I've been reading here for a couple of months now and hoped to never post, but here begins my saga.
In 2007, during a routine physical, my general practitioner did a DRE and felt my prostate was somewhat enlarged. He decided to do a PSA test and it came back at 3.7. He suggested we wait and watch. I was 46 at that time, I am now 49.
Well, my doctor moved out of town and I let the annual physicals slip. This past January, I finally went to another doctor. I was pretty sick with the flu and wanted to talk to a doc about maybe getting some Lunesta and I knew a physical was in order anyway. At that time, another PSA test was done and the results came back at 5.0 with a free PSA of 17%. The doctor put me on a 10-day regimen of Levaquin, 750 mg daily. I did not experience any of the side effects I've read so much about with this drug. After the Levaquin regimen was finished (in early February), I went back for another blood test, which subsequently came back at 4.5. At this time, no DRE has been performed since 1997 and my doctor immediately referred me to a urologist.
Two nights ago while watching TV, I felt a pretty significant pain in the perineum area , kind of like a muscle cramp. I walked it off and it went away in a couple of minutes. The next morning, I had a swollen and somewhat angry hemorrhoid (which had been acting up for the past week anyway). I figured this little episode was largely due to stress.
Yesterday was my appointment with the urologist, during which a DRE was performed. He said my prostate was enlarged and that the left side felt "firm" as opposed to the right. Coupled with my PSA of 4.5 in February, he immediately suggested a prostate biopsy. Although a urine sample was taken yesterday prior to the DRE, no blood was drawn.
I discussed my situation with the urologist for a few minutes, suggesting another round of antibiotics might be in order before we moved right to the biopsy, maybe something longer term with a different drug. I also tried to tell him that I have what I believe are symptoms of BPH (delayed starting of urine flow, stopping and starting urine flow, and what I perceive to be low flow). To be completely honest, I've had these systems for at least 10 years. I got the impression from the urologist that these symptoms were insignificant. He was focused on my age, the results of his DRE, and my most recent PSA level. He stressed that a biopsy was in order and that he estimated my chances of PC at 30%.
So here is where I'm at:
Last PSA (Feb 11): 4.5
DRE: Enlarged prostate with firmness on left side
No family history of PC
Would you folks agree that a biopsy is in order or should I insist on a round of antibiotics or perhaps asking my family practitioner to recommend another urologist? I’d appreciate any advice.
You certainly need a biopsy right away. It sounds like there is something going on and you want to deal with it quickly especially at your age. A normal PSA at your age would be below 2.5 but PSA can be elevated by infection, working on vibrating equipment, sexual activity in the previous days, or other things. I think that 25% of men form PSA 2.5 to PSA 10 actually have prostate cancer but if you have you don't want leave it as it is often more virulent when discovered at a younger age. My surgery failed and I had Proton Therapy at Loma Linda. Google that and check out other therapies also so that you have a heads up on choices you may have to make. Good Luck.
Just to allay your fears, perineum area pain and hemorrhoids are not symptoms of PC. A good urologist will measure your urine flow rate and retention levels to see if they are significant. He should also check your urine for bacteria. I agree that it certainly sounds like BPH. If it's prostatitis, you can try another antibiotic, but you should know that most cases are not caused by bacteria, so an antibiotic might not work.
If you've had symptoms of BPH, why hasn't your Uro put you on finasteride? That should reduce your PSA. But if it doesn't, or if it does initially reduce your PSA and then your PSA starts climbing while you're taking finasteride, then it may be time for a biopsy. There are way too many biopsies ordered by Uros trying to cover their a**, imho.
Your PSA is only slightly elevated and seems to be growing very slowly (PSA velocity is an important measure) -- certainly nothing to be alarmed about. Just take it step by step. If you can eliminate prostatitis and BPH and your PSA continues to go up, that would be a better time for a biopsy. PC is typically slow-growing, so you have the time.
Given your DRE and PSA, I agree that your Uro is right about the 30% chance, so it seems logical to first try to fix it with the more likely 70% chance of what it more probably is.
Although it's not very accurate, Free PSA is another lab test you can do without undergoing an invasive procedure. Also, ask your Uro for your prostate volume, as PSA density is another helpful measure.
I would not take anything until I had a biospy since the Urologist has felt something firm during the DRE. Anything that reduces your PSA as it will throw your PSA reading right out the window and you will want to keep a close eye on it now. A biopsy is a minor outpatient procedure that is more uncomfortable than painful for a few seconds. The whole procedure might take 5 minutes.
Firmness is often (not always) a sign of inflammation, whereas lumpiness is often (not always) a sign of cancer. Finasteride and dutasteride are actually useful for improving the predictive value of PSA. This was determined in one of the larger PC studies in recent years. What they now do is give it until the PSA bottoms out (reaches nadir) and then watch the PSA doubling time. This is far more accurate than the old way because it gets rid of the confounding sources of PSA from BPH and prostatitis. Here are a couple of references:
A biopsy involves punching a dozen holes through the bacteria-laden rectum into the prostate. In spite of prophylactic antibiotics, some men get UTIs or sepsis. In the following study at Stanford, 44% of biopsied men had bacteria in the urine and 16% had bacteria in the blood afterwards. There will likely be blood in the urine for days and blood in the sperm for weeks afterwards. It also causes scar tissue in the prostate -- a fact that anyone afterwards performing a DRE should be aware of. Multiple biopsies over the years may cause cumulative damage. In one of my biopsy experiences, the doctor did not use an anaesthetic, and it was painful and caused a vasovagal attack. In my opinion, it is not a procedure to have until it is unequivocally necessary.
Patrik Finne of the University of Helsinki has developed an algorithm based on the PSAs and biopsies of 1,775 men. He found that the biopsy results could be predicted with 76% accuracy just by knowing the PSA, the % Free PSA, the prostate volume, and the DRE finding. It's a good way to eliminate unnecessary biopsies.
My Urologist at Loma Linda was horrified that as a patient with recurrent prostate cancer I was prescribed dutasteride as screen my true PSA and made my PSA reading useless. Fear the cancer which is a lot more likely to kill you than the biopsy. I am definitely of the opinion that you find out and then seek a cure promptly if needed.
Please feel free to forward those references to your Urologist. Thank God, there's progress in the diagnosis and treatment of PC every day. Every day, pub med lists 20-50 new PC research studies. I often email to my doctors articles pertinent to my case that they sometimes were not aware of. That's not a criticism, they are great doctors who are very busy tending to folks like us.
Fear is our enemy, imho. Thanks to better diagnostic tools and treatments, PC is unlikely to kill us. A quick pubmed search of "unnecessary biopsies" and "prostate cancer" gave 152 papers on the subject -- it's a cause of concern among many doctors. I think it is much better to approach diagnosis and treatment rationally and methodically than to rush into action out of fear.
Well, today I went to my family practitioner to discuss my appointment last week with the urologist. She is in agreement with him and recommends I do the biopsy. I talked again with the urologist and got the biopsy scheduled for Apr 5th. I asked a bit about his procedures and he told me:
He will put me on antibotics for a few days before and a few days after the biopsy to minimize the chances of infection.
He will use ultrasound to guide the needles during the procedure and he will also use the ultrasound to determine a more accurate size of my prostate.
A local anesthetic will be used during the biopsy to lessen / eliminate any pain.
He intends to take 12 cores / samples and possibly more if needed.
The urologist is part of a "Urology Center" here in town and they have pathologists on site who will review the biopsy samples. They have done "thousands" of prostate pathology studies and are well-versed in reviewing prostate samples.
Results will take upwards of a week after the biopsy has been performed.
So now it looks like I have a 2-part waiting game ahead of me: (1) Waiting for the day of the biopsy to be done, and (2) then waiting for the results.
Can anyone recommend any additional questions I might ask or ways to prepare for the biopsy? Thanks again.
I'm not against biopsies having had 13 over a period of 10 years, but I agree with Allen. Finisteride will result in a more accurate reading of psa due to PC rather than BPH. I would also get a PCA3 and a free psa and have the doctor calculate my psa density before I would get a biopsy. I would also try another course of antibiotics, Cipro or Bactrum, for a few weeks.
If you are going to get a biopsy take a vicodine about 1 hour before the procedure; it makes all the difference in the world.
I'm responding to your post #1, but I've read the responses including Tall Allen's response #6. I would like to strongly endorse what he said.
That downturn in PSA points strongly toward an infection, in my layman's opinion, though there is a chance that cancer could also be present along with BPH and infection.
In addition to the "free PSA" test that he mentioned, another helpful test is the "PCA3 test," which in one version is known as the PCA3Plus test. There have probably been at least a dozen comments about it on the board. I would also like to strongly recommend you read "Invasion of the Prostate Snatchers -- No More Unnecessary Biopsies, Radical Treatment Or Loss of Sexual Potency," August 2010, by Ralph H. Blum and Mark Scholz, MD. It provides details on the tests that have been mentioned as well as biopsies. The emphasis on the title is on unnecessary biopsies. When appropriate, the biopsy yields very useful information. It appears that course now seems right to you, and that matters too. While it may well be possible to discover evidence that would make a biopsy unnecessary at this time, it appears you may gain peace of mind. Your doctor is covering the right bases for doing the biopsy properly, according to what I've learned as an informed layman with no enrolled medical education.
There is an outstanding Us Too group in your city, and one of the men active in that program is Chuck Maack. He is extremely knowledgeable about prostate cancer. I suggest you look him up.
I'm responding to your post #7 about the use of dutasteride (or finasteride for that matter) in a patient with recurrent prostate cancer. You wrote in part:[/COLOR]
Originally Posted by harpman
My Urologist at Loma Linda was horrified that as a patient with recurrent prostate cancer I was prescribed dutasteride as screen my true PSA and made my PSA reading useless....
Tall Allen has already addressed par of this, but I wanted to highlight that your Loma Linda urologist is probably mistaken. Finasteride and dutasteride decrease PSA by shrinking the prostate, getting rid of excess benign growth and low-grade cancer if it's there. For someone who has had their prostate removed, those circumstances would not be involved, as I understand it. The PSA might well not match some institutional benchmarks for a patient who was not on one of these drugs, but the level and trend information would still be useful to a savvy doctor. I have been on finasteride continuously since September 2000, and my PSA readings from then to now have tracked well and logically in relation to my intermittent treatment.
I believe many doctors are kind of stuck in their negative opinions of these drugs because they have told patients for years that they were of no help. Now that the evidence has shown they do impact prostate cancer, the doctors have difficulty accepting the evidence, maybe at a subconscious level, because it will mean telling the same patients that these drugs would have been helpful after all. The evidence is in the Prostate Cancer Prevention Trial and in the REDUCE trial for Avodart (dutasteride).
Thanks everyone for your supportive comments. I've learned a lot these past few weeks and most of that knowledge came from this board.
When I went to the urologist appointment for the DRE, I went in there fully intending to discuss another round of antibiotics to treat an infection that might be present. I'm sure he saw the .5 drop in my PSA level after 10 days of Levaquin. But like I mentioned before, he seemed to be less impressed by that than the firmness he felt on one side of my prostate, my current PSA level of 4.5, and my percent free PSA of 17% (Jan 2011). Granted, he's a urologist and probably has his own way on doing things and I'm just another patient to be evaluated.
I guess the only way to verify the presence of PCa is to do the biopsy, though I understand that even a biopsy is not 100% accurate (false positives, false negatives, etc.). From what I've read, the biopsy is really a "non-event" with minor discomfort and side effects (other than the low risk of infection). It's the anxiety leading up to the event and then waiting for the results that exact their toll on the psyche.