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Fluctuating psa


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Old 08-25-2017, 04:42 AM   #1
KEN247
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Fluctuating psa

Hi, over the past 18 months my psa has risen from 4.09 to 5.3, back down to 3.7 and most recently 4.3. Over the year my free psa has gone from 19 to 21. During the exam the other day the urologist did the dre before drawing blood for the psa. The dre was "normal," no lumps, hard areas, etc. My brother, aged 71, was recently diagnosed but they are "watching" his progress. I am 60 and the doctor has suggested a biopsy. Can I ask you all your thoughts? I was considering another psa, but am leaning towards the biopsy. Oh, and I do have an enlarged prostate and am on a version of flomax.

Last edited by KEN247; 08-25-2017 at 04:48 AM. Reason: left something out

 
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Old 08-25-2017, 11:56 AM   #2
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Re: Fluctuating psa

I don't know if you are aware of this but there are things that can raise your PSA. For example, riding a bicycle before being tested or having sex. And your diet can have the effect of raising or lowering your PSA.

Also, prostate can become enlarged by exposure to cold. This happened to me when I worked in a freezing cold place. It wasn't easy but I got over it without going to a doctor as I didn't have insurance at the time. Now, decades later, I have no problem peeing.

Last edited by JohnR41; 08-25-2017 at 11:57 AM.

 
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Old 08-25-2017, 01:04 PM   #3
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Re: Fluctuating psa

No sex or bike riding for a few days before test. It always fluctuates. I am having the biopsy done to get a better idea. I also understand the enlarged prostate increases psa.

 
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Old 08-29-2017, 10:20 AM   #4
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Re: Fluctuating psa

Hi Ken,

I hesitated before replying because you just said that you are having the biopsy done. But then it struck me that you are having it done "to get a better idea," and you may want to consider some additional facts before choosing the biopsy alternative.

First, the biopsy actually samples a tiny fraction of the prostate. What makes it work fairly well is that substantial cancers can be picked up in one of the cores that is sampled a fair amount of the time. However, small cancers can be missed.

Another point is that what is called multiparametric MRI (mpMRI) is a whole lot better at picking up meaningful cancer than a biopsy, though it is not yet able to fully assess that cancer with a Gleason score, which a biopsy can do. mpMRIs also take in the whole prostate, not just tiny samples. When something of concern is seen, it can be followed with a biopsy that includes the areas of concern, which strongly enhances the effectiveness of the biopsy. In one study comparing the standard 12-core random biopsy to mpMRI, the MRI picked up significant cancer 93% of the time, compared to just 48% - under half the time - for the biopsy. Moreover, mpMRI ruled out cancer 89% of the time compared to a fairly good but still inferior 74% for the biopsy. A negative mpMRI report often enables patients to avoid a biopsy that is highly likely to be negative.

mpMRI is not intrusive, except if you consider the contrast agent (Gadolinium) intrusive. In contrast, while biopsies are a very important tool when well used and generally quite safe, there is typically some discomfort and short-term minor side effects, plus a small risk of more burdensome infection that at times requires hospitalization. Make sure your doctor is having you take antibiotic pills that do a lot to minimize the risk of infection, and check to ensure that he gives his patients anesthetics before the biopsy to lessen the discomfort.

It strikes me as odd that the doctor took blood for the PSA test after the DRE. Like other factors mentioned that can increase PSA, a DRE can also do so.

Regarding your PSA levels, as you apparently know, an enlarged prostate (BPH) elevates PSA levels. A rule of thumb is that you get 1 unit of PSA for every 10 cc of healthy (meaning non-cancerous, uninfected) prostate cells. "Enlarged" can cover quite a range, but the lower bound would probably be around 35 cc, which would produce about 3.5 units of PSA. A somewhat more enlarged prostate of 45 cc would produce about 4.5 units of PSA, which is within the range you are reporting.

However, while PSAs vary slightly from day-to-day and lab-to-lab, PSA due to BPH does not decline, unless you are treated so that the volume of the prostate declines, yet you have seen rather substantial variation. Cancer, unless treated, also does not result in a decline in PSA. But infections wax and wane, and the typical pattern of PSA is up and down, sometimes way up and way down, and fast. My layman's guess is that your PSA is elevated because of a combination of BPH and infection, but not cancer. However, again, I am not a doctor and have never been enrolled in medical education; your doctor may be seeing something that concerns him that is not in your description. Apparently your doctor is not trying to screen you for an infection; if that's correct, has he explained why not?

Good luck with this, and good luck to your brother. I hope he is on what is called "active surveillance," which has become a highly respected approach for men with appropriate risk characteristics of their cancers.

Last edited by IADT3since2000; 08-29-2017 at 10:23 AM. Reason: Corrected text right after posting.

 
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Old 08-30-2017, 02:45 PM   #5
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Re: Fluctuating psa

Hi,

Thanks for your reply and advise. After careful consideration, I have decided to get a second opinion on everything from Sloan Kettering Cancer Research Hospital. I called them today and made an appointment for late September. While I do like my doctor, I just felt a little uneasy with a few things, one being that he seem to become angry with me when I mentioned that the blood test was supposed to be done before the dre. He insisted that he "didn't push hard" so it should have no effect. I also wasn't happy with the fact that he didn't mention the mri/ultrasounds, just straight to a biopsy. As I said, all dri's are normal, my enlarged prostate is 40cc, psa fluctuates all over the place (last one 4.3), and the bit of an attitude just rubbed me the wrong way. Further, he kinda "roller skates out the door" when you have an appointment with him and you have to ask him to come back if you have a question.

I always like to err on the side of caution. So, I am going to see what they say at Sloan. I want the best advice possible,

 
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Old 08-30-2017, 02:53 PM   #6
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Re: Fluctuating psa

Hi Ken,

I'm relieved to learn you are giving this another look, especially at Memorial Sloan Kettering. As you probably already know, that institution is one of the best in the world for prostate cancer, and they often pioneer new treatments and diagnostic techniques. You are fortunate to have access to MSKCC. I'm confident they will do whatever needs to be done for you.

Your mention of the clues you picked up in the interaction with your doctor reminds me of my interaction with the doctor who did my biopsy. I believe he did a fine job with that, but he did a number of things that were really off putting, and I soon found other doctors. I have always been glad I made that move.

 
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