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Requesting thoughts on PSA activity


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Old 09-27-2017, 02:15 PM   #1
cajunhandlebar
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Requesting thoughts on PSA activity

I have been on Testosterone Replacement Therapy (TRT) for a few years (I am 55). Over time, my PSA has increased, and sometimes quickly jumped. And sometimes really subsided. At the advice of my urologist, I have stopped the TRT. He is STRONGLY suggesting a biopsy, and at the same time is open to at least letting me speak my peace about my hesitation at letting him cut pieces out of what MIGHT be a healthy organ. My DRE is always normal and smooth, I have no problems peeing. As far as "down-there" everything seems normal.

I am trying to get my GP on the GenPath list so that he can draw blood for a 4kScore test, just so that I can have some other data to look at to help me make up my mind before I have the biopsy.

I figure that you guys on the forum will have so much knowledge and experience, you may be able to give me some thoughts and hopefully recommendations. I have been tracking my PSA for years.
All comments most welcome and appreciated.

Last edited by Administrator; 09-27-2017 at 05:01 PM.

 
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Old 09-28-2017, 04:53 AM   #2
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Re: Requesting thoughts on PSA activity

I am trying to post a graph of my PSA history, but do not yet see how to attach an image to a post. So I am including the historical values below..

Date - PSA value
Sep 1, 1998 - 0.6
Feb 21, 2001 - 0.61
Apr 17, 2003 - 0.78
Mar 29, 2004 - 0.53
Dec 1, 2005 - 0.71
Apr 7, 2012 - 1
Apr 25, 2012 - 1.06
Oct 22, 2012 - 1.2
May 2, 2013 - 1
Aug 4, 2014 - 1.1
Feb 27, 2015 - 1.7
Jul 20, 2015 - 1.5
Jan 11, 2016 - 1.6
Mar 28, 2016 - 1.9
Aug 15, 2016 - 4.6
Sep 20, 2016 - 1.6
Nov 23, 2016 - 1.7
Jan 4, 2017 - 2.8
Jan 31, 2017 - 2.7
Feb 10, 2017 - 1.67
Apr 3, 2017 - 3
Apr 18, 2017 - 2.2
Aug 7, 2017 - 6.2
Sep 1, 2017 - 5.1
Sep 19, 2017 - 6.33

 
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Old 09-29-2017, 05:42 AM   #3
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Re: Requesting thoughts on PSA activity

Hi cajunhandlebar,

I’m visualizing you in Louisiana with a long handlebar mustache.

Seeing those PSA results helps. You started with normal numbers for a younger man, and over the long term you have seen an overall increasing trend as you hit mid fifty, as happens to many of us, though not usually as high as the latest three scores. That suggests you are experiencing some BPH (Benign Prostatic Hypertrophy, aka benign growth of the prostate), which is typical. BPH does not need to be treated if it is causing no problems, but there are things you can do with diet/nutrition and some usually mild medications. However, it is very likely that at least one other thing is going on.

The clue is in the up and down pattern, which you noted. Neither BPH nor cancer is related to such a pattern, as both are associated with steady increases with no declines, but that up-down-up-down pattern is a telltale sign of an infection or inflammation. The increase can be rapid, and it can drive the PSA really high; I’ve read about multiple instances where PSA can be pushed into the 50s, for example, and the highest I heard about was about 200, with subsequent falls back to normal after effective treatment of the infection/inflammation. To my layman’s eye, you appear to have an infection – either a series of infections, or perhaps more likely a chronic infection that wanes and waxes. The usual medical strategy is to try to culture the bacteria causing the infection or to use trial and error with successive antibiotics to see if any work, starting with the drugs more likely to be successful. Sometimes it proves impossible to nail the cause and eliminate it.

However, I’m thinking that your urologist is seeing that this latest rise is double what you have seen in the past. That could easily still be due to infection, though not the gradual slow rise due to BPH. However, you are now at the level past the obsolete threshold of 4 that used to routinely trigger biopsies, and, at double the highest old level, there is a concern that cancer might be part of the reason for your current elevated level. On the other hand, even in your past three scores you have seen some up and down then up again movement that is likely beyond the day-to-day, test-to-test variation that is common, and this again points toward infection as a likely cause.

Here are some ideas in addition to the 4K test, just to give you some more good options. The main one is a “multiparametric MRI” (mpMRI) done at a facility (including the radiologist interpreter) that knows what it is doing. I described that MRI within the past few days elsewhere. This mpMRI technology has rapidly emerged as a pre-biopsy look to help determine whether a biopsy would be wise. Also, if it shows likely cancer, then its results can be used to guide the biopsy to sample the spots that look suspicious for cancer, while not wasting biopsy probes on areas that look perfectly normal. This approach has proven far superior in picking up meaningful cancer while avoiding insignificant cancer that experts feel hardly deserves the name. Another idea is to use one of the “5-alpha reductase inhibitor (5-ARI) drugs – either Avodart®/dutasteride or Proscar®/finasteride – to shrink the prostate and reduce its blood supply, which eliminates or at least decreases BPH tissue. This makes PSA trends and DRE results more efficient indicators for whether there is cancer. It also counters the milder forms of prostate cancer. A third idea is just to wait a bit and do another PSA test. That has the risk that you might not be countering an unlikely rapidly growing cancer as quickly as you could have, but in your circumstances, especially doing it in early October, would probably not risk much; another downward trend, perhaps a big one, would point toward an infection.

Biopsies are not huge deals for the vast majority of us. It’s important to get antibiotic protection before the biopsy and anesthetic just before the probing begins. If unusual side effects occur, prompt attention is needed. All in all, while there is a risk of bothersome burden on the patient from side effects, with very few patients experiencing long-term significant side effects, the risk is low and most significant side effects can be very well managed. The idea here, as you seem to already know, is not to jump to a biopsy if it is not time to get one, but to go ahead if the evidence so warrants.

Good luck with this.

 
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Old 09-29-2017, 06:34 AM   #4
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Re: Requesting thoughts on PSA activity

IADT3since2000,

Thank you so much for your reply. I am not sure whether my GP will be set up to draw blood for the 4KScore test by the time of my biopsy, so I drew blood yesterday at a lab to get my PSA again and free PSA (which I have never tested before).

I have a neophyte question about infection causing an increased PSA... Can this be an infection anywhere in the body, or would it have to be an infection of the prostate or the area around the prostate? I did have a throat infection recently that my doctor thought was strep.

 
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Old 09-29-2017, 08:46 AM   #5
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Re: Requesting thoughts on PSA activity

Hi again,

You are welcome. I'm glad to help.

Regarding an infection causing elevated PSA, I'm almost certain that it is a prostate infection and not an infection elsewhere.

Free PSA is also influenced by infection, so it probably will not be much help. I believe the 4K score is not influenced by infection.

 
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Old 10-02-2017, 12:44 PM   #6
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Re: Requesting thoughts on PSA activity

Well I got another set of PSA scores in today ...

PSA
4.9

PSA, Free
0.53

%Free PSA
10.8

PAP
2.0

So, although I am hoping for BPH or infection, I am prepared for the biopsy to show something else - we will see...

 
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Old 10-03-2017, 02:23 PM   #7
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Re: Requesting thoughts on PSA activity

That nice substantial and quick drop in PSA to 4.9 sure makes it look like infection is playing a significant role in what is going on, but it may not be the only thing.


There is a fairly good chance that the biopsy will not show cores for any significant prostate cancer, perhaps just a small amount of Gleason 3+3=6, which probably should not be treated but be under active surveillance instead, if even that much is found. After all, biopsies usually sample less than 1% of the prostate, and they can easily miss cancer that is small, especially if not guided by results from a multiparametric MRI scan.


If I were you, I would call the doctor or his/her staff ahead of time and check whether the doctor routinely records the size of the prostate as revealed by the imaging used for the biopsy, which usually is what is known as "transrectal ultrasound," or TRUS. The size statistic is very important, especially if the biopsy reveals no cancer or no significant cancer. Once you have an accurate and reliable size figure, you can easily calculate the "PSA density" (PSAD). If you need to decide someday whether to use active surveillance after a diagnosis, a PSAD of 0.15 or lower is quite favorable to active surveillance, while a higher figure is not and suggests that treatment would be better. If the doctor does not routinely record size, you could try to negotiate that for your biopsy, or perhaps consider finding a doctor who does record the size.

 
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Old 10-04-2017, 06:09 AM   #8
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Re: Requesting thoughts on PSA activity

Thank you again IADT for keeping up with me and my situation. I will FAX the doctor today and ask these and some other pre-procedure questions.

 
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Old 10-17-2017, 03:14 PM   #9
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Talking Re: Requesting thoughts on PSA activity

IADT,

Thank you again for all of your help! I had a 14-core biopsy last Thursday, and the nurse called me today with the results. The fact that the nurse called instead of the doctor gave me optimism, and she reported back that all 14 cores were negative. So I go back in 6 months for a follow-up visit.

That was a huge relief. But based on what I have read on this forum, I am still going to learn as much as possible about PC, because from what I can tell, it is up to us to be our own advocates. Gone are the days (hopefully) when people just do what the doctor says because s/he knows best.

 
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