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Inconsistent results?

In May 2003 my primary physician found my PSA to be 4.8 ng/ml, DRE negative. He sent me to a urologist who also said my DRE was negative. The urologist did a 6-core biopsy; all 6 cores were negative. She said that she had never had a patient with PSA 4.8 who did not have PCa. Thus, after a couple weeks, she did a 12-core biopsy. One core (on the left side) had 15% cancer volume at Gleason 3+3 = 6; the other cores were negative. I decided to pursue "watchful waiting", which turned into mostly "unwatchful waiting".

In June 2009 my new primary physician found my PSA to be 10.2 and strongly encouraged me to see a urologist, but I did not.

In July 2012 my PSA was measured at 24.5, and a 12-core biopsy showed only 1 core positive (again on the left side) with 20% cancer volume at Gleason 3+4 = 7a. I visited with him about surgery and also visited with a radiation oncologist about IMRT but ultimately decided to not take any action.

In July 2013 my PSA was measured at 34.9 and I am now thinking I need to begin treatment. Two radiation oncologists have suggested Lupron followed by IMRT.

I am wondering if anyone has any insight as to a scenario whereby after 10 yr the extent of the cancer (as shown by the biopsy result) would remain essentially constant (1 positive core out of 12 cores; 15% and 20% cancer) but the PSA would rise from 4.8 to 34.9 ng/ml, and the Gleason increase negligibly from 6 to 7a. The results seem inconsistent to me.

Thanks for any ideas you might have.

Re: Inconsistent results?

G’day Nelio,

My first thought is something that I learned early on in my personal journey. The Golden Rule Of Prostate Cancer is: There Are No Rules. The second most important one was that PSA is NOT prostate cancer specific. So I view everything about prostate cancer through those lenses.

Although PSA is not prostate cancer specific, and therefore it cannot be said with any certainty that a rising PSA is universally associated with prostate cancer, there is a high probability that the constant and consistent rise in your PSA levels is in fact associated with the disease.

What else could it be? Well, bladder and urinary tract infections can cause high levels of PSA. I saw one report from a doctor in Australia reporting that a patient with a PSA of over 300 ng/ml reverted to a normal level after his UTI was dealt with medically. Although I would not bet on that being the position in your case, it may well be worthwhile investigating the possibility of infection if you have not done that already. This step in the chain is sometimes overlooked because of the immediate assumption that the rising PSA is prostate cancer related.
Why does your biopsy not show a substantial change in the tumour over time? Because the biopsy is quite literally a hit and miss affair. There could be a large tumour which it is simply not possible to reach with a normal biopsy – if you have studied the structure and positioning of the various organs you will se this quite clearly. So the normal biopsy keeps hitting the same areas where there is no obvious danger. Depending on where you live and the funds available it is possible to use more sophisticated methods – particularly a Doppler scan which may help in identifying areas of the gland that might be cancerous and out of the reach of a normal biopsy.

Finally, for the moment! - I find it truly extraordinary that a qualified urologist can say She said that she had never had a patient with PSA 4.8 who did not have PCa. when all th studies show that at least 65% of men with a PSA over 4.00 ng/mml will not be diagnosed with prostate cancer after biopsy. In fact there are more men with what we currently call prostate cancer with a PSA below 4.00 ng/ml.

Good luck with your exploration and your efforts to assess status before determining strategy.

All the best
Terry in Australia

Re: Inconsistent results?

Greetings Terry,

Thank you for your thoughtful comments regarding my diagnosis. You mentioned the need to rule out infection as the cause of my rising PSA. In both July 2012 and 2013 my urologist found no evidence of infection in my urine samples at the time of my DRE and PSA tests. I'm assuming that would be the way any infection would be identified. Or is there some other more definitive test that could be done? Also, I have never had any symptoms (pain, blood in urine, painful urination, etc.) that would indicate an infection. Thus, I had dismissed (perhaps prematurely) infection as a likely cause for my rising PSA. Over the past 10 yr, I would have surely had some rather serious symptoms if a UTI were causing my rising PSA, no?

I appreciate your comment about prostate biopsy being a hit-or-miss sampling of the total prostate. Theoretically, this raises the question of how many cores should be taken routinely in a biopsy. It also relates to my first urologist initially taking 6 cores but then doing another biopsy of 12 cores when the first biopsy did not show any cancerous cells. I wonder if she would have taken a 24-core biopsy, if the 12-core had also not shown any cancer!

I can appreciate that a biopsy might miss any given tumor(s) present. However, based on what you have said (and the position of some areas of the prostate outside of the area sampled during a biopsy), it would appear that a biopsy is not as definitive a test for PCa as I thought it was. Perhaps I am/was expecting more information from the biopsy than it can give.

I guess one of my primary concerns at this point (assuming that I have a tumor volume sufficiently large to produce PSA 34.9 ng/ml) is whether the tumor(s) is still confined to the prostate gland. I have two questions pertaining to that issue: 1) Does a Doppler scan or an MRI have sufficient resolution to show whether or not a tumor has escaped the gland?, and 2) would the presence of extracapsular extension mean that a particular treatment (eg. Lupron followed by IMRT, as suggested by my radiation oncologists) would be more advantageous than other treatments (eg. surgery) for me to pursue?

Any additional thoughts you (and others) have would be appreciated. And thanks again for your previous comments.

Nelio

Re: Inconsistent results?

Nelio,

A quick response to your latest post before I head for hospital:

You say …..my urologist found no evidence of infection in my urine samples at the time of my DRE and PSA tests. I'm assuming that would be the way any infection would be identified. Or is there some other more definitive test that could be done? Over the past 10 yr, I would have surely had some rather serious symptoms if a UTI were causing my rising PSA, no? UTIs are strange beasts that also conform to the “No Rules” Rule and are notoriously difficult to spot and to deal with – especially if the doctor does not believe in them! By chance one of my correspondents in India recently asked me about a similar problem that he had and said that an ‘alternative medicine’ doctor of his acquaintance had suggested he ask his urologist for some specific tests. One of these tests showed a bacterial infection of enterococcus faecalis. I had never heard of that but quick sweep of Google sites show that it is commonly associated with UTI and therefore seemed likely to be a potential cause of fluctuating PSA results. My correspondent is now talking about specific antibiotics that have a good track record for this particular bug.

Then you say I wonder if she would have taken a 24-core biopsy, if the 12-core had also not shown any cancer! It is not out of the question at all. Men are in your position are persuaded to have what are termed saturation biopsy procedures where a very large number of needles is used – the number may depend on the size of the gland but I have seen reports of up to sixty samples being taken. These do sometimes turn up some fragments designated as adenocarcinoma, which leaves the man concerned rather like the dog who has chased a bus to the next stop. What to do now?

And then Perhaps I am/was expecting more information from the biopsy than it can give. biopsy material can give more information than is usually provided. I don’t know if you have been through all the sequential pages of the Yana site, but it may be worthwhile doing that and considering what else can be done to “Assess Status Before Deciding Strategy”. You might at least go through the Choosing a treatment to get some idea of options and potential outcomes.


You say I have two questions ….

1) Does a Doppler scan or an MRI have sufficient resolution to show whether or not a tumor has escaped the gland?
Yes and no. There are high degrees of false positives and false negatives. The newer PET scans which are available in a limited number of institutions claim more accuracy but not certainty.

and

2) would the presence of extracapsular extension mean that a particular treatment (eg. Lupron followed by IMRT, as suggested by my radiation oncologists) would be more advantageous than other treatments (eg. surgery) for me to pursue? There is considerable debate about if and when prostate cancer cells escape from the gland and what they do after they have escaped. I tried to cover some of the aspects in a piece in this June 2012 E-Letter which you might like to have a look at. My personal opinion is that once a tumour is large enough to be identified by biopsy there is probably a good chance that some wandering cells are elsewhere in the body. That does not mean that they will proliferate or that they are generating PSA (because they may not have enough mass) but it does, for my money, point to systemic therapies i.e. ADT at present as being part of the therapy choice, if indeed the concern is that the disease might be aggressive

Oh, and you say to Don If you can direct me to some studies that have shown increasing Gleason scores for a given tumor over time, I would definitely like to read more about that. and I will be very interested in his response because this is something I have been looking for for years. There are articles and studies that demonstrate the theory of evolving Gleason Scores but they are based on the assumption that this happens. Of course it is simply not possible to prove, given our current tools. What is of interest is some of the commentary from the AS studies where it has been said that in the small number of cases where secondary biopsies show a higher Grade (usually one step up) that the most likely cause is not progression but a difference in interpretation.

Good luck – I’m off – back in a couple of days.

Terry in Australia

Re: Inconsistent results?

as Terry said, the high PSA is most likely indicative of PCa somewhere the biopsies cannot reach. that high PSA, and the Gleason 7a should lead you to seek some treatment, IMO.

At least get the latest biopsy result looked at by a second (or third!) Pathologist to confirm Gleason 7a.

best of luck!

Walt

Re: Inconsistent results?

I do not disagree with Terry or Walt. As a matter of fact their comments appear to be on target. I also tend to agree you may be reaching the point to think in terms of some form of treatment.
One way of looking at the data you provide is that you have a slow growing cancer that is picking up momentum. Your PSA gained an average of two points a year from 2003 to 2009. The last three years it has gained an average of 10 points. The change from 3+3 to 3+4 may be a more significant change than you realize.
The increase in PSA velocity could be due to (1)the presence of more cancer cells and (2) a change to a more aggressive form of cancer.
The more research you do at this point, the more likely you are to make a good decision for yourself. You might wish to consider reading Bob Marckini's book, "You Can Beat Prostate Cancer..." One of the strengths of this book is that Mr Marckini Discusses the pros and cons of most of the current methods of treating Pca.
Best wishes Don O.

Re: Inconsistent results?

well said Sir.

Re: Inconsistent results?

Greetings Don,

Thanks for providing thoughts about my situation.

I appreciate your two proposed, possible reasons for the increase in my PSA. I had thought about the possibility of more cancer cells being present, i.e. the tumor(s) having grown in the intervening 10 yr. That is why I was surprised that the biopsy did not show much higher volume of cancerous cells in the recent biopsy than the one in 2003. However, as Terry pointed out, the biopsies may not be sampling all the tumor(s) present. Regarding your second point, I was unaware that the Gleason score of a given tumor can change over time. Is this known to occur routinely? My thought was that the 3+3 had "changed" to 3+4 either because of the "Gleason migration" that has come about in the scoring by pathologists between 2003 and 2013. Or the possible differences among pathologists in their scoring. There has to be some variability in the scoring, otherwise the same biopsy cores would not lead to different Gleason scores when analyzed by different pathologists. If you can direct me to some studies that have shown increasing Gleason scores for a given tumor over time, I would definitely like to read more about that.

Thanks for suggesting the book by Bob Marckini. I am most interested in learning more about the pros and cons of various possible treatments. The CONS I have read about thus far certainly are of concern to me! It appears that ALL the treatments come with considerable, possible risks.

Thanks again.

Nelio

Re: Inconsistent results?

Nelio:
Don't rightfully know if Gleason scores actually change over time. I guess I just assumed that was the case. I do know that pathologists differ in their analyses. Marckini emphasizes the need for second opinions on biopsies. I also know that results from a biopsy often differ from an analysis of the dissected gland following a prostatectomy.
Whether or not some cancers actually become more aggressive over time poses an interesting technical question. Perhaps someone following this thread can educate us both.
Best wishes Don O.

Re: Inconsistent results?

An after thought: How rapidly your PSA is rising is an indication of the aggressiveness of your cancer.

Re: Inconsistent results?

Don, Terry, et al:

I picked up this article which deals with the progression of Gleason grade/score for a tumor over time. What are your thoughts?
http://prostatecancerinfolink.net/2013/08/13/how-low-is-the-risk-for-gleason-score-progression-over-time/

Nelio

Re: Inconsistent results?

I reviewed the article fairly quickly. My initial reaction is as follows:
1.Excellent article.
2.Stongly suggests Gleason scores are stable over time.
3.Double whammy for guys like me with an initial diagnosis of 4+3 (subsequently judged to be 4+4 after first-line treatment, same biopsy slide, different pathologist).
You did a great job locating information the two of us (and possibly many others) wondered about.
Best wishes Don O.

Re: Inconsistent results?

saw that article as well. make sure to read the comments at the bottom, as it is fleshed out even more and has some great information in it.

Re: Inconsistent results?

Walt:
Yes! I agree. I suspect Terry will too.
Don O.

Re: Inconsistent results?

Don it was somewhat ironic that I read this study last week while I was in hospital after my recent procedure and just before I rerceived the pathology results.

When I was diagnosed back in 1996 I had four pathology labs examine my biopsy cores and got results oof 3+3=6, 2=3=5 and 3+4=7. My latst result seventeen years later was a surprising 5+4=9!

So....some tumours may well progress!! Full details to be published.

All the best
Terry in Australia

Re: Inconsistent results?

Exception to the rule? One wonders.*
All of us will be looking for the details Terry. To be published in your YANA story line?
Best wishes Don O.
* Are you tuned in Nellio?

Re: Inconsistent results?

Greetings Don (and Terry),

I have read the latest comments regarding Gleason grade progression. The results of the Penney study and Terry's most recent biopsy would indicate that once again with PCa "There Are No Rules". This disease must be as extremely frustrating for researchers and clinicians, as it is for patients.

Have a Great Day!

Nelio

Re: Inconsistent results?

I would like to comment on having a MRI to find the location of your cancer. While a conventional MRI is not very good at seeing prostate cancer. A multi-modal MRI is very good at finding prostate cancer. Here is a link to a article that says the accuracy of detection cancer with a multi-modal MRI is more than 90%. http://www.umcn.nl/Zorg/Afdelingen/Radiologie/Documents/MRI%20in%20PCa%20PCRI%20Insights%20short%20(2).pdf

Mitch

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