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Old 09-18-2012, 01:08 PM   #1
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elevated PSA after TES treatment

I am new to this board and need your opinion or advice. In December 2011 my psa level was 1.5 but my testosterone level was low. Around 300. So my urologist put me on androgel first for 2 months but it didn’t raise my testosterone level. So he recommended testopal 10 pellets implants in my buttock. I went forward with that and in 2 months it doubled my testosterone level but my PSA went up to 4.1. Now my urologist is suggesting biopsy to rule out any prostate cancer but I am hesitant as i want to wait and see if my psa will come down in a month or so. I went to other urologist for a second opinion, he did the rectum test and felt enlarge prostate but still recommended to do biopsy. I did another psa test in (two weeks timeframe) and it came out the same (4.1), PSA, free .89, % Free PSA 21.7. I heard that testopal effect lasts up to 4 months. Is it possible that when the testopal effect is gone my psa level may come down? What if implanted pellets are taken out now, would that make a difference? Can testosterone treatment cause psa level to rise? Should I start the medicines to rule out prostatis and BPH first? I am 50 years and otherwise healthy. Any advice is much appreciated. Thanks!

Last edited by sehat3; 09-18-2012 at 01:10 PM.

 
Old 09-18-2012, 02:10 PM   #2
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Re: elevated PSA after TES treatment

With an enlarged prostate (BPH), it is likely that the testosterone aggravated your BPH causing your PSA to rise. Testosterone is metabolized into DHT which will further aggravate your BPH. Proscar or Avodart will block that conversion and eventually bring down your BPH and its PSA. I think you have a good idea to try one of those first to eliminate BPH as a confounding source of PSA increase. That will reset your PSA baseline to give a truer reading of what is behind the PSA increase. It may take 6 months.

Your high % free PSA is a good, albeit imperfect, indicator that the rise in PSA is not caused by cancer. Soon (if you're in the US -- it's already available in Europe) there will be another test called PHI which will be an even better indicator.

- Allen

 
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Old 09-18-2012, 02:36 PM   #3
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Re: elevated PSA after TES treatment

Thank you Allen for your prompt reply. I have read most of your comments on this board and you seem to have a good grasp of the subject matter. I have an appointment with the 3rd uro this week and i will ask him to put me on the medicines first to rule out the effect of BPH . I will also ask him about the PCA3 test. Thanks again!

 
Old 09-19-2012, 12:28 PM   #4
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Re: elevated PSA after TES treatment

sehat3,
Be aware that Proscar or Avodart will most likely affect your sexual function perhaps permanently. If that is a concern then I would go with the biopsy.
Bob

 
Old 09-19-2012, 03:17 PM   #5
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Re: elevated PSA after TES treatment

Thanks Bob for your reply. I am also considering MRI prior to starting meds. After reading many posts on this board, I think MRI is not a bad option either. I think biopsy should be kept as a last option as per one oncologist i know in Chicago. I am still surprised that testosterone treatment can raise psa level that high, i mean from 1.5 to 4.1 in 6 months? I read the reviews on testopal treatment that i started in june but no one indicated that it causes your psa level to go up. I am not sure about taking proscar yet but if this is my best option to possibly lower my psa then i guess i have to go for it. Do you or anyone know of MRI place that i need for my diagonsis in the Chicago area? I read many different names on MRI machines, not sure which one is available here. How about ultrasound first? Thanks in advance.

 
Old 09-19-2012, 05:22 PM   #6
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Re: elevated PSA after TES treatment

Ordinary MRIs or USs are lousy at detecting small lesions, and would be a waste of time right now, inho.Save the imaging for later if you need it. Testosterone can certainly make BPH flare, or you may have some prostatitis - both will increase PSA. I liked your plan to try to eliminate those as causes first. Your insurance may not pay for PCA3 unless you've had a negative biopsy first -- check with them. PCA3 has a lot of false negatives. I'm hoping PHI will be available soon.

- Allen

 
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Old 09-19-2012, 06:17 PM   #7
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Re: elevated PSA after TES treatment

sehat3,
My father had testosterone treatment. I didn't know much about enlarged prostates or anything at all about prostate cancer at that time but I realize now that he was exhibiting all the classic signs. The doctor didn't check him for prostate problems and just gave him testosterone. It was like throwing gasoline on a fire. He was dead in two years.

Your problem isn't a high PSA reading and lowering your PSA will not help you. You have tripped an alarm and you need to investigate this warning. A MRI will be useless as it does not differentiate normal tissue from prostate cancer. I had a Prostascint Scan with Fusion which is more effective. Some posters have mentioned other scans. My advice is not to mess around with anything that will screen a potential problem and lull you into thinking you are ok. Hormones and testosterone blockers are mostly for someone who has incurable advanced cancer. Have the biopsy and then if a problem is indicated you have the opportunity treat it early with fewer side effects.
Bob

 
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Old 09-20-2012, 12:14 PM   #8
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Re: elevated PSA after TES treatment

The subject of testosterone replacement and prostate cancer comes up a lot, and I welcome the opportunity to address it, as I've looked into it. A lot of people, urologists included, draw an unwarranted conclusion from the fact that completely blocking testosterone down to castrate levels seems to slow down or stop progression of known cancer. They conjecture that adding testosterone when a man has normal ("eugonadal") or somewhat below normal levels ("hypogonadal") levels will either promote prostate cancer or "add fuel to the fire" and awaken any indolent disease. The opposite appears to be true.

Research has consistently failed to find an association between endogenous testosterone (T) levels and risk of PC development, and I think that most authorities would agree that T does not cause PC. This has been substantiated by many prospective controlled research studies. For example:

In a very highly regarded and oft-quoted study, data from 18 worldwide prospective studies were pooled in this analysis of 3886 men with PC and 6438 controls. They found that serum concentrations of sex hormones were not associated with the risk of PC.
Endogenous sex hormones and prostate cancer: a collaborative analysis of 18 prospective studies, J Natl Cancer Inst. 2008 Feb 6; 100(3): 170-83

In a very recent study of 1,365 men followed for up to 20 years while they were on testosterone replacement therapy (TRT), they found that initiating testosterone treatment had no statistically significant effect on total PSA, free PSA or free/total PSA ratio, and any initial PSA change had no predictive relationship to subsequent diagnosis of cancer.
"Is Testosterone Treatment Good for the Prostate? Study of Safety during Long-Term Treatment." Feneley and Carruthers, J. of Sexual Medicine, June 6, 2012.

In this interesting research, they examined frozen serum samples of 166 men who were originally cancer free but were diagnosed with PC 24 years later and found no association between serum T levels and later PC development.
"Serum T and SHBG concentrations and the risk of PC: a longitudinal study", Heikkila et al, Cancer 1999 Jul 15; 86(2):312-5


Another tissue study with 727 PC cases and 889 matched controls found PC risk was unrelated to serum T:
Endogenous sex hormones and the risk of prostate cancer: a prospective study, Weiss et al. (Natl Cancer Inst, NIH) , Int J Cancer 2008 May 15;122(10):2345-50

In a small randomized double-blind placebo controlled study, researchers at UCLA found that TRT raised T serum levels but had little effect on T prostatic tissue levels. They found no association between T levels and PC incidence. (Researchers at UW-Seattle found this to be true of DHT as well).
Effect of TRT on prostate tissue in men with late-onset hypogonadism. Marks et al, JAMA July 6, 2011(306:1)

There are a couple of studies that show a positive association between free T, but not total T and PC. It may be that PC is associated with a deficiency in SHBG (sex hormone binding globulin). However, other studies have found the opposite association (see below).
“Serum T and the risk of PC” Parsons, et al (Johns Hopkins) Cancer Epedemiol Biomarkers Prev 2005 Sep; 14(9):2257-60
But this later analysis of the same data set found that serum T was associated with high risk disease only among men older than 70, but not among men under 70.
“Serum testosterone is associated with aggressive prostate cancer in older men”
Pierorazio, et al. (Johns Hopkins) BJU Int. 2010 Mar; 105 (6):824-9


There is no evidence that higher T levels causes PC. But can it aggravate known PC?

There is one uncontrolled small study, by Morgentaler, in which T was given to men with known untreated PC. In this remarkable study, 13 men with known PC (12 with Gleason 6, 1 Gleason 7) were given T. On the average, there were two follow-up biopsies after a median of 2.5 years. Amazingly, no cancer was found in more than half the f/u biopsies. Two men showed higher grade on initial f/u biopsy, but was not confirmed by a second f/u biopsy in one case or by RP in one case. No PC progression or distant disease was observed.
“T therapy in men with untreated prostate cancer” Morgentaler et al. J Urol 2011 Apr; 185(4):1256-60

In fact, there is a large and growing body of evidence that suggests that low testosterone (hypogonadism) rather than high testosterone is a risk factor for prostate cancer. Testosterone may have a protective effect on healthy prostate tissue. Low testosterone has been associated with both prevalence and aggressiveness of prostate cancer:
"Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less." Morgentaler and Rhoden, Urology. 2006 Dec;68(6):1263-7.
"Is low serum free testosterone a marker for high grade prostate cancer?" Hoffman et al, J Urol. 2000 Mar;163(3):824-7.


Dr. Morgentaler at Harvard Medical School has championed the saturation theory of prostate cancer. He concludes from the evidence that prostate cancer is completely fueled by very low levels of androgens, castrate levels, in fact, and anything above that will have no effect of prostate cancer growth:
"Rapidly Shifting Concepts Regarding Androgens and Prostate Cancer" Morgentaler, The Scientific World Journal (2009) 9, 685–690

I hope this helps to clear up this very common misunderstanding.

- Allen

 
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Old 09-20-2012, 10:22 PM   #9
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Re: elevated PSA after TES treatment

Quote:
Originally Posted by Tall Allen View Post
The subject of testosterone replacement and prostate cancer comes up a lot, and I welcome the opportunity to address it, as I've looked into it. A lot of people, urologists included, draw an unwarranted conclusion from the fact that completely blocking testosterone down to castrate levels seems to slow down or stop progression of known cancer. They conjecture that adding testosterone when a man has normal ("eugonadal") or somewhat below normal levels ("hypogonadal") levels will either promote prostate cancer or "add fuel to the fire" and awaken any indolent disease. The opposite appears to be true.

Research has consistently failed to find ........................................ ......... - Allen
Allen

Thanks for the above explanations.
In reference to the studies listed in your above post, I sincerely would like to understand their perception with regards to the “Flare” theory which has been proven and demonstrated in LHRH agonist treatments. One may say that; raised levels of T do not cause cancer in benign issues but it increases cancer “behaviourism” in the presence of PCa tissues.
Hormonal and some chemo drugs work because they manage to lower absorption of androgens or by lowering levels circulating in body tissue.

Best.
Baptista

 
Old 09-24-2012, 12:30 PM   #10
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Re: elevated PSA after TES treatment

I went to see another uro for 3rd opinion. This dr is a surgeon and he just sit in his office for two days a week only. He told me that my high level of PSA is due to T treatment that aggravated my prostate. He said once the effect of testosterone is gone then PSA level should eventually y come down provided there are no other prostate conditions exist otherwise I have to go through all the tests (mri, US, biopsy). The surgeon told me he has seen patients on T treatment having high psa and get lowered after the T effect with no other known conditions existed. The surgeon suggested that I should wait another 3 months before getting another blood test for PSA and % free because testosterone treatment takes time to wear off and my treatment was started two months ago. He added that if I keep on taking blood tests for psa on a monthly basis it won’t do any good because levels won’t change much so better give it about 3-4 months. He also did the DRE and found a slight enlarge prostate due to age but he doesn’t think that’s this is the main culprit for my high psa. He also told me that I don’t have prostatitis either so there was no point giving meds for any of that. Now I am confused, the other two uros said to get the biopsy done and this uro surgeon is saying to wait and don’t rush things. So Should I wait for my next psa test? Get another opinion? Any advice is much appreciated. Thanks all !

 
Old 09-24-2012, 12:47 PM   #11
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Re: elevated PSA after TES treatment

As you can tell from my previous comments, I agree with your urologic surgeon. Biopsies are way overdone and often lead to missed cancers, on the one hand, or overdiagnosis of insignificant cancers, on the other hand, that leads to "cancer panic" and overtreatment. Since you have a known aggravator of PSA due to BPH, it makes sense to eliminate that source before you move onto the next step.

- Allen

 
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Old 09-24-2012, 08:26 PM   #12
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Re: elevated PSA after TES treatment

sehat3,
That's interesting. If you had a biopsy it is not guaranteed that it will clear up your situation. I've talked to some men who went through several biopsies before one showed a positive result for cancer. What's your gut feeling and what can you lose by waiting?
Decisions...
Bob

 
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