estimate. The subsequent PSA was 4.5. I am scheduled for a biopsy in 2 weeks.

I will be able to deal with the result if cancer is detected. It is the not knowing that is difficult. What is the likelihood with the family history and these results that there is cancer?

Is there anything specific I should be doing or reading?

Thanks.

 
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Old 02-14-2011, 02:51 PM   #2
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Re: Enlarged prostate, 4.5 PSA

There is a genetic component to PC. A PSA of 4.5 isn't that high, and your PSA doubling time of 2.5 years isn't that bad either. Hopefully it's just BPH, which is very common. If it is PC, you are probably catching it early, so there is nothing to fear. There is nothing you need to rush into right now -- even if it is PC, you will have plenty of time to read, research and get several opinions. It's hard not to get anxious while waiting, but try to take it as it comes.

- Allen

 
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Old 02-14-2011, 06:52 PM   #3
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Re: Enlarged prostate, 4.5 PSA

Hi zecqxon,

I'm glad you found the Board, welcome!

I'm reading your post after reading Tall Allen's response, which made key points. I'll add some thoughts in green to your post.


Quote:
Originally Posted by zecqxon View Post
I am 52. Family has prostate cancer history. My father was diagnosed with it at age 60 and passed away 10 years later. His father had it also.
I have a similar family background, though my father and his father were older when they were diagnosed and when they passed on. Just in case the biopsy does indicate prostate cancer, you need to know that case assessment, decision making, treatment or active surveillance, and coping with the disease are far different and improved over what they were when our grandfathers and our fathers were treated.

Cases are roughly divided into low-, intermediate-, and high-risk. These days, virtually 100% of low- and intermediate-risk patients are alive at the ten year mark, with more good years before them, and 95% of even high risk patients are alive at that mark, also with good years before them. (I'm one of them! )


Quote:
4 years ago my PSA was 1.5. Last week during the DRE my doctor was concerned about an enlarged prostate. I did not get a size estimate. The subsequent PSA was 4.5. I am scheduled for a biopsy in 2 weeks.
You should feel free to pick up the phone and get that size estimate. Even better, request a copy of the doctor's notes, including the estimate. Size makes a big difference in PSA. There are some rules-of-thumb to relate size to expected PSA from healthy prostate cells. One is to multiply the size in cc by 0.066 to get the PSA. Reversing that, dividing PSA by 0.066, if that PSA of 4.5 were solely due to benign growth (not infection, not cancer), the prostate would probably be around 68 cc in size. That's quite large, but some doctor's might describe such a prostate as "enlarged". Another rule of thumb is to multiply the size in cc by .1 to get the expected PSA from healthy cells; reversing that, you would get a size estimate of 45 cc, which is well within the range that would be called "enlarged".

The point here is that the enlarged size alone may be able to account for that PSA of 4.5. Frankly, if your prostate is big enough that size alone is probably responsible for the PSA level, you should at least think through whether it makes sense to have a biopsy. Biopsies are not a huge deal, but they are not trivial either, and there is no point in having one that is very unlikely to be helpful. An alternate might be to get another PSA in three months, and I've added another alternate below, the "free PSA test. There's even another test known as the PCA3Plus test.


Quote:
I will be able to deal with the result if cancer is detected. It is the not knowing that is difficult. What is the likelihood with the family history and these results that there is cancer?
The likelihood with two direct relatives involved is substantially higher than risk without family involvement, though that risk is weaker if the relatives were in their later years when diagnosed. One outstanding book for orienting newly diagnosed patients is “A Primer on Prostate Cancer - The Empowered Patient’s Guide,” by Dr. Stephen B. Strum, MD, and Donna Pogliano (rev. ed., 2005). It makes some general statements on risk toward the beginning of the book but gives more detail in Appendix section B2.1 “About Hereditary and Familial Prostate Cancer,” including Table B-1: “Hereditary Prostate Cancer (HPC) versus Familial Prostate Cancer (FPC). These are descriptive terms defined by the type and number of relatives who have had prostate cancer. “Hereditary” PC, considered to be due to genes with high penetrance, is the term that describes a stronger relationship than “Familial”, but both indicate above average risk, and both are described in the book. While only a quarter of patients fall in either category for increased genetic risk, only 19% of that quarter have HPC, with FPC being four times more common, taking the remaining 81% of that quarter.

By definition, you do not have enough generational evidence to have hereditary PC and the age at your father's diagnosis doe not qualify: three generations have not been diagnosed yet, nor have three first-degree relatives (brothers, father) been diagnosed, nor have two of the relatives been diagnosed before age 55.

There are some well-researched figures about hereditary PC conveying added risk, but apparently the situation for FPC is not as clear cut; the Primer does not say much about it. Dr. Patrick Walsh is a very famous surgeon, and he has authored several editions of a widely read book," Dr. Walsh's Guide to Surviving Prostate Cancer." My 2001 edition, not the most recent, says on page 74 that for a relative diagnosed at age 60, such as your father, with an additional relative also being diagnosed, such as your grandfather, the odds of getting prostate cancer are five times greater than normal; however, he may be addressing just "hereditary" prostate cancer and not "familial". The overall lifetime risk is one in six for all men without regard to risk factors.


Quote:
Is there anything specific I should be doing or reading?

Thanks.
There is an outstanding new book out for prostate cancer patients: "Invasion of the Prostate Snatchers -- No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency," Ralph Blum and Dr. Mark Scholz, MD, published last August. Several of the chapters have to do with men who have not yet been diagnosed. The decision whether to have a biopsy is also addressed. Among other things, the book talks about foods and supplements that may help prevent or minimize prostate cancer. If you are diagnosed, one other key book provides more in-depth detail.

Depending on the size question, the doctor may be rushing the biopsy a bit. There is a test known as the "free PSA" test that also often gives important clues whether or not a man has prostate cancer. A score of 20% or higher, especially 25% or higher, indicates a low likelihood of prostate cancer, while a score of 10% or below indicates a considerably higher risk, assuming no infection. Infection can throw off the free PSA result as an indicator of prostate cancer. You might want to have that test done before having a biopsy.

If you do have a biopsy, it should be at least a ten core biopsy, and you should ask that the doctor send you a copy of the report as well as giving you the result. (The Primer has a form for recording details.) It would be good to clarify with the doctor who will do the biopsy that he and the pathologist will make sure the biopsy report covers the number of biopsy cores that are positive (quite standard), the Gleason score for each (not as standard), the percentage of cancer in each positive core (not as standard), and the location (fairly standard).

It is also very, very important that the pathology results be evaluated by an expert in reading prostate biopsies; and you should ask the doctor to do that, asking that they go to a known expert. The Primer identifies a number of expert pathologists and labs, and generally universities with substantial programs for prostate cancer are good at reading them. Local hospitals are right more than half the time, per studies, but they are wrong a substantial proportion of the time. It is important to get the Gleason score right. This may be a touchy point, but it is very important not to just rely on local resources, which is the typical way of doing business. One approach is to get the biopsy and accept a local version if all cores are deemed negative, but to insist on an expert second opinion if any of the cores are judged to contain prostate cancer. I would call the doctor's office before the biopsy and work this out.

You are a partner with your doctor in this, and you should not be a silent partner! Good doctors welcome a patient's desire to be meaningfully involved. If the biopsy does show cancer, you will be faced with the question what you should do and whether you should find a different doctor (or doctors) to help. You current doctor's interaction with you in responding to your questions may help provide clues whether you feel comfortable with the doctor.

Take care,

Jim

 
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Old 02-14-2011, 07:19 PM   #4
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Smile Re: Enlarged prostate, 4.5 PSA

IADT3since2000 posted this below in an earlier post to me and I have an 80 gram Prostate with a psa of 6.7:

“Did you know that healthy prostate cells also produce PSA, and that an enlarged prostate of completely healthy cells will produce more PSA than a smaller healthy prostate? There are a few different, research-based rules of thumb for assessing PSA from healthy cells. One is to multiply the grams of prostate by 0.066 ("A Primer on Prostate Cancer, p. F4, citing research). In your case, the size alone would explain 80 X 0.066 = 5.28 out of the 6.7 found in your tests, leaving only about 1.4 to be explained by prostate cancer, a rather small volume of disease. Another rule of thumb is to take the grams or cc and multiply by .1, which would yield a PSA of 8 in your case, again suggesting little PSA due to the cancer. I'm thinking that doesn't leave much room for infection, either.”

The waiting is hard. I’m waiting for the prostate and rectal wall to heal post biopsy before I can have surgery. I felt the biopsy is not that bad of procedure and don’t forget to drink lots of water post. It helps.

The first shock finding out there might be something going on is a bit scary, but your PSA and PSAV is, as Allen said, still very low and may be caused by other non-pCA issues, even with your family history. So until otherwise take the high road that it is not pCA .

There is a lot of information you can read and a number of people to bounce your thoughts off of here while doing so.

Keep in mind there is also a lot of misinformation out there, so ask questions no matter how dumb you think they are.

There are a lot of smart guys here. IADT3since2000, Baptista and Tall Allen are just a few who can give you good feedback.
OK, I see IADT3since2000 responded just before I sent. I’ll send and see what he has to say.
Steve

Last edited by Kirkwood; 02-19-2011 at 10:26 AM.

 
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Old 02-15-2011, 10:44 AM   #5
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Re: Enlarged prostate, 4.5 PSA

Thank you Jim. Very helpful information. I appreciate you taking the time to respond.

 
Old 02-17-2011, 12:32 PM   #6
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Re: Enlarged prostate, 4.5 PSA

Jim,

I had the free PSA test this morning and should know the results soon. Thanks for the info on this. It seems Kaiser would have ordered this test in lieu of the standard PSA, but that is probably a cost-based decision Kaiser makes. Additionally, I ordered the two books you mentioned in your email. They will be here today and I look forward to reading them.

I spoke with my older brother quite a bit yesterday regarding PC. He is a Ph.D. at the National Institute of Health and has much more knowledge than I regarding the body and PC. He has regular DRE and PSA tests continue to be normal.

Our father was a scientist at Lawrence Livermore National Labs. As a routine a physical was given by a lab doctor regularly. His lab doctor had expressed concern several times after performing a DRE and referred him to see his Kaiser doctor. Kaiser told him subsequently several times that the PSA test result was low and there was no issue. After the lab doctor was insistent that there was likely a serious issue going on with his prostate, Kaiser finally performed a biopsy but by this time the cancer had metastasized. He had his prostate removed after which he did extensive personal studying on PC. Chemo and radiation were never given. He did participate in a few clinical trials. He fought a great fight for 10 years after the removal of the prostate.

I will let you know the result of the free PSA test when I receive them. My biopsy appointment is scheduled for next week. However, I will be meeting with the Urologist for another exam and discussion prior to moving ahead with the biopsy.

David

 
Old 02-19-2011, 09:38 AM   #7
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Re: Enlarged prostate, 4.5 PSA

Just because your PSA is up does no mean you need a biospy. Read

 
Old 02-22-2011, 12:49 PM   #8
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Re: Enlarged prostate, 4.5 PSA

Jim,

My FPSA came back at 15.6%. To summarize PSA is 4.5 with enlarged prostate (no approx. measurement at this time). I meet with Urologist next week for another exam and discussion prior to scheduled biopsy.

Any thoughts based on the FPSA result?

David

 
Old 02-22-2011, 07:14 PM   #9
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Re: Enlarged prostate, 4.5 PSA

Free psa of 15% is borderline. Another test to consider is the PCA3 urine test.
JohnT

 
Old 02-23-2011, 01:52 PM   #10
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Re: Enlarged prostate, 4.5 PSA

Hi David,

That's a pretty decent free PSA result. I see it the way John does in his post #9 to you. Make sure the doc gives you his prostate volume estimate when he does that DRE.

Are you into the books yet? In your case, Invasion is particularly relevant.

Take care,

Jim

 
Old 02-23-2011, 05:38 PM   #11
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Re: Enlarged prostate, 4.5 PSA

Jim,

I am currently reading Invasion of the Prostate Snatchers. Enjoying the read so far. It is full of good information and written at the level of the lay person.

My brother sent me this article today "Dutasteride May Slow the Growth of Early-Stage Prostate Cancer" with this link http://www.cancer.gov/ncicancerbulletin/022211/page3

I thought this might be of interest to you and others.

David

 
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Old 02-24-2011, 01:36 PM   #12
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Re: Enlarged prostate, 4.5 PSA

Hi David,

I'm responding to your post, just preceding this response.


Quote:
Originally Posted by zecqxon View Post
Jim,

I am currently reading Invasion of the Prostate Snatchers. Enjoying the read so far. It is full of good information and written at the level of the lay person.
Thanks for your review. That's the way it struck me too, but I've been working with PC for so long that it's sometimes hard for me to see PC again from the viewpoint of someone who has just been diagnosed.

Quote:
My brother sent me this article today "Dutasteride May Slow the Growth of Early-Stage Prostate Cancer" with this link http://www.cancer.gov/ncicancerbulletin/022211/page3

I thought this might be of interest to you and others.

David
[COLOR="darkgreen"]

Yes, thank you. I had seen the abstract of the research a few days earlier, but it is very interesting and encouraging to me to see that the NCI is picking this up. (By the way, the senior author was the surgeon for the husband of another one of our active board participants, Rhonda.) The NCI article mentions Dr. Fleshner's emphasis that use of dutasteride by men on active surveillance (AS) is "off label". What that means is simply that the drug was not approved by the FDA for the purpose of AS. Patients can be prescribed off-label drugs provided the doctor explains the risks, benefits, and that the drug has not been approved for the use. Many, many prescriptions are written for off-label use because it is extremely expensive for drug developers to run the clinical trials for specific purposes in addition to the initial purpose that already established key details of safety and effectiveness, though not in the population for the off-label use.

For example, most of my main drugs have been prescribed off-label, including bicalutamide (approved for stage D2 metastatic prostate cancer, which I don't have) in conjunction with an LHRH-agonist like Lupron), finasteride (approved for controlling BPH), Fosamax and Boniva (approved for treating osteoporosis, which I technically did not have - had osteopenia with an osteoporosis qualifying level only in one bone for a while, in post-menopausal women - I'm certainly not qualifying there!), and thalidomide (approved for multiple myeloma and leprosy, neither of which I have).

The NCI article also notes that the FDA rejected a request to approve dutasteride for the prevention of prostate cancer, just as it had earlier (Dec. 1, 2011) rejected finasteride (in the same drug class) for prevention. The reasons for the rejections are not simple, and the rejections don't mean the FDA rejected some solid evidence of effectiveness. I listened carefully to the finasteride committee meeting, and it was clear that bang-for-the-buck was paramount in some members' minds. (Others were misled by a surprisingly ignorant understanding of DHT by Dr. Patrick Walsh, the famous surgeon - brought his knife to a drug fight , but he's still one of our legitimate heroes, and there were other reasons.) What it boiled down to for me was that these drugs look good to help prevent and fight Gleason score 6 or lower prostate cancer, but I had to agree that paying for many years of possibly unnecessary prevention of low-grade disease for a broad population of men was hard to defend in view of the success of active surveillance in this group.

If medical science gets better at figuring out who to target for prevention, use of finasteride or dutasteride in that role would probably become a wise tactic for many men. Meanwhile, it becomes an individual "off-label" decision between a patient and his doctor, as one of the FDA committee members noted. Your brother might want to look into this, considering both benefits and side effects; side effects are mild or almost non-existent for most of us, but there are also some child bearing aspects to consider. Finasteride is much less expensive than Avodart, though neither is an exceptionally high cost drug.

On the other hand, certain lifestyle tactics, especially nutrition, may be just as good or better. As just one example, quality pomegranate juice or extract is looking most promising after a recent confirmatory Phase II study indicating partial effectiveness in helping men with recurrent prostate cancer; it's logical to me to think that pomegranate juice or extract would also help in a preventive role.

If, when you have the biopsy, you could show the doctor the biopsy form in the Primer and ask if he would fill in the details he knows at the time as well as making sure you get a copy of the official biopsy report.

By now you may have already had the biopsy, but I just realized your location in Santa Monica opens up an option that is less convenient for most of us: getting a color Doppler ultrasound (CDU) guided biopsy by Dr. Duke Bahn in nearby Ventura. You have probably already read about him in Invasion. He is one of perhaps a half dozen experts in the country who has the equipment and expertise to do the high-resolution CDU biopsy. That special biopsy is particularly valued because it indicates blood flow to the tumor (vascularity), but it also gives key information about the number of tumors and their sizes and shapes (determination of both is aided by the vascularity clues), and precise locations, as well as the usual information about percent of cancer and Gleason scoring. The vascularity clues also enable the doctor to target areas that are much more likely to be cancer, in contrast to the routine approach of randomly targeting samples, with some aid from the conventional ultrasound images. Invasion describes the CDU on pages 130-131, 134, and 136. (By the way, unless he has moved, the medical co-author of Invasion practices just down the coast from you at Marina del Ray.)

Take care,

Jim

 
Old 02-24-2011, 05:48 PM   #13
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Re: Enlarged prostate, 4.5 PSA

Quote:
Originally Posted by zecqxon View Post

4 years ago my PSA was 1.5. Last week during the DRE my doctor was concerned about an enlarged prostate. I did not get a size estimate. The subsequent PSA was 4.5. I am scheduled for a biopsy in 2 weeks.
Zecq,

Glad to see that you had the Biopsy scheduled out two weeks. This info therefore is not too late. It appears in all likelihood from what you stated above is that you had the blood draw for the PSA test on the same day? AFTER the DRE? That is not a good idea if that was the case. A DRE can easily stir up the PSA level artificially to a much higher level. I doubt all the way to 4.6 (if it was still 1.5 before DRE) but still UP.. If the PSA draw was after the DRE I would decline the biopsy for now, wait a month and get another PSA check. Then take it from there with the new results. (And no intercourse or masturbation or bicycle/exercycle/rowingmachine in the days leading up to the blood draw-- all those can jump up the PSA abnormally too ).

Just sayin'

J

 
Old 02-24-2011, 06:31 PM   #14
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Re: Enlarged prostate, 4.5 PSA

yes I did have the PSA after the DRE. I will be sure to avoid that in the future.

All of the information received here has been extremely helpful. Thank you. I am beyond the panic mode that was induced by the initial email I received from my Doctor. After the DRE I had blood drawn for the PSA test. The next day I received an email in which I was instructed to contact Urology to schedule a biopsy. There was a voicemail prior saying "This is your Doctor. I will send you an email". The email was vague with no details. It didn't even include the PSA result - just a phone number for Urology. Needless to say that shook me up.

The "Invasion of the Prostate Snatchers" is excellent. I am learning a lot and and feel much more confident and in control. I will continue to read, talk, question, learn and make informed decisions and choices.

My intent is to meet with the Urologist next Tuesday (who I have not spoken to yet) and skip the biopsy. I will find out if the Urologist is advocate or adversary for active surveillance.

I will have the doctor do a DRE so I get the opinion of someone more experienced tha my personal Doctor. I have no idea if my doctor felt any nodules or other irregularities or was simply concerned about the size.

Additionally I plan to request 500mg Cipro to take 2X/day for 2 weeks and then repeat the PSA 6 weeks after starting Cipro. I will be sure not to ride my bike or my wife a day or two prior to the test.

Thanks again to all of you for your information and support.

David

 
Old 03-02-2011, 08:27 PM   #15
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Smile Re: My Appt yesterday

I am extremely grateful I found this forum and for the input provided. The past 3 weeks have been a journey of various emotions and quick learning that feel more like months than weeks.

With the good suggestions from this group to take time, get additional tests, read the relevant books and articles that were suggested, and learn about PC, I went from having the hollow gut wrenching feeling of mental emotional shock of receiving a vague email from my Doctor that I was scheduled for a biopsy to feeling very calm and empowered with newly acquired knowledge about PC.

I was scheduled for a biopsy yesterday based on the recommendation of my Doctor following a DRE where she thought my prostate felt enlarged, a subsequent PSA test that came back at 4.5, and concern about my father dieing of PC. With the knowledge and recommendations I gleaned from reading responses to this thread and from reading the book "Invasion of the Prostate Snatchers" along with other articles, I headed into yesterday's appointment well calm and prepared.

I informed the Doctor I would not be having a biopsy at this appointment and wanted to spend the time meeting her, asking questions, getting answers, having additional tests performed, discussing the results, and planning additional steps. My list of pre-written objectives for the appointment included getting a DRE, a transrectal ultrasound, prostate size, PSA Density, and a prescription of Cipro to take for a few weeks and then a subsequent PSA a few weeks later.

My Urologist was a great listener and very open to what I proposed and the path I wanted to take. The DRE was normal. The ultrasound pictures of my prostate were printed and did not show any abnormalities or areas for concern. The measurements of my prostate were recored, prostate size determined, and my PSA Density calculated as 0.07, which my Urologist said concerned her. She prescribed 3 weeks of Cipro and ordered a PSA test for 6 weeks out.

I walked out with a copy of the Patient Summary notes from the appointment that included the ultrasound pictures, prostate measurements, and PSA Density result 0.07. There was also a note that said the PSAd of .07 "places me in the higher risk group of finding cancer on the biopsy".

Not knowing the range to be looking for I came home and decided to verify the calculation and result. I like numbers and math and this was one of the few medical test results I could verify with a calculator. I went to Dr. Google and found that a result of >.15 is often the threshold indicator for a higher risk of finding cancer on a biopsy.

With this information I wrote to my Doctor through the Kaiser email system the following:
"Doctor, with regard to the PSAd results, my calculation and conclusion differ from yours.

Using the standard ellipsoid formula, width × height × length × pi/6, I come up with 56.956. Dividing my PSA of 4.5 by the prostate volume of 56.956 gives a quotient of .0795. It is my understanding that PSAd > .15 is the threshold for concern, with more conservative thresholds at .10.

This is all new to me so I may be overlooking something or not calculating correctly. Please clarify or advise."

Shortly afterwards I received an email response stating she had made an error and that I was right.

It was a great day. I felt confident walking in, felt very good walking out knowing the results of the tests, and felt even better after receiving my Urologists response to my email regarding my PSAd.

I am on my second day of Cipro and will follow the plan to take this for 3 weeks and then get a PSA 3 weeks later.

Thanks again for your thoughts and suggestions.

David

 
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