It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....



Cancer: Prostate Message Board

  • Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

  • Post New Thread   Reply Reply
    Thread Tools Search this Thread
    Old 01-06-2020, 05:01 PM   #1
    IADT3since2000
    Senior Veteran
    (male)
     
    Join Date: Nov 2007
    Location: Fountain Valley, CA, USA
    Posts: 3,172
    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Lightbulb Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Many of us are going to experience benign prostatic hyperplasia (BPH, meaning benign enlargement) as we get older, and assessment of prostate size is likely to play at least a temporary role in the work-up to find whether there is prostate cancer. (I had mild BPH at diagnosis myself, but my PSA was so high that that was not considered a factor, except perhaps a brief consideration to judge that I did not have a rare prostate “infarction”, which can cause PSA to soar to levels of over 100.) It is a well-established fact that BPH itself causes PSA to increase, often into the range where PSA suggests prostate cancer might be present, and that can cloud the early clues before a biopsy whether there is also prostate cancer.

    Recently there have been vigorously expressed differences of opinion about this on the Board. As none of us frequent participants want to spread old and misleading information, I am initiating this thread to at least help me confirm that what I have been posting is correct, or learn that some of what I have presented might be misleading. I use extra care to ensure I am providing reliable information so I am highly confident, but that is not a guarantee of being right, and I would welcome discussion.

    The old view of PSA was that a PSA of more than 4 warranted a biopsy. That view was prevalent at the time I was diagnosed in 1999 and until a number of years afterward; I found it expressed by a leading NYC prostate cancer surgeon in his 2005 book. At some point, an awareness emerged that “normal” PSA fell in an increasing range as men got older, and that was because of typical increasing BPH; a PSA of 6 was considered normal for a somewhat older man. Even back in his 2001 book, “Guide to Surviving Prostate Cancer,” famous prostate cancer surgery expert and pioneer Patrick Walsh, MD, stated that “It is common for a man’s PSA to be as high as 10 percent of his prostate weight.” (p. 112; you can use weight in grams or cc in volume to do the 10% calculation). He also noted that “… when a man’s PSA level rises because of BPH, the more of the PSA is in the free form…. The higher the free PSA, the more likely that you are free of cancer.” (p. 112)

    In a recent, popular 2018 guide entitled “The Key to Prostate Cancer”, in chapter 2 which was authored by Dr. Stanley Brosman, MD, a senior urologist, we find this statement: “PSA is only abnormal (the official term is a “high PSA density”) when it’s 50 percent higher than would be expected, based on the prostate’s size. For example, a man’s PSA is abnormal if he has a 30cc prostate and his PSA is above 4.5. An abnormal PSA for a 50cc prostate is above 7.5. For a 100cc gland, PSA would need to be above 15 to be suspicious.” Whew! Such a high PSA would really worry non-medical people, me included, but this is the considered judgement of a highly experienced urologist that he is not only committing to in writing but publicizing in a popular book.

    The association for American urologists has weighed in regarding PSA levels and biopsies; the bottom line is that the association’s advice to its members includes prostate size as an important consideration in considering the PSA level and whether to have a biopsy. Here is the site of the American Urological Association’s guideline, which we patients can access: https://www.auanet.org/guidelines/prostate-cancer-early-detection-guideline . Here are some key sentences bearing on size of the prostate and PSA from this rather long document. (The numbers after the ends of sentences are references, which any of us can access to check that level of detail.)


    “PSA values can be elevated for many reasons. Normal physiologic variation often occurs and as many as 20% of elevated values will return to normal within one year.88 Serum PSA levels also vary with age, race, BMI and prostate volume. They can increase as a result of benign prostate hypertrophy, prostatitis and any prostate manipulation such as prostate massage and biopsy. Finasteride and other 5α reductase inhibitors can decrease PSA values by approximately 50%.89”


    "For every 1,000 men tested, approximately 100 to 120 will have an elevated PSA value.90 Most of these men will undergo a prostate biopsy, and approximately one third will experience some type of mild to severe symptom including pain, fever, bleeding, infection or problems urinating. Approximately 4% will be hospitalized within 30 days after biopsy.28,2"


    "Biopsy Trigger
    There is no PSA level below which a man can be informed that prostate cancer does not exist. Rather, the risk of prostate cancer, and that of high grade disease, is continuous as PSA increases.104 … However, the Panel believes that the urologist should consider factors that lead to an increased PSA including prostate volume, age, and inflammation rather than using an absolute level to determine the need for a prostate biopsy, keeping in mind that PSA is not a dichotomous test but rather a test that indicates the risk of a harmful cancer over a continuum. The Panel believes that postponing and/or avoiding a prostate biopsy 1) in a man with a large prostate, 2) in the older male especially if in less than excellent health, and 3) in the setting of a suspicion of prostatic inflammation, would be acceptable even at PSA levels exceeding 3-4ng/mL." (my emphasis) What I would also like to see is a statement from research consistent with Dr. Brosman’s advice about very large prostates and PSA approaching and even exceeding 10.

    I hope we will be able to locate research that clarifies the matter of prostate size and biopsies.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

    Last edited by IADT3since2000; 01-07-2020 at 05:21 AM. Reason: Deleted inadvertently repeated text. Added "from research" in 2nd to last text paragraph.

     
    Reply With Quote
    Sponsors Lightbulb
       
    Old 01-06-2020, 05:57 PM   #2
    ASAdvocate
    Senior Member
    (male)
     
    Join Date: Dec 2019
    Location: Alexandria, VA USA
    Posts: 290
    ASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB UserASAdvocate HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by IADT3since2000 View Post
    Many of us are going to experience benign prostatic hyperplasia (BPH, meaning benign enlargement) as we get older, and assessment of prostate size is likely to play at least a temporary role in the work-up to find whether there is prostate cancer. (I had mild BPH at diagnosis myself, but my PSA was so high that that was not considered a factor, except perhaps a brief consideration to judge that I did not have a rare prostate “infarction”, which can cause PSA to soar to levels of over 100.) It is a well-established fact that BPH itself causes PSA to increase, often into the range where PSA suggests prostate cancer might be present, and that can cloud the early clues before a biopsy whether there is also prostate cancer.

    Recently there have been vigorously expressed differences of opinion about this on the Board. As none of us frequent participants want to spread old and misleading information, I am initiating this thread to at least help me confirm that what I have been posting is correct, or learn that some of what I have presented might be misleading. I use extra care to ensure I am providing reliable information so I am highly confident, but that is not a guarantee of being right, and I would welcome discussion.

    The old view of PSA was that a PSA of more than 4 warranted a biopsy. That view was prevalent at the time I was diagnosed in 1999 and until a number of years afterward; I found it expressed by a leading NYC prostate cancer surgeon in his 2005 book. At some point, an awareness emerged that “normal” PSA fell in an increasing range as men got older, and that was because of typical increasing BPH; a PSA of 6 was considered normal for a somewhat older man. Even back in his 2001 book, “Guide to Surviving Prostate Cancer,” famous prostate cancer surgery expert and pioneer Patrick Walsh, MD, stated that “It is common for a man’s PSA to be as high as 10 percent of his prostate weight.” (p. 112; you can use weight in grams or cc in volume to do the 10% calculation). He also noted that “… when a man’s PSA level rises because of BPH, the more of the PSA is in the free form…. The higher the free PSA, the more likely that you are free of cancer.” (p. 112)

    In a recent, popular 2018 guide entitled “The Key to Prostate Cancer”, in chapter 2 which was authored by Dr. Stanley Brosman, MD, a senior urologist, we find this statement: “PSA is only abnormal when it’s 50 percent higher (the official term is a “high PSA density”) when it’s 50 percent higher than would be expected, based on the prostate’s size. For example, a man’s PSA is abnormal if he has a 30cc prostate and his PSA is above 4.5. An abnormal PSA for a 50cc prostate is above 7.5. For a 100cc gland, PSA would need to be above 15 to be suspicious.” Whew! Such a high PSA would really worry non-medical people, me included, but this is the considered judgement of a highly experienced urologist that he is not only committing to in writing but publicizing in a popular book.

    The association for American urologists has weighed in regarding PSA levels and biopsies; the bottom line is that the association’s advice to its members includes prostate size as an important consideration in considering the PSA level and whether to have a biopsy. Here is the site of the American Urological Association’s guideline, which we patients can access: https://www.auanet.org/guidelines/prostate-cancer-early-detection-guideline . Here are some key sentences bearing on size of the prostate and PSA from this rather long document. (The numbers after the ends of sentences are references, which any of us can access to check that level of detail.)


    “PSA values can be elevated for many reasons. Normal physiologic variation often occurs and as many as 20% of elevated values will return to normal within one year.88 Serum PSA levels also vary with age, race, BMI and prostate volume. They can increase as a result of benign prostate hypertrophy, prostatitis and any prostate manipulation such as prostate massage and biopsy. Finasteride and other 5α reductase inhibitors can decrease PSA values by approximately 50%.89”


    "For every 1,000 men tested, approximately 100 to 120 will have an elevated PSA value.90 Most of these men will undergo a prostate biopsy, and approximately one third will experience some type of mild to severe symptom including pain, fever, bleeding, infection or problems urinating. Approximately 4% will be hospitalized within 30 days after biopsy.28,2"


    "Biopsy Trigger
    There is no PSA level below which a man can be informed that prostate cancer does not exist. Rather, the risk of prostate cancer, and that of high grade disease, is continuous as PSA increases.104 … However, the Panel believes that the urologist should consider factors that lead to an increased PSA including prostate volume, age, and inflammation rather than using an absolute level to determine the need for a prostate biopsy, keeping in mind that PSA is not a dichotomous test but rather a test that indicates the risk of a harmful cancer over a continuum. The Panel believes that postponing and/or avoiding a prostate biopsy 1) in a man with a large prostate, 2) in the older male especially if in less than excellent health, and 3) in the setting of a suspicion of prostatic inflammation, would be acceptable even at PSA levels exceeding 3-4ng/mL." (my emphasis) What I would also like to see is a statement consistent with Dr. Brosman’s advice about very large prostates and PSA approaching and even exceeding 10.

    I hope we will be able to locate research that clarifies the matter of prostate size and biopsies.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.
    One of the variables that would have to be determined to consider not doing a biopsy is the prostate volume. While a DRE is of some value, that measurement would require an ultrasound or an MRI. So, there would be some additional imaging to help determine the necessity of performing a biopsy.

     
    Reply With Quote
    Old 01-07-2020, 01:27 AM   #3
    Prostatefree
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Posts: 617
    Prostatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    How about when your doctor recommends one?

    Early detection of prostate cancer is the hallmark to beating it. Lose the advantage of early detection and you lose the biggest advantage you have against a treatable cancer.

    Talking yourself out of a biopsy, and this includes a second follow up biopsy, is the most common mistake made in screening for prostate cancer.

    The saddest tales of this disease are those who waited or missed early screening and detection by their own doing.
    __________________
    Born 1953;family w/PCa-grandfather, 3 brothers
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, upgraded to G3+4, Tumor vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months
    7-9-21 PSA less than 0.02; zero club 6yrs

     
    Reply With Quote
    Old 01-07-2020, 03:24 AM   #4
    Nishari
    Newbie
    (female)
     
    Nishari's Avatar
     
    Join Date: Jan 2020
    Posts: 1
    Nishari HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by Prostatefree View Post
    How about when your doctor recommends one?

    Early detection of prostate cancer is the hallmark to beating it. Lose the advantage of early detection and you lose the biggest advantage you have against a treatable cancer.

    Talking yourself out of a biopsy, and this includes a second follow up biopsy, is the most common mistake made in screening for prostate cancer.

    The saddest tales of this disease are those who waited or missed early screening and detection by their own doing.
    it is not that early screening is important for prostate cancer, early screening is common for all the cancer. the disease can be cured at the right time so that it can be cured at the right stage. detecting early provides easy cyring advantage. such that proper cancer screening procedures to be followed to get rid off cancer.

     
    Reply With Quote
    Old 01-07-2020, 06:40 AM   #5
    DjinTonic
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Location: NC
    Posts: 574
    DjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by Prostatefree View Post
    How about when your doctor recommends one?....
    I'll just put my take on why I hold the same view.

    Since I came across them, I've been haunted by studies like:

    Clinical and Genomic Characterization of Low-Prostate-specific Antigen, High-grade Prostate Cancer [2018, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615042/

    Quote:
    Objective:
    To evaluate the clinical implications and genomic features of low-PSA, high-grade disease.

    Design, setting, and participants:
    This was a retrospective study of clinical data for 494 793 patients from the National Cancer Data Base and 136 113 patients from the Surveillance, Epidemiology, and End Results program with cTl–4N0M0 prostate cancer (median follow-up 48.9 and 25.0 mo, respectively), and genomic data for 4960 patients from the Decipher Genomic Resource Information Database. Data were collected for 2004–2017.
    ,,,
    Results and limitations:
    For Gleason 8–10 disease, using PSA 4.1–10.0 ng/ml (n = 38 719) as referent, the distribution of PCSM by PSA was U-shaped, with an adjusted hazard ratio (AHR) of 2.70 for PSA ≤2.5 ng/ml (n = 3862, p < 0.001) versus 1.97,1.36, and 2.56 for PSA of 2.6–4.0 (n = 4199), 10.1–20.0 (n = 17 372), and >20.0 ng/ml (n = 16 114), respectively. By contrast, the distribution of PCSM by PSA was linear for Gleason ≤7...
    This MSK study found:

    Genomic Assessment of a High Grade Low PSA Prostate Cancer Cohort [2018]
    https://www.redjournal.org/article/S0360-3016(19)32618-5/fulltext

    Quote:
    Conclusion
    Patients presenting with high grade prostate cancer and a PSA <4 should undergo genomic testing since about one third harbor DDR mutations and may be future candidates for PARP inhibitor therapy. Alterations commonly associated with small cell neuroendocrine prostate cancer were not seen with increased frequency.
    Most non-metasatic PCa present with signs, but no symptoms, of disease. But as Jim quotes above, and the above papers point out, even that isn't always true:

    Quote:
    There is no PSA level below which a man can be informed that prostate cancer does not exist.
    I don't remember which, but one paper found the almost 3% of high-risk PCa presents with a PSA <4.

    My own biopsy advice is:
    If you have concerns about PCa, put yourself into the care of a uro, regardless of what your PCP says.

    If you are doubting the competence of your uro, find another one.

    If you trust your uro, and a biopsy is advised, take the advice. In other words, have the biopsy, which may very well come back negative, but may also prolong your life.
    A uro has different tools to make the biopsy call in addition to PSA-related factors like history & trend, density, %free. These include family history, other blood tests, imaging, DRE (not only nodules), imaging, patient concerns, calculation and prediction tools & tables, etc. Uro's have more than these tools, however. They have the training and experience. You are also paying for their "hunches" which can be the fruit of decades of experience.

    The aim is not to predicts G6 in 10 years from now by finding microlesions now. The aim of screening & diagnosis is to catch potentially metastatic disease early.

    There are many papers coming out with nomograms and advice how to combine mpMRI data (especially for PIRADS 3) with other factors, like PSA density in the "gray area" (PSA 4-10 ng/mL). So one camp is trying to determine who can skip a biopsy. The other camp is more cautious and advises to always take cores in all zones, regardless of where the MRI targets are and to biopsy even when the MRI is negative. And I suspect that perhaps the majority of uros are in favor of repeat biopsies when there is continuous suspicion for PCa.

    BPH increases healthy tissue and thus PSA levels, but I and many other had both BPH and PCa. (A curious side note: it isn't known just why, but the incidence of PCa in men with BPH is actually lower than what it statistically should be. One paper hypothesized that the increase physical pressure on prostate cells pays a role, perhaps inhibiting either the formation or progression of PCa.

    Transperineal biopsies, with their near zero infection rates may prove to be the solution for the period where we transition from "barbaric" biopsies to liquid biopsies where we can trust the tale that circulating tumor cells (CTCs) and genetic markers in blood or urine tell more than the histological grading of tissue under the microscope. In any case, the rates of serious infection are not uniform: docs who do many TRUS biopsies have much lower rates than those who do a few a year.

    As a layman, I don't feel at all comfortable advising anyone not to have a recommended biopsy based on any guidelines, which after all are statistical rules of thumb -- especially given the very murky picture that PSA alone provides and the serious PCa that presents with a PSA within normal limits (or limits adjusted for your prostate volume).

    Yes, there will be times when your uro says "We can biopsy now or wait 6 months and see whether..." And joint decision-making is the name of the game. But I'll come back to my starting point: either take your uro's advice or find another uro if you have reason to doubt it.

    I'll add that an initial biopsy biopsy is especially important. Even if negative, you and your doc will have some idea of what has been going on, and have this baseline to use as a metric for future developments.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.023 (4 yr. 6 mo.)

     
    Reply With Quote
    Old 01-07-2020, 07:52 AM   #6
    guitarhillbilly
    Senior Member
    (male)
     
    Join Date: Jan 2020
    Posts: 257
    guitarhillbilly HB Userguitarhillbilly HB Userguitarhillbilly HB Userguitarhillbilly HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    [QUOTE=Prostatefree;5499666]How about when your doctor recommends one?

    'Talking yourself out of a biopsy, and this includes a second follow up biopsy, is the most common mistake made in screening for prostate cancer.'


    Why do I need a second follow up biopsy when my First one discovered
    T2a Gleason Score 8 PSA 6.9 ?

     
    Reply With Quote
    Old 01-07-2020, 07:55 AM   #7
    guitarhillbilly
    Senior Member
    (male)
     
    Join Date: Jan 2020
    Posts: 257
    guitarhillbilly HB Userguitarhillbilly HB Userguitarhillbilly HB Userguitarhillbilly HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    I cannot place enough emphasis on knowing your PSA Velocity and
    PSA / Prostate Density Ratio.
    PSA number by itself is only a starting point.

    In my case the PSA Velocity started the very close surveillance by my PCP and UR. My PSA went from 2.5 to 6.9 in about 3 years. My UR wanted to do a biopsy at PSA 5.3 after receiving the results of my MRI due to my Prostate Density / to PSA ratio. I declined at that time due to the risks involved and once my PSA jumped to 6.9 from 5.3 in 6 months that forced me to choose a biopsy.
    MRI and Biopsy are both tools that should be used by the UR to diagnose PC.
    I'm presently 1 month into Lupron Therapy and scheduled to start radiation in late FEB.

    T2a
    Gleason = 8
    PSA at Biopsy = 6.9

    There is lots of information on the web from Medical people that state that Prostate Biopsies are over used and create unnecessary risks.
    The one I read was that PSA less than 10 only 25 % come back with PC and over 10 that 50 % come back with PC. In my case this information gave false hope/denial.
    Unfortunately I was in the 25 % group with a 6.9 PSA.

    DO NOT ASSUME that an elevated PSA is just the result of of BPH.

     
    Reply With Quote
    Old 01-07-2020, 08:58 AM   #8
    BlueHeron2020
    Junior Member
    (male)
     
    Join Date: Jan 2020
    Location: Gulf Coast
    Posts: 20
    BlueHeron2020 HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    When my psa slowly hit 5.1 my UR recommended biopsy. I opted for MRI. MRI determined prostate was 53 cc and two areas of pirad 4. So I agree, there are many things to consider when deciding to biopsy. If we only measured prostate volume and relied only on a guideline related to prostate size and volume, we would possibly have delayed biopsy when cancer was present. I agree with using all available information when deciding to biopsy, but then, I don’t think there is any perfect formula, just guidelines and probabilities.

     
    Reply With Quote
    The following user gives a hug of support to BlueHeron2020:
    DjinTonic (01-07-2020)
    Old 01-07-2020, 09:04 AM   #9
    DjinTonic
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Location: NC
    Posts: 574
    DjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by BlueHeron2020 View Post
    When my psa slowly hit 5.1 my UR recommended biopsy. I opted for MRI. MRI determined prostate was 53 cc and two areas of pirad 4. So I agree, there are many things to consider when deciding to biopsy. If we only measured prostate volume and relied only on a guideline related to prostate size and volume, we would possibly have delayed biopsy when cancer was present. I agree with using all available information when deciding to biopsy, but then, I don’t think there is any perfect formula, just guidelines and probabilities.
    I think there is general agreement a biopsy is warranted if there are PIRADS 4 or 5 areas, regardless of other parameters. And all the studies I've come across advocate for investigating intermediate, PIRADS 3 lesions via a biopsy.

    DJin

     
    Reply With Quote
    The Following User Says Thank You to DjinTonic For This Useful Post:
    ASAdvocate (01-07-2020)
    Old 01-07-2020, 09:14 AM   #10
    BlueHeron2020
    Junior Member
    (male)
     
    Join Date: Jan 2020
    Location: Gulf Coast
    Posts: 20
    BlueHeron2020 HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by DjinTonic View Post
    I think there is general agreement a biopsy is warranted if there are PIRADS 4 or 5 areas, regardless of other parameters. And all the studies I've come across advocate for investigating intermediate, PIRADS 3 lesions via a biopsy.

    DJin
    sorry, my point was not clear
    If we used some other method to determine prostate size, (and did not get pirad report), we may not have gone further with biopsy

     
    Reply With Quote
    Old 01-07-2020, 09:25 AM   #11
    DjinTonic
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Location: NC
    Posts: 574
    DjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Yes, agreed. I've seen far too many signatures of guys (me included) whose G8-10 diagnosis was made with a PSA under 10.

    Djin

     
    Reply With Quote
    Old 01-07-2020, 09:36 AM   #12
    Prostatefree
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Posts: 617
    Prostatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB UserProstatefree HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Quote:
    Originally Posted by BlueHeron2020 View Post
    When my psa slowly hit 5.1 my UR recommended biopsy. I opted for MRI. MRI determined prostate was 53 cc and two areas of pirad 4. So I agree, there are many things to consider when deciding to biopsy. If we only measured prostate volume and relied only on a guideline related to prostate size and volume, we would possibly have delayed biopsy when cancer was present. I agree with using all available information when deciding to biopsy, but then, I don’t think there is any perfect formula, just guidelines and probabilities.

    Your PSA was over 4.0. If it is steady and persistent rise then it triggers a biopsy. In your case an MRI confrimed the suspicion. This is not always the case. You fit the perfect protocol of a simple PSA test screening for a biopsy. An MRI is expensive and resource consuming, and made no difference except to help you set aside your anxiety over accepting a biopsy (I assume). That's an expensive procedure for uncertainity in understanding the risk of prostate cancer when a PSA test was sufficient.

    Did your doctor recommend a biopsy and you repsonded with a request for an MRI? It is a common denial and delay response. Also common is the idea of an infection and a round of anitbiotics. The random drop in PSA following the anitbiotics is often used to dismiss a biopsy when they are unrelated occurences.

    Waiting for your PSA to hit 5.1 is common, but sacrificies the opporunity for even earliar detection. I did it. I waited until over 7.0. I'll never advise someone wait. It's cancer and it's treatable if detected and treated early. I was lucky.

    An interesting question about your biopsy is how many samples hit cancer between the targeted samples and the random samples?

    In your experience and in mine, our PSA was/is a perfect barometer for the presence and progression of your cancer. PSA testing is the single most important advancement in the diagnoses and treatment of prostate cancer.

    Toss in an MRI if you can, but never dismiss a biopsy based on an MRI report if your PSA is calling for it. You ran this risk. What if your MRI had come back negative? Were you prepared to proceed with the biopsy regardless? If you had and the cancer was missed would you have followed through with a second biopsy within a year? And during this entire period your PSA was accurately reflected your cancer risk.

    Early detection is not easy. Simple, but not easy.
    __________________
    Born 1953;family w/PCa-grandfather, 3 brothers
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, upgraded to G3+4, Tumor vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months
    7-9-21 PSA less than 0.02; zero club 6yrs

     
    Reply With Quote
    Old 01-07-2020, 09:51 AM   #13
    DjinTonic
    Senior Veteran
    (male)
     
    Join Date: Dec 2019
    Location: NC
    Posts: 574
    DjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB UserDjinTonic HB User
    Re: Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?

    Back to Jim's question about what PSA and prostate volume can tell us, here is one study about ongoing nomogram development and PCa detection rates in the gray zone (4.0–10 ng/mL), here is an example of the ongoing research:

    Comparison of cancer detection rates by transrectal prostate biopsy for prostate cancer using two different nomograms based on patient’s age and prostate volume [2019, Full Text]

    https://www.dovepress.com/comparison-of-cancer-detection-rate-by-transrectal-prostate-biopsy-for-peer-reviewed-fulltext-article-RRU

    I am by no means touting this study as any kind of benchmark, but rather to point out that we are still coming to grips with screening and diagnosis questions, and deciding who/when to biopsy is a priority. I mention this Japanese study because of the detection rates at low PSA.

    Djin

     
    Reply With Quote
    Reply Reply




    Thread Tools Search this Thread
    Search this Thread:

    Advanced Search

    Posting Rules
    You may not post new threads
    You may not post replies
    You may not post attachments
    You may not edit your posts

    BB code is On
    Smilies are On
    [IMG] code is Off
    HTML code is Off
    Trackbacks are Off
    Pingbacks are Off
    Refbacks are Off




    Sign Up Today!

    Ask our community of thousands of members your health questions, and learn from others experiences. Join the conversation!

    I want my free account

    All times are GMT -7. The time now is 02:06 AM.





    © 2022 MH Sub I, LLC dba Internet Brands. All rights reserved.
    Do not copy or redistribute in any form!