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Risng PSA on Active Surveillance

I was 66 in 9/08, when a rising PSA to 3.2 prompted a 12 core biopsy which showed no cancer. PSA continued to rise to 5.1 in 11/09 which prompted another biopsy where two cores (left and right apex) were found to have a small amount (<10%) of GS-6. Went on Active Surveilance. PSA continued to rise. 5.5 in April and 6.3 in July. In Sept I had another 12 biopsy by same lab/same pathologist and no PCa was found- only a little PIN in the left apex. My uro has no explanation why the PCa might be small enough to be missed but big enough to give a PCAV of 1.3 and a PSADT of less than 3 years. (test for infection came back negative) I'm concerned there might be a tumor located in an area not reached by a normal biopsy. Is there such an area?

Re: Risng PSA on Active Surveillance

G’day Joe,

Sorry to read of your (understandable) concern.

Starting with the ‘bad news’ first, the answer to your question

I'm concerned there might be a tumor located in an area not reached by a normal biopsy. Is there such an area?

The simple answer is: Yes, there is.

If you look at any of the anatomical illustrations of where the prostate gland lies you will realise that there are some areas that are simply impossible to reach with a biopsy needle, which can’t turn corners. It is also a fact that prostate glands are probably as unique as fingerprints – as are all our glands and physical attributes (think left handed people, blue eyes v green eyes, height, size of feet etc etc. So it is possible to have a gland that is not quite what might be regarded as ‘normal’ which might make getting the needle to all the relative spots as being difficult.

Having said that, I feel I should also say that, because PSA is NOT prostate cancer specific, ( anyone unaware of this might like to read PSA 101) it is very important to consider all potential causes of changes in PSA levels. It is good that some tests were run for infection, but it has to be said that bladder and prostate infections are notoriously difficult to diagnose and to treat.

I also think that there may not be enough data to start calculating doubling times. I ran a small bit of self-study - 28 Day Experiment . Using some of the figures selectively, I could calculate a doubling time as low as 9 days or 8 months but the fact of the matter is that my PSA did not double in those time frames.

I don’t know where you are or what your financial ability/insurance plan is, but if it is possible to get to the men who use Color Doppler tests – two of the best, by repute, are Bahn in Ventura and Lee in Rochester – their scans might be able to identify areas of concern.

Hope this helps some.

Terry in Australia

Re: Risng PSA on Active Surveillance

I can attest to there being places that a biospy cannot reach. I had 13 biopsies over a 10 year period the last being a 26 core biopsy. I went to Dr Bahn who uses a color doppler ultrasound to take biopsies and an area he identified as suspicious came up with 3 out of 3 positive cores; a 16mmX18mm tumor. He showed me the tracks of my previous biopsy, that could be clearly seen and they went all around it or not deep enough. He said that if I would have had 13 more biopsies they still wouldn't have hit it because of the angle through the rectum, and said there were only two doctors in the country that had the skill to hit that spot.Anterior and transition zone tumors are very difficult for a urologist to biopsy.
f you are still concerned than I would recommend a color doppler guide biopsy for you next biopsy.
JohnT

Re: Risng PSA on Active Surveillance

Terry and John T,
Thank you so much for your responses. I have read some books that support the use of color doppler ultrasound as well as spectrographic endorectal MRIs
(like Scholz/Blum's excellent "Invasion of the Prostate Snatchers"). The problem being I can't seem to find the tests here in North Carolina. My plan is to have three more PSAs done next year (1/11, 4/11, 7/11), look for a trend and decide what to do then. I'm sure I can scrape up a few bucks to go out to see Dr Lee or Dr Bahn; hopefully they would agree see me.
Funny when I found out my Uro didn't do these tests, I asked my PCP to find one who did. He came back a few days later saying that he taked to a bunch of Uros in the area and they basically "poo-pooed" the tests saying they tried those kinds of tests back in the '90s without much success and didn't think they would show any more than a regular biopsy.
I find it interesting that I seem more concered about having a higher PSA and a negative biopsy then having a lower PSA and a positive biopsy.
Recently I have joined a PCA support group and everyone in the group (except me) has had some form of "treatment" and while they are all a great bunch of guys you can really hear how the negative aspects of their treatments have affected their lives. But to be fair, perhaps those whose treatments resulted in no negative aspects, don't go to support meetings.
Anyway Thanks for this wonderful site and thanks for that link to that A.S. article Dr Klotz you recently posted.

Re: Risng PSA on Active Surveillance

Joe,

Power Color Doppler Sonograms gives a list of the well known practitioners who use Color-Doppler. I'd guess the ones in Florida are closest to you? I have seen another list that gives ALL known practitioners, but can't lay my hands on it right now. In any event because the interpretation of results requires a good deal of training, you'd be better to see one of these doctors rather than someone who doesn't use the scan regularly. It is this requirement for investment in training (and the equipment) which is often a significant bar to the acceptance of the technique by some doctors. If you haven't read JON NOWLIN'S story, you might find his approach and use of Color-Doppler of interest.

Your comments about men who join Support Groups may well be correct - why would you join a group if you have no problems? There are some people who will join the groups out of a desire to help others, but it is probably true to say that most members are troubled, as are most people who contribute to Forums like these on the Internet.

I believe that one of the truly unique aspects of Yana is that most of the men who contribute do so either soon after they are diagnosed or soon after they have had their primary therapy, NOT after they develop any problems or concerns. Although, as critics of th site never hesitate to point out, the stories have no 'scientific' value, I believe they represent a good cross section of what really happens after diagnosis and therapy. .... But then I would say that, wouldn't I? Our children and grandchildren are always the most beautiful and cleverest:-)

Good luck on your path, wherever it may lead you.

Terry, on a beautiful Spring day in Australia - doves cooing in the trees, mild sunshine warming the old dog as he llies in the doorway. Jeez, ain't it good to be alive?

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