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Old 03-26-2011, 07:56 AM   #1
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PSA rise/urologist referral

I'm 57. My primary care doctor noted increased velocity in my PSA score, which was 3.9 a week ago, an increase of nearly a full point from early 2010. He referred me to a urologist. I'm inclined to consent to a transrectal ultrasound but not to a biopsy of the prostate without further consultation (with all parties fully clothed.) I also think another PSA test should be done just BEFORE the urologist does his thing. What I've read about the PSA leaves me with the impression that it produces many false positives as a result of numerous factors, notably benign prostatic hyperplasia (the most common cause of an elevated PSA), ejaculation within 48 hours of the test, manipulation of the prostate during the digital rectal exam, etc. Since we're talking tenths of points here, a fresh PSA result -- say 3.4. or 3.5 if I behave myself and refrain for a couple of days -- could lessen the medical motivation to biopsy as a precaution, to be "on the safe side" or some other subjective rubbish. Besides, while intending no disrespect, I'm not about to allow a young, non-board-certified urologist to fire needles into my prostate because he thought he saw something on a computer monitor. Indeed, if I'd scored in the mid-3s on my test a week ago, I doubt I'd even be in this situation.
Would I be out of line insisting on these conditions (ultrasound only and a fresh PSA)?

 
Old 03-26-2011, 09:51 AM   #2
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Re: PSA rise/urologist referral

Hi Chris and welcome to the board! (I hope you are only a temporary participant.

I'll respond to your initial post in green, but I'll answer your last question first: "Would I be out of line insisting on these conditions (ultrasound only and a fresh PSA)?" No, you would not be out of line, but it may not be the best course at this time. You wrote in part:


[QUOTE=Chris61;4715848]I'm 57. My primary care doctor noted increased velocity in my PSA score, which was 3.9 a week ago, an increase of nearly a full point from early 2010.]

Those scores and the pattern actually give you two indications for a biopsy. First, these days a lot of doctors are using a PSA of just 2.5 as a trigger point. While that strikes me as overly eager in the absence of other clues (the net benefit appears to be catching about 1.5% more significant cases somewhat earlier than they would otherwise be caught), your PSA of 3.9 is almost at the traditional threshold for concern of 4.0. Moreover, you are not that old, and the "normal" PSA for a man in his 50s is 3.5. ("Normal" is a subjective term here, meaning less than strong likelihood of prostate cancer. The actual norm for a man in his 50s with no infection, benign enlargement or prostate cancer is a PSA of just 0.9.

The second factor is the increase of 1.0 in a year. That's enough to trigger concern. It's more than you would normally expect from benign enlargement in a year, as I understand it as a fairly savvy layman with no enrolled medical education, but it is less than is often seen with an infection. That leaves cancer as a suspect , but infection and benign growth, either separately or in combination, could still be responsible. Even if the culprit is cancer, the increase of just 1.0 is well below the threshold rise of 2.0 in a year due to cancer that is an independent risk factor for more aggressive disease.


Quote:
He referred me to a urologist. I'm inclined to consent to a transrectal ultrasound but not to a biopsy of the prostate without further consultation (with all parties fully clothed.) I also think another PSA test should be done just BEFORE the urologist does his thing.
That referral is sound and wise. The urologist is the expert in doing digital rectal exams, which not only can reveal clues of possible cancer but also give a good estimate of the size of the prostate, which can be related to PSA, giving more clues. The urologist should also be able to consider and execute a workup that has a good chance of smoking out an infection. Some infections are stealthy and very hard or impossible to pin down, by the way. The urologist can also prescribe other tests, such as the follow-up PSA you mentioned, a "free-PSA" test from the same blood draw, and perhaps a PCA3 or PCA3Plus test that nicely complements normal PSA tests and overcomes limitations of "free PSA" tests.

Quote:
What I've read about the PSA leaves me with the impression that it produces many false positives as a result of numerous factors, notably benign prostatic hyperplasia (the most common cause of an elevated PSA), ejaculation within 48 hours of the test, manipulation of the prostate during the digital rectal exam, etc.
Right, but PSA is very useful as a hyper alert sentry that something is going on; hopefully it is not cancer. Generally, the odds would be about 25% just based on the elevation.

Quote:
Since we're talking tenths of points here,
As I noted above, that's not really the case. There is a sound basis for concern.

Quote:
a fresh PSA result -- say 3.4. or 3.5 if I behave myself and refrain for a couple of days -- could lessen the medical motivation to biopsy as a precaution, to be "on the safe side" or some other subjective rubbish. Besides, while intending no disrespect, I'm not about to allow a young, non-board-certified urologist to fire needles into my prostate because he thought he saw something on a computer monitor. Indeed, if I'd scored in the mid-3s on my test a week ago, I doubt I'd even be in this situation.
Would I be out of line insisting on these conditions (ultrasound only and a fresh PSA)?
It's true that many urologists are over eager. There is an outstanding, expert book that was published just last August that is right in line with the concerns you are raising, as you can see from the full title. Here's the info: "Invasion of the Prostate Snatchers -- No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency," by Ralph Blum and Dr. Mark Scholz, MD. The emphasis is on determining what is necessary and what is unnecessary using tools we now have and sound thinking.

Take care,

Jim

 
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Old 03-26-2011, 02:18 PM   #3
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Re: PSA rise/urologist referral

I think your plan sounds like a good one, in my non-professional opinion. There is absolutely no indication that you need to rush to biopsy at this point. I would want to be well-satisfied that the increase in PSA is not due to BPH or prostatitis. Perhaps your primary care doctor would be willing to prescribe a couple of weeks of Cipro, which might help eliminate the possibility of bacterial prostatitis. (There are other kinds of prostatitis that aren't so easily cured.) I think you are right to avoid sex or other mechanical prostatic stimulation (e.g., bike riding) for a couple of days before your Uro visit.

The order in which one does the following can affect the results. At your urologist,
  1. get a pre-DRE blood draw for both PSA and % Free PSA,
  2. then have the DRE,
  3. then do the urine test for bacteria and for PCA3, if it's available (your insurance may not cover PCA3).

You are wise to have him do an ultrasound. He can use it to compute the size of your prostate. PSA density, PSA divided by prostate volume, can be a danger signal if it is too high. The ultrasound cannot prove there is no cancer, as it will only show very large, obvious nodules, which is unlikely.

Based on the findings, you can make a more informed decision:
  • If the DRE shows lumpiness or nodularity, schedule a biopsy.
  • If your % Free PSA is low or your PCA3 is high, schedule a biopsy.
  • If the DRE and the tests are negative, your urologist might be willing to put you on finasteride for about 6 months. If your PSA was due to BPH, that should cut it in half.
  • If after 6 months your PSA is still growing, schedule a biopsy.

My hope is that all indications will be negative.

- Allen

 
Old 04-01-2011, 11:46 AM   #4
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Re: PSA rise/urologist referral

Chris61

There are a lot of articles in the media these days concerning PSA testing and it seems to me that many of the negative views are generated by those wishing to ration and reduce the availability of healthcare. While it is not a perfect test it may be indicative of prostate cancer and the important thing is to find out as much as you can and as early as you can if it is indeed prostate cancer. It is your life and quality of life that is at stake here. I would not be squeamish about having a biopsy as it's not a big deal and only takes a few minutes of slight discomfort. There is usually no pain involved but disconcerting feeling a painless slap on your prostate. The ultrasound is used to direct the needle placement and doesn't often show any signs of cancer. It would be foolish in my opinion to delay.

Bob

 
Old 04-01-2011, 02:47 PM   #5
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Re: PSA rise/urologist referral

Thanks for writing, Bob. I'm not opposed to biopsy but I'll have to see evidence that it's necessary before I consent. The procedure is not without its risks. I'll go step by step, beginning with an ultrasound. It appears that the urologist works the same way: I was not told to prepare for a biopsy (course of antibiotics, medicated enema, etc) so I figure he'll just be doing the ultrasound that day and proceed from there. Again, thanks for your reply. Chris61

 
Old 04-01-2011, 03:25 PM   #6
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Re: PSA rise/urologist referral

Chris
The biopsy is what ultimately provides the evidence. Many men have more than one biopsy before ultimately being diagnosed with prostate cancer so that one negative biopsy does not mean that you are in the clear. If you are diagnosed with prostate cancer then the earlier that you are treated the better the result you will receive in terms of cure rate and side effects such as impotence, incontinence, bowel problems, and failure no matter which treatment regimen you choose.
Bob

 
Old 04-02-2011, 11:54 AM   #7
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Re: PSA rise/urologist referral

Hi Bob,

I'm responding to your post #6 to Chris in order to mention a clarification regarding Chris and to present essential information regarding one key issue. You wrote in part:


Quote:
Originally Posted by harpman View Post
Chris
The biopsy is what ultimately provides the evidence. ...
Chris has already had an RP.

Quote:
If you are diagnosed with prostate cancer then the earlier that you are treated the better the result you will receive in terms of cure rate and side effects such as impotence, incontinence, bowel problems, and failure no matter which treatment regimen you choose.
Bob
While Chris is beyond this point, other readers may not be, and there is an essential piece of information they need. Many major, highly respected institutions treating prostate cancer in this country (and in Canada and the Netherlands), including a number of the world's best surgeons for prostate cancer, are now vigorously advocating a different course for low-risk men: active surveillance with deferral of treatment to the point it is needed, if ever! In the 1990s there was a real question whether active surveillance would work well without substantial risks. Throughout the just past decade this question has been answered by multiple studies with ever-longer follow-up and remarkably consistent results: YES! Active surveillance works very well! For properly qualified men - meaning that their cases do not show any of about a half-dozen risk characteristics, or that risk is mild compared to their overall health situation, well-done AS is freeing men from the burdens of treatment while it protects them from the disease - a "win win" proposition.

Check out research published on AS by doctors/researchers associated with the U. of Toronto, Sunnybrook; Johns Hopkins; Memorial Sloan Kettering; Erasmus Medical Center; MD Anderson; UCSF; and the Cleveland Clinic.

Take care,

Jim

Last edited by IADT3since2000; 04-02-2011 at 11:56 AM. Reason: duplicated phrase

 
Old 04-02-2011, 10:18 PM   #8
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Re: PSA rise/urologist referral

Hi Jim
We may be getting our Chris's crossed. Chris61 has not had an RP as he writes, "I'm inclined to consent to a transrectal ultrasound but not to a biopsy of the prostate without further consultation. For the record I did have a biopsy of the prostate bed before my Proton Beam salvage.

As for active surveillance Chris is only 57 and in my opinion he is greatly risking not seeing 70 if he doesn't act aggressively while he has a high percentage chance of achieving a cure. Early treatment means less drastic treatment and minimizes side the chance of side effects such as impotence, incontinence, heart problems, etc. instead of waiting. If he was 75 or 80 it might be different but I would even then opt for Proton Therapy. Many doctors are against active surveillance.
Bob

Chris61 is 57

 
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