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  • BPH, high PSA no cancer diagnosis to date

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    Old 01-07-2020, 08:04 PM   #1
    saros
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    BPH, high PSA no cancer diagnosis to date

    Hi,

    Curious to know if anyone has thoughts about my prostate saga and treatment to date.

    My PSA started going up back in 2005 or so from about 1 and gradually crept up to 9 in 2017 and I had a biopsy done that August--12 cores came back negative. DREs were unremarkable throughout.

    In 2018 my urologist suggested an MRI which I did in Nov. 2018--it also was essentially negative with these findings:

    FINDINGS:
    The entire prostate is moderate-to-markedly enlarged measuring
    approximately 6.2 x 4.8 x 4.8 cm. There is pronounced enlargement of the
    transitional zone which is heterogeneous compatible with underlying
    hyperplasia. Within the transitional zone on the right side is somewhat
    ill-defined area of T2 hyperintense signal within the mid-to-apex of the
    prostate best visualized on image 18 of sequence 9. The area measures
    approximately 0.5 x 0.6 cm in size. There is mild-to-moderate restricted
    diffusion of this area. No obvious abnormal enhancement identified. This
    is categorized as a PI-RADS category 3 lesion. No additional suspicious
    lesions identified to target for biopsy. Prostatic capsule is intact. No
    bulky pelvic lymphadenopathy. There is circumferential wall thickening
    which may be due to chronic bladder outlet obstruction. No obvious
    aggressive osseous lesion.

    ------

    The prostate volume was about 75 cc.

    At that point my urologist suggested following up in 6 months. This past June (2019) I got a PSA reading of 15, with 14% free. With the negative MRI he still recommended just following up in another 6 months, which I did the other day. My PSA reading this time was down somewhat, from 15 to 10.

    Now he is suggesting I take finasteride 5mg for 6 months to see if the prostate shrinks and PSA goes down, which I gather would be evidence of the elevated PSA being due to a combination of size and inflammation rather than cancer. If it doesn't go down then perhaps another biopsy is in the cards.

    Does this course strike others as reasonable/optimal?

    He has mentioned the drawbacks of PSA, and that it's still early days in MRI/prostate diagnosis, and the hit-or-miss aspects of biopsy particularly with a large prostate and possibly small cancerous areas. It's all so inconclusive and reminiscent of Groundhog Day.

     
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    Old 01-08-2020, 05:51 AM   #2
    Prostatefree
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    Re: BPH, high PSA no cancer diagnosis to date

    How old are you?

    You should have had two biopsies by now, at least. MRIs are fallible. It's true biopsies have a better success rate the smaller the prostate. You've lost that opportunity waiting so long to start looking.

    If your PSA doesn't drop back down below 10 your at least a 50% risk of cancer. Your free PSA puts you closer to 60%.

    Shrinking may help improve the chances of the biopsies. It will mess with your PSA, but its already raised the red flag. Now the problem is proving it.

    Biopsies require skill. You may consider a cancer center of excellence to up the game on finding it.

    For some reason, men seem to prefer BPH to cancer. For me, it just complicates things and is the source of all the same side effects of cancer treatment such as incontinence and ED. Sounds like its already restricting your bladder.

    Follow up biopsies significantly reduce the chances of false negatives. Who's dragging their heel here, you or the doctor?

     
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    Old 01-08-2020, 06:19 AM   #3
    saros
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    Re: BPH, high PSA no cancer diagnosis to date

    I'm 64. I just do what the doctor recommends (center of excellence). Very minimal bladder issues to date. Seems like a biopsy and MRI so far is fairly proactive but those have been largely non-events (better than the alternative surely). For this latest recommendation (finasteride) he consulted with two other docs and they recommended that course and waiting another 6 months before another MRI/biopsy.

     
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    Old 01-08-2020, 06:23 AM   #4
    DjinTonic
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    Re: BPH, high PSA no cancer diagnosis to date

    Given your history and that most research papers I've seen conclude that intermediate PIRADS 3 lesions do warrant a biopsy, I agree with Prostatefree that you are due -- it's just a matter of the timing. Finasteride should roughly halve your PSA over the course of somewhere around 6 months, which of course has to be taken into account in your PSA trend.

    Both MRIs and biopsies can miss existing cancer, and cancer can arise at any time. I had a history of BPH and when my PSA rose more than expected I was biopsies (repeatedly over the years).

    Keep us posted and good luck!

    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, neg. 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
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 01-08-2020, 06:33 AM   #5
    IADT3since2000
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    Re: BPH, high PSA no cancer diagnosis to date

    Hi saros and welcome to the Board!

    We are not physicians, and we have different views. Here is mine.

    That drop in PSA from 15 to 10 is great news in the context of your very large prostate (75cc). PSA does not decrease with either BPH (gradual increasing pattern) or prostate cancer (a steady exponential increase as cells split). Therefore, this pretty much nails down that you have an infection. Take a look at our thread on “Benign Prostate Enlargement (BPH), PSA and Prostate Cancer: When to Biopsy?” Basically, it gives sources for information that about 1 unit of PSA is produced for every 10 cc of benign prostate tissue (so 75 X .1 = 7.5 expected PSA), with one respected, senior urologist stating that up to 50% more than that value can be considered normal, which could give you an upper bound of 11.5, even without continuing infection, and it seems reasonable that some of that current value of 10 is due to infection.

    Furthermore, while a free PSA value of 14% is approaching the worrisome zone, free PSA, like PSA, is reduced by infection, so that percentage may not be a caution light for prostate cancer as your free PSA if uninfluenced by infection would likely be higher. I've learned that free PSAs in that midzone percentage range are not very helpful as indications of either cancer or freedom from cancer.

    Going on finasteride looks sound to me. It will reduce the size of your prostate and also reduce blood flow to the prostate, a good thing if cancer is involved. Some research indicates that finasteride can eliminate at least some prostate cancer up to Gleason score of 6 if it is there. Finasteride reduces “noise” from BPH in the PSA signal for cancer or infection. Once you hit your low point on finasteride, any PSA increase, if not due to infection, is likely due to cancer. (I have been on finasteride or dutasteride continuously since the fall of 2000.)

    You may have a mild form of prostate cancer that is best either not found or managed with active surveillance. It seems unlikely, in view of your workups and history, that you have a dangerous form of prostate cancer.

    As biopsies are much less sensitive than mpMRIs, your urologists reluctance to do a biopsy at this time is understandable; he doesn’t want to search for a very small needle in the proverbial haystack. As for the statistics noted earlier, my understanding is that they do not account for BPH or infection.

    There is some risk in this business, but I think your case is being well managed and that you can be confident.

    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.

     
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    Old 01-08-2020, 07:02 AM   #6
    saros
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    Re: BPH, high PSA no cancer diagnosis to date

    Thanks, ProstateFree, DjinTonic and IADT3since2000 for the thoughtful replies.

    Judging by his recommendations, it seems like my urologist, based on previous DRU, TRUS and MRI doesn't feel I have cancer, or at least a large aggressive case, despite PSA levels. I have a feeling that mileage might vary with another doc, hence my question. I think he's good, but the field seems very much in flux.

    My impression is that before prostate removal, cyberknife or whatever procedure is indicated I would normally need a positive cancer finding. So just keep getting biopsies every six months until I can't stand it anymore and say just the the whole thing out?

    This paper came out coincidentally the same time as my MRI with the PIRADS 3 result:

    https://experts.umn.***/en/publications/which-scores-need-a-core-an-evaluation-of-mr-targeted-biopsy-yiel

    From that conclusion: "Biopsy yields differ across biopsy indications which should be considered when selecting a PIRADS score threshold for biopsy. Biopsy of PIRADS 3 lesions could potentially be avoided in men who have previously undergone a negative TRUS biopsy."

    That would be my situation (negative TRUS followed by PIRADS 3), so it would seem my doc is going by the book there in downplaying the PIRADS 3 for now?

    Re antibiotics, I have never heard infection as a possibility mentioned by any of my doctors to explain PSA readings. Is that controversial? If I bring it up will he dismiss the idea? Seems like the PSA elevation has been going on for years which would make it a pretty stable infection! I get the point about cancer generally going by an exponential script though.

     
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    Old 01-08-2020, 08:24 AM   #7
    jorlo
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    Re: BPH, high PSA no cancer diagnosis to date

    I'm someone who had a rising PSA and a history of negative MRIs and biopsies until they finally found some cancer.

    My only suggestion would be that when the doctor recommends a new biopsy, consider a saturation biopsy. That's a procedure where they put you under and take 30 or 40 samples. It's the most thorough way to determine if there is any cancer. It's pain free, although there was some discomfort for a day or two after the procedure.

     
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    Old 01-08-2020, 08:55 AM   #8
    guitarhillbilly
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    Re: BPH, high PSA no cancer diagnosis to date

    What is the normal prostate density?

    "The normal prostate volume is 15 to 30 cc. Men with prostate volume larger than 30 cc are more likely to be diagnosed with BPH or prostate cancer. ""Prostate Volume and Density" is also a practical medical calculator to calculate prostate density. Prostate density is prostate specific antigen (PSA) divided by prostate volume."


    "A high PSA density means that a relatively small volume of prostate tissue is making a lot of PSA, while a low PSA density means that a large volume of prostate tissue is making relatively little PSA."

    My UR zeroed in on my Prostate density after receiving my MRI results. He recommended a biopsy at that time but I waited another 11 months before having the biopsy. My UR was spot on in his assessment of my Prostate density. The Lab results were T2a and Gleason = 8.
    My prostate was 22 cc at the time of the MRI.

    Please note that the Density Number is also very important in the diagnosis of PC. In my case it was 6.9 / 22 = .313

    My PSA velocity is why all the testing was generated in the first place.

    Knowing your PSA Velocity is very important and that comes from annual PSA Blood Tests

     
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    Old 01-08-2020, 09:09 AM   #9
    IADT3since2000
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    Re: BPH, high PSA no cancer diagnosis to date

    Hi again saros,

    I'm sure we are all trying our best to be observant and thoughtful here. Here's my thought about this statement:

    Quote:
    Originally Posted by DjinTonic View Post
    Given your history and that most research papers I've seen conclude that intermediate PIRADS 3 lesions do warrant a biopsy, I agree with Prostatefree that you are due
    If it were not for your case evidence including clear evidence of infection with its typical impact on your PSA levels, documented evidence of a very large prostate, and rise of only 1 (after that rise and fall) in over two years to this point in that context of BPH and infection, bolstered by that prior negative biopsy done at a center of excellence when you had a PSA level of 9, I would agree. However, in your circumstances, if it were me in your shoes (and that is never completely realistic), I would follow your doctor's strategy. He is likely thinking that the odds of finding any significant prostate cancer at this point are extremely low, and his strategy, sometimes referred to as "finasteride (or dutasteride) challenge", should yield further useful evidence, as well as relieving at least some of that BPH.

    I have not seen research papers on PI-RADS scores that address the influence of BPH and infection, but I expect they exist, and I expect they would confirm your doctor's approach. It would be helpful if anyone can find them.

    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.

     
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    Old 01-08-2020, 09:34 AM   #10
    DjinTonic
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    Re: BPH, high PSA no cancer diagnosis to date

    I didn't mean that you need another biopsy urgently -- but rather that your and your doc can reach decisions as to when imaging and/or another biopsy is called for. It isn't the case that anyone here knows better than your doc. Part of joint decision-making means taking the patient's level of comfort into consideration. If you and your doc are comfortable with let's wait and see, that's good.

    It's a good thing I didn't get frustrated having had so many negative biopsies over the years because of my rising, fluctuating PSA. My uros were being cautious. You could conclude overly cautious; however, my last biopsy did find very significant cancer at a PSA of about 8.6 (correcting for finasteride). So I can't impartially put myself in your shoes.

    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, neg. 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
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 01-08-2020, 09:59 AM   #11
    ASAdvocate
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    Re: BPH, high PSA no cancer diagnosis to date

    Quote:
    Originally Posted by saros View Post
    Thanks, ProstateFree, DjinTonic and IADT3since2000 for the thoughtful replies.

    Judging by his recommendations, it seems like my urologist, based on previous DRU, TRUS and MRI doesn't feel I have cancer, or at least a large aggressive case, despite PSA levels. I have a feeling that mileage might vary with another doc, hence my question. I think he's good, but the field seems very much in flux.

    My impression is that before prostate removal, cyberknife or whatever procedure is indicated I would normally need a positive cancer finding. So just keep getting biopsies every six months until I can't stand it anymore and say just the the whole thing out?

    This paper came out coincidentally the same time as my MRI with the PIRADS 3 result:

    https://experts.umn.***/en/publications/which-scores-need-a-core-an-evaluation-of-mr-targeted-biopsy-yiel

    From that conclusion: "Biopsy yields differ across biopsy indications which should be considered when selecting a PIRADS score threshold for biopsy. Biopsy of PIRADS 3 lesions could potentially be avoided in men who have previously undergone a negative TRUS biopsy."

    That would be my situation (negative TRUS followed by PIRADS 3), so it would seem my doc is going by the book there in downplaying the PIRADS 3 for now?

    Re antibiotics, I have never heard infection as a possibility mentioned by any of my doctors to explain PSA readings. Is that controversial? If I bring it up will he dismiss the idea? Seems like the PSA elevation has been going on for years which would make it a pretty stable infection! I get the point about cancer generally going by an exponential script though.
    I was in your position a year ago. A PIRADS 2 a year after a negative biopsy. Having had five previous biopsies over the years, I did not want another one. My doctor was Bal Carter of Johns Hopkins, the founder of active surveillance in the USA, and highly respected. He argued strongly that I must have a biopsy, as that area had not been previously targeted. I found that hard to believe, but he was adamant. He said that JH found significant cancer in 8 percent of systemic/targeted biopsies even after clear MRIs.

    I only agreed after he said that he would use the new Precision Point transperineal system, which does not cause infections, and has a better reach than TRUS biopsies. Only one core of 5 percent G(3+3) was found, and we were both happy.

    Infections and chronic nonbacterial protatitis are frequent causes of elevated PSA. But, they are temporary. Antibiotics work on infections, and the nonbacterial cases, which are the majority, clear up by themselves after a few months.
    __________________
    In Active Surveillance program at Johns Hopkins since July 2009.

    Six biopsies from 2009 to 2019. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 01-08-2020, 11:00 AM   #12
    IADT3since2000
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    Re: BPH, high PSA no cancer diagnosis to date

    Your Question about Infection, And One Predictor that Does Not Cover Infection or Size

    Hi again,

    You wrote:

    Quote:
    Originally Posted by saros View Post
    Re antibiotics, I have never heard infection as a possibility mentioned by any of my doctors to explain PSA readings. Is that controversial? If I bring it up will he dismiss the idea? Seems like the PSA elevation has been going on for years which would make it a pretty stable infection! I get the point about cancer generally going by an exponential script though.
    Infection is a thoroughly established and well accepted factor for understanding PSA values. It's one of the big 3: infection or inflammation is the biggest driver for younger men with an elevated PSA, with BPH taking the honors for older men, cancer third, and some other incidental causes also contributing. To my layman's (but now savvy) eyes, you have clear evidence of a combination of BPH and infection, with a significant type of prostate cancer in real doubt.

    Here is the predictor, which is recommended by the US National Institutes of Health, but which does NOT include consideration of BPH or infection/inflammation; presence of these factors for a patient would decrease the risk, to the vanishingly low level for some. Note that the calculator also omits the trend or pattern of PSA (which for you is very favorably negative toward cancer). Consideration of these factors for you, as I see it, would sharply reduce your odds of having significant prostate cancer.

    http://myprostatecancerrisk.com/

    I ran your situation. For the non-African American patient with age 64, PSA 10, DRE normal, negative prior biopsy, and an unknown family history, you would have a 17% chance of high-grade cancer, a 14% chance of low-grade cancer, and a 69% chance that another biopsy would be negative for cancer. For an African American man with the same other characteristics, the odds would be: 23% for high-grade, 22% for low-grade, and 55% for a negative biopsy. Again, knowing your BPH and specifically your prostate size, infection/inflammation experience, and PSA trend, your odds would be much better.

    Here's a great paper I found that explains PI-RADS in super detail, though in doctor's language. Tables 1 - 8 clarify scoring. It is a guideline paper, and the authors and their institutions are heavy hitters in prostate cancer imaging from around the world. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467207/pdf/nihms-1005396.pdf

    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.

     
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    Old 01-08-2020, 11:21 AM   #13
    DjinTonic
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    Re: BPH, high PSA no cancer diagnosis to date

    Using the calculator Jim linked to, I just ran my numbers at the time of my high-grade positive biopsy with the and I got, by coincidence, exactly the same figures: 17%, 14%, and 69%.

    I'm not sure where they are putting G7 (4+3), the Intermediate Unfavorable Grade Group, but I imagine they are calling G8-10 high grade and G6-7 low-grade. G7 (4+3) is nothing to sneeze at.

    Djin

     
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    Old 01-08-2020, 01:16 PM   #14
    saros
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    Re: BPH, high PSA no cancer diagnosis to date

    OK, sounds like after 6 months of "finasteride challenge" and target shrinkage I should be in for another MRI plus targeted biopsy in any case, even if it's a 69% chance of another negative, because, heck, you only live once. I suppose I could mention the possibility of infection and see what he says.

    The last biopsy+MRI cost me $1,800 or something like that out of pocket. I suppose next time it should be less as I go on Medicare next month.

    If finasteride so definitively shrinks the prostate, reduces PSA and even may prevent/stop some cancers, I wonder why my docs didn't prescribe it years ago.

     
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    Old 01-08-2020, 04:10 PM   #15
    Prostatefree
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    Re: BPH, high PSA no cancer diagnosis to date

    In my world, you would have had a follow up biopsy within a year of the first one. It's been more than two years. It is possible you could be a year and a half into your recovery from treatment by now and it's all a distant memory.

    Instead, your still in the same spot wondering if you have cancer. And, in my expereince most guys know in their head before they do anything about it. The first instinct is to wait on it. Not a good instinct around cancer. It waits for no one.
    __________________
    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, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    12-8-19 PSA less than 0.02, zero club 3.5 yrs

     
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