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    Old 11-19-2005, 08:01 PM   #1
    welshterriermom
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    Unhappy Questions about low fPSA

    5 years ago my husband's PSA's were 1ish, then 3ish, then last year he was declined for insurance for a 4.5 PSA with free at 13%.

    Family Dr. did u/s = neg. Referred to urologist.
    Urologist said prostate small, not hard, but had a soft spot that was probably an inflammation. Rx'd month of antibiotics followed by zinc.
    PSA came down to 3.79 so he wrote letter to insurance about PSA being elevated from a low grade prostatitis.

    Insurance said wait 6 mo. to reapply. He did. PSA then was 5.47, free PSA was 11%. Rx'd more antibiotics & more zinc.

    Retest was 4.9 with free of 8%... Rx'd one more month of antibiotics and told to retest in a week after that.

    Retest total PSA 5.05 and fPSA now only 5%. (eek!)

    Nurse said Dr. wasn't too concerned & was going to suggest a repeat u/s, but instead said to wait 4 mo. and test again. Probably just a stubborn prostatis?

    What do you think? I know a free PSA of 5% is really worrisome, but is it less worrisome if his total isn't all that high? Can a low grade prostatitis cause this? He doesn't have any symptoms of a prostate infection, just the soft spot felt on exam. Over the past year or two he's had a few rare episodes of bloody semen (which we were told "just happens sometimes").

    What do you think of the total PSA of 5.05 and the free at 5%????
    Doesn't a fPSA this low pretty much suggest cancer, or could an inflammation mess with the amount of free too???? I don't know what to think.

    Thanks for your help.
    & worried about my dear husband.

    Last edited by welshterriermom; 11-19-2005 at 08:02 PM.

     
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    Old 11-20-2005, 01:57 PM   #2
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    Re: Questions about low fPSA

    This web site might help explain PSA and free PSA.
    http://www.phoenix5.org/Basics/PSAmenu.html
    My husband had a PSA of 3.8 and his prostate was full of cancer in numerous spots. Had his prostate out. A low PSA doesn't mean you are cancer free. A rise in a low PSA over time may indicate cancer. The only way to know for sure is a biopsy of the prostate.

     
    Old 11-20-2005, 05:57 PM   #3
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    Re: Questions about low fPSA

    You never mentioned the age of your dh or if he was having other symptoms of prostatitis?
    I agree with the poster Kuch that a biopsy is the only way to know for sure if a prostate has cancer or not and even then biopsies are not 100%.


    A.

     
    Old 11-20-2005, 07:30 PM   #4
    welshterriermom
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    Re: Questions about low fPSA

    Thank you for your replies (((Kuch))) & (((3sweeties2005)))

    My DH is 51. He doesn't have any symptoms of prostatitis. The only abnormalities are the soft area the Dr. found, the elevated PSA, low fPSA, and a few rare episodes of blood in his semen (a couple times a year in the past 2 years.)

    The Dr. was just so confident this was an "asymptomatic prostatitis" but I'm worried about the fPSA being so low.

    Would you insist on something done now, or go ahead and wait the 4 months for more labs?

    His father has prostate ca but he was diagnosed in his mid 70's.

    I've read where prostate biopsies don't always rule out cancer - only maybe that there's no cancer in the samples taken.

    I'm sorry about your DH (((Kuch))) How was his discovered??

    Thanks again for helping me sort through this.

     
    Old 11-21-2005, 12:20 PM   #5
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    Re: Questions about low fPSA

    Insist on a biopsy. At age 52 I also had no symptoms other than a psa of 6.7. The biopsy saved me from a very nasty outcome.

     
    Old 11-22-2005, 05:51 AM   #6
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    Re: Questions about low fPSA

    Thanks for your reply (((Avoca))). I'll share these with my DH. He's strangely calm about this. I'm the worrier in the family. Never expected to be dealing with something like this with him only in his 50's, but I guess none of you guys expected to either.

     
    Old 12-01-2005, 07:00 PM   #7
    positive4u
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    Re: Questions about low fPSA

    Welshterriermom,
    PSA velocity(change in PSA over time) seems to now be more of what doctors are looking at than absolute PSA levels. You husband's PSA did change rapidly but than took a step backward. You are right that the free PSA is highly suspicious. My urologists said that my prostate felt like that of a 20 year old at age 45. They could not feel the tumors inside the gland. Biopsy revealed only one sample with microscopic cancer. After prostatectomy, when the gland was dissected, 2 tumors were found, one of which would have broken through the top of the capsule if I had waited. I was lucky. I'm not trying to be negative, but I'd get a second opinion if you are allowed to. In matters like this, one can not be too careful. Keep us posted please.
    -Positive4U

     
    Old 12-02-2005, 09:13 AM   #8
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    Re: Questions about low fPSA

    Several years ago I experienced a PSA roller coaster with rises and falls (between 2.1 and 9.9) that seemed to correspond with antibiotic treatments. I assumed that I was simply dealing with persistent prostatitis. However, I got hooked up with a smart urologist, and he carefully observed PSA velocity over an 18 month period. When my post-antibiotic PSA creeped up to just 2.9, he recommended a biopsy. I thought this was a little extreme, but he pointed out that about 25% of men who are in the 2.5 to 4 range have cancer, and he asked me if I wanted to accept those odds. I chose to have a biopsy. I did have cancer, but it was apparently caught early enough to be limited to the prostate. The only treatment I've had is surgery, performed 9 months ago.

    I have a friend who was not so lucky, since his doctor only responded to cases where the pre-biopsy PSA was much higher. His surgery was followed with radiation and hormone treatment. On the other hand, I have another friend whose PSA has been hovering around 5 for years, and two biopsies have discovered no indications of cancer. Biopsies are not 100% definitive. I've read that there is about 25% incidence of false negatives after the first biopsy, but this figure drops to 10% false negative after two biopsies.

    I'd recommend getting a second opinion from a proactive urologist. As I found out, prostate problems are not an either/or proposition: I had problems with both prostatitis and cancer before my surgery.

     
    Old 12-08-2005, 06:46 PM   #9
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    Re: Questions about low fPSA

    Hi (((Positive4u))) & (((All Sevens))),

    Thank you both for your kind and helpful replies. Reading your experiences and outcomes has definately helped. My instinct has been telling me to ask for a biopsy and get a second opinion, but I was unsure if I was overreacting or being too impatient.

    -Did either of you have an ultrasound prior to your biopsies?
    -If so, did it show anything?
    -Also did either of you have the free PSA done and what where your results?
    I'm glad he started having his PSA tested years ago so we could see the velocity you mentioned.

    -Did your pathology show evidence of any inflammation in addition to the cancer cells? (Might his pathology confirm prostatitis if that's what this is?)

    Somewhere on some prostatitis web page I read that it can be helpful and save some time for the "asymptomatic prostatitis" patient to routinely do the course of antibiotics before each PSA. I like that idea b/c it would save the "Take this for a month and repeat the PSA" routine!
    -I would like to ask the urologist to give him antibiotics now - before he sees him again. Is there any reason this wouldn't be a good idea?

    Thank you again for your input. My husband leaves all the family medical issues to me and I have no-one our age to talk to about this, so whatever input I can get is greatly appreciated. I will share your posts with him and I know he'll appreciate it too.

     
    Old 12-08-2005, 08:11 PM   #10
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    Re: Questions about low fPSA

    My free PSA ranged between 19% and 24% prior to biopsy. I had no ultrasound performed until the day of biopsy, and it did not show anything unusual, except for a large-sized prostate (about 40 cc, I believe).

    I messed around with antibiotic treatments and PSA tests for about 18 months until my urologist recommended a biopsy. Early in this 18 month period, my urolologist was reluctant to perform a biopsy because of the risk of a systemic infection caused by doing a biopsy during a period of protatitis. Infection is the number one risk associated with biopsy. Also, this doctor knew that it takes a while (like months) for PSA to reach its low point following antibiotic treatment. So, I just hung in there, taking antibiotics for an extended period, and then getting PSA taken every 6 months. When my doctor was convinced that my PSA was not returning to its original baseline (1.5), and when it even started to creep up a little, he recommended biopsy. Prior to the biopsy I took antibiotics for a week, was given a shot of antibiotics on the day of the biopsy, and then tooks antibiotics for a few days after the biopsy-- all to reduce the risk of infection. The biopsy indicated that two cores out of eight had cancer.

    Following the surgery, the pathology report showed that I had two foci of cancer, one with some capsular penetration, but the surgical margins were clear (meaning that the surgeon probably removed all of the cancer). The pathology report also discovered abnormal pre-cancerous cells throughout the prostate, but no mention was made of inflamation.

    My surgeon/urologist is a University researcher who was very familiar with the probabilities associated with various levels of PSA and fPSA. He had performed over 1000 prostatectomies at the time I saw him, and he had worked closely with pathologists to compile his own statistics. Also, he hired an independent firm to get quality-of-life data from his patients following the surgeries he performed. He was very up-front with the probabilities and with the stats on his own results, so I trusted him when he recommended biopsy.

    Please make sure that your husband's doctor has lots of experience with prostate cancer treatment, and that he or she is up to date on the latest research. If you have any doubts at all, do not be shy about getting a second opinion. I got two other opinions following my biopsy, before committing to surgery. I even flew to Baltimore from Arizona. An ethical urologist will not be offended by your husband seeking another opinion, at any stage of the game. If he or she is offended, then you'd be wise to go somewhere else anyway.

    At this point, you need to make sure that your husband's antibiotic treatment was sufficient (a long course of an effective antibiotic) and that his PSA has reached its low point following antibiotic treatment. My doctor said this can take several months. I suspect that the risk in simply repeating another antibiotic treatment is that he might start developing some resistance to the antibiotics. My doctor switched drugs during the two treatments I had, and both treatments were pretty long (like three or four weeks, I think). However, after two treatments, and with my PSA at 2.9, this doctor recommended biopsy, and I'm glad he did. I found out that the other risk in treating the situation as prostatitis is that you may be giving cancer more time to grow.

    Please don't be shy about taking your husband's data to the best urologist you can find. And, feel free to ask the folks on this board about any concerns that arise. Every "veteran" understands how helpful it is to get and provide some support.

     
    Old 12-08-2005, 08:22 PM   #11
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    Re: Questions about low fPSA

    My PSA was 4.7, free 13%. I had PC and I am 51 years. The only ultrasound I had is when they did the biopsy. It showed no signs of PC and was quite normal size. When the doctor removed the prostate via ROBOT he still could not see any signs of cancer. I tried the antibiotic trick for two months and my PSA went from 4.3 to 4.7. PSA numbers have lots of variations anyway. That should be your first approach. Also regarding the biopsy. They did 6 shots at my prostate and one came back 5% positive. Itís easy to miss with only 6 shots! Only when they did the final biopsy did they find two tiny tumors with a Gleeson 6. Same number as pin biopsy.

     
    Old 12-08-2005, 10:37 PM   #12
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    Re: Questions about low fPSA

    Welshterriermom,
    The only ultrasound I had was before the biopsy to look at the prostate, take films of it & guide the biopsy needles. Ultrasound to me didn't reveal anything & my urologist did not comment much on it. Free PSA was 12 if I remember right. That's what really concerned me since my family doctor said over 90% of prostate cancer has a low free PSA (less than 25). Nothing was said about inflammation from pathology. There would almost certainly be inflammatory cells in the pathology if inflammation was present. A good pathologist should be able to see this.
    The problem with all this is that no one has been able to predict that the cancer found will actually result in death unless it has advanced far enough. In other words, if only a small amount of cancer is found, is it worth suffering all the treatment side-effects, if it's not life threatening? Usually the younger the person the cancer is found in, the more chance it is or will become aggressive. That is what I based my decision on. Needless to say, having the "gland" removed has given me a lot of peace of mind.
    You are not overreacting. It is your husband's & your life you're looking out for. Better to offend a doctor than lose what is most important to you. My first urologist gladly referred me to a more experienced urologist to do the surgery, but is now doing my followup. That to me says a lot about my doctor. Keep us posted.
    Positive4U

     
    Old 12-09-2005, 07:01 AM   #13
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    Re: Questions about low fPSA

    (((Allsevens))), (((positive4u))) & (((AZguy2)))

    Thank you all so much for sharing more details, it sure helps.

    -Where are the biopsies usually performed? Out-patient surgery centers? Dr. office?

    -He had a prostate u/s when his GP started the work-up and I told him I thought a biopsy would be similar to that, is this correct?

    -Are all the samples taken at once, or does each core require another punch/sample?

    -How soon do you go home afterwards, etc.

    Thanks again.

     
    Old 12-09-2005, 07:47 AM   #14
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    Re: Questions about low fPSA

    Prostate Biopsy for me was done in the URO's office. A device shaped like a penis is insert into you rectum a few inches. This device has the ultrsound and pin sampling capability. This device is guided by the URO's via watching a CRT monitor. Each pin sampling is positioned via the CRT and hardly noticable to the patiant. The procedure lasts less than 5 minutes for 6 pricks. I did not have any blood in the urine but ejaculate was bloody for a few weeks. No real pain during or after the procedure.

    Last edited by azguy2; 12-09-2005 at 07:49 AM.

     
    Old 12-09-2005, 09:54 AM   #15
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    Re: Questions about low fPSA

    My biopsy was done in the urologist's office on a Friday. He likes to do them on Friday, to increase the likelihood that the patient will not feel compelled to go to work the next day. After an antibiotic shot and an exploratory ultrasound, my prostate was sampled with eight successive pinpricks, or "cores", each one taken from a different area. The urologist warned me each time he took a sample. He also encouraged me to keep breathing deeply, and the whole thing was over in a few minutes. It was uncomfortable, but the urologist and his nurse were sensitive to my needs every step of the way. Afterwards, the urologist asked me to urinate in a cup to look for signs of blood (negative), and then I drove myself home. I took it easy that weekend, and was easily able to shop and do my regular routine around the house.

    The urologist called with the results in the middle of the next week. After I got the results, he assured me that I had plenty of time to read about my diagnosis and make a decision about treatment, because he likes to allow at least 8 weeks for the biopsy site to heal. I was a little sore, but I did lots of work and traveling during that 8 week period, with no problems. I'm single, and I was able to do the whole biopsy thing on my own. When I entered the treatment phase, I got help from my sister.

     
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