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Biopsy wisdom

QUESTION - TO BIOPSY OR NOT TO BIOPSY?

After two years of 3.7 readings the PSA test today was 4.7

Dr recommending biopsies.

??? What do you think ????


His stats - which I also wanted to check for accuracy;
Reading came back at 4.7 PSA
40% chance of finding cancer (another article I read said 30% chance)
10% chance that it is aggressive cancer - the kind worth treating
2% chance serious infection from biopsy (article said up to 7% chance)

My history of PSA
Oct 2000 0.8
Oct 2005 1.1
Oct 2006 1
Oct 2007 1.3
Oct 2008 1.6
Oct 2009 2.6
Nov 2010 not done (I think doc said not needed every year)
Nov 2011 not done - dr checked wrong box apparently
Nov 2012 not done
May 2013 3.78
Jun 2013 3.79
Feb?2014 3.7 - (Not sure of exact figure)
Oct 2014 3.5
Mar 2015 4.7

Age now 57 years

One article quoted a 50% chance of single high psa coming back down in 2 months. "The number of men whose elevated levels returned to normal in a subsequent test ran from 44 to 55 percent, depending on the threshold. Of those who could be tested again after their level had dropped down to normal, a great majority, 65 to 83 percent, remained normal."

Other articles found no relation between high PSA/PSA jumps and finding treatable cancer, if I am summarizing them correctly. But I think I would rather know what I can so I can do what I can.
------

So I am thinking another PSA test would be in order and then with the less than 10% chance of it being worthwhile for treatment purposes - the biopsies. I suppose there is a 90% chance of some peace of mind by doing the biopsies compared with the low rate of sepsis - which can usually be treated.

Thanks


PSA jump no help:
------------------
they found little evidence that ordering a biopsy for men whose velocity was greater than 0.35 helped find prostate cancer. And it was particularly useless in uncovering the most aggressive types of cancer, the ones most important to treat.

http://www.nytimes.com/2011/03/01/health/research/01prostate.html
http://www.npr.org/2011/03/07/134273751/doctors-debate-criteria-for-prostate-biopsy
---------------

Biopsies can be dangerous:
--------------------------
Doctors are changing their approach to prostate biopsies as evidence mounts that the danger of complications from the procedure may outweigh its usefulness identifying some cancers.

An increasing incidence of potentially lethal, difficult- to-treat bloodstream infections tied to prostate biopsies has become so serious that urologists are reassessing when, how and even if they do the procedure.

http://www.bloomberg.com/news/2013-04-24/prostate-cancer-test-causing-sepsis-spurs-biopsy-concerns.html
----

Chance of sepsis
----------------
A Johns Hopkins article that says up to 7% chance of sepsis
http://urology.jhu.edu/newsletter/2011/prostate_cancer_2011_19.php

Re: Biopsy wisdom

don, I guess it all boils down to a question of trust in your treating physicians. There are a number on here who have a basic distrust of for conventional medicine. Either you accept the expert advice of your treating physicians or you choose to take another path. It is your choice, but be prepared to live with the outcomes of your choice whatever that may be.

In respect to your own situation, you really need to ask yourself, "do I really what to know"? If not, continue procrastinating, if so, follow your treating physicians advice. Needless to say that of course does include second opinions as warranted.

It would be prudent to remember don that your age combined with your psa history, places you squarly in the target range for PCa. It my own circumstance, had I not underwent investigations and subsequent treatment, in all probability I would be now dead.

best wishes
john

Re: Biopsy wisdom

Thanks

I think what I am hearing and agree with is that even though odds are slightly in my favor that I don't "need" biopsies, on the other hand the odds are still pretty high that I desperately do need biopsies and possible further treatment. And considering the plusses and minuses of each decision - not getting tested has the only really bad downside.

I don't feel like I am procrastinating the appointment was yesterday. I just don't want to walk into it blind - blindly trusting my doctor, yes. The doctor (in another specialty) I have that I trust the most has encouraged me to do my own research because, as he said, "I don't have time to do a lot of thinking about your condition so it is good that you take the time." He works at NIH and always seems to be in the best doctors list in local magazines.

Anyway, considering the downside of not getting samples is a really good point. The downside of getting samples - a 1-2% chance of ending up in hospital with a fever that most likely can be treated in a few days. The downside of not getting sampled - I have seen that close up for the last 8 years.

I have two friends that took different avenues - the one who didn't bother to see any doctors till it was spread to his bone just died in January. The other that got the samples done recently ended up in the hospital twice with high fever but has fully recovered. He is in my house tonight and I was asking him about his experience.

So, I agree with your point and thank you for caring enough to respond with wisdom. But just to be fair there are major medical organizations that question the wisdom of getting tested at all - PSA and or biopsies too I think. Trusting the doctors doesn't really clear things up sometimes - which mainstream doctors do you trust?

I have emailed the Urologist to inquire about getting a "free psa" test (a second opinion of sorts), or at least a repeat test and then I plan to get the samples taken if nothing changes (which I expect it probably won't).

Thanks

Re: Biopsy wisdom

Fine Don it sounds like you are heading in the right direction. It is good to hear that you have seen the results of inaction first hand. Do let us know how things pan out.

best wishes
john

P.S. you asked, which mainstream doctors do I trust? Well in my case my treating physicians were former colleagues that trusted without reservation. But in general I expect a certain level of expertise by virtue of training. For the most part, with two notable exceptions, my expectations have been met.

Re: Biopsy wisdom

Thanks

Just asked my friend about his "sepsis" - ecoli infection. Had to go back to hospital three times and the last time took "high power" antibiotic for 6 weeks. He said it wasn't a big deal. The samples - not painful at all. The infection - kind of annoying but not painful or awful - just had to keep taking meds for a long time.

So there is the worst case scenario of biopsy close up, I suppose.

My friend who had "stage four" (they called it at the time) got on Lupron and was doing pretty well for 3-4 years. Then decided against chemo but tried lots of nutritional things that probably helped. Radiation helped a couple times. But eventually morphine and hospice were what helped him come to peace. Ended up in the ER several times cause he still didn't trust the doctors very much, but he was at peace and went from feeling ok to passing away quickly. He lived almost 8 years after diagnosis with it spread to his bones.

I have no idea who is reading this and how it will affect them - but thought I would share my second hand experience.

Re: Biopsy wisdom

Thank you for sharing Don.

Re: Biopsy wisdom

Don,

Another option is a mpMRI. It is very good at finding tumors that may need to be treated and not identifying ones that don't need to be treated. No infection risk and gives you a good baseline to work from. I think it is the wave of the future.

Fred

Re: Biopsy wisdom

If I was in your position I would wait and get another PSA test. You had a generally downward recent trend except for the last test. As you get older you will normally have an upward trend, which over the many years that you have PSA results, is exactly what you have. If the next PSA result is greater than the last, then get a biopsy.

Re: Biopsy wisdom

Hi Don,

I shared your reluctance to have biopsies too frequently. This came about from my first transrectal biopsy 8 years ago that led to an infection which became an abscess that was stubborn to various antibiotics. After several months I had the abscess drained and the drain became a fistula. There were three different attempts to repair the fistula, and after nearly two years my bum was finally fixed. After that experience, my two later biopsies were done through the perineum under a light general anaesthetic. Much cleaner and much more comfortable. Also this procedure gives better targeting of the prostate.

My PSA was up around 6.4 and I started a course of Avodart (for urinary improvement). After nearly three years my PSA had dropped to 2.28, so I was very relaxed. Then consecutive tests went to 2.46, 2.92 and 3.18. This was enough to trigger a multiparimetric 3T MRI, which identified a "tumour suspicious area with intermediate to high grade features". This area of suspicion was targeted by a transperineal fusion biopsy and a Gleason 4+5=9 tumour was the diagnosis. That certainly attracted my attention and I had robotic surgery less than three weeks later.

So I believe the fundamentals of sound management is:

1. Trust your own judgement as much as, or more than your doctor's judgement. You have had more time on your case than your doctor and have had a closer look at all the details. In my own case, my GP thought that my recent PSA history looked OK, but I thought it needed attention.

2. Maintain close monitoring of your PSA history. After reasonable stability, distrust any small to medium trend of PSA elevation, even in smallish numbers. Also trust in the value of free PSA numbers.

3. Have a multiparimetric 3T MRI from a highly reputable practitioner who specialises in prostate MRI.

4. Have a transperineal (not transrectal) fusion biopsy that targets any suspicious looking area on the MRI. If the MRI looks OK, consider having a biopsy anyhow.

Brian.

Re: Biopsy wisdom

Well Don as I warned you, "the don't trust your doctor brigade" would soon be out of their boxes. It never ceases to amaze me how they can be "so frivolous", with another person's life. Needless to say when their strategy came back to bite them on the bum, guess where they ran?

best wishes.
john

p.s. expect a few more skeptics as well

Re: Biopsy wisdom

Don, last year I announced that I would not post on a thread that John Bonneville was involved in because of his argumentative, abrasive and insulting style. Unfortunately, in an attempt to add something to this topic, I broke this rule. As one in the "don't trust your doctor brigade", I decided it was time for a biopsy when my GP didn't think I needed one. I went ahead anyhow and 4+5=9 was the result.

After being an avid reader of, and occasional poster on this forum for more than eight years, I am now back in my box. Terry put up with John Bonneville for years, but my skin is not as thick. I will not be posting on the YANA forum again.

Re: Biopsy wisdom

The "don't trust your doctor brigade" have lost another comrade. Gone forever? Unlikely methinks.

Don the previous poster's comments re, "I decided it was time for a biopsy when my GP didn't think I needed one", is of course the expurgated version. You may care to enquire of the previous poster as to how many years passed before they chose to have the biopsy? The 4+5 was the direct result of the previous poster taking charge. Sheer folly in my opinion.

best wishes
john

p.s. still more to come

Re: Biopsy wisdom

I personally would consider just getting my PSA rechecked in 6 or 12 months. Your velocity is low. My PSA was 3.2 but my velocity was 85 % so I had a biopsy where they found a little low grade ( gleason 6 ) cancer. I was 58. The biopsy was no fun...lots of blood in my urine for about a month.

Re: Biopsy wisdom

You appear to have established a baseline of 3.5 to 3.8 over the past two years. Regarding 3.78 as the top of the baseline range, I find a bump up to 4.7 in five months ambiguous; not an emergency, but not to be ignored either. I would suggest a repeat PSA in three to six months. A urologist would have a better idea of the appropriate time interval.

I had two biopsies, didn't have much trouble with either. The procedure wasn't bad; each needle insertion produced a sensation which was very startling, I couldn't help bu jump, but it was not painful. I had blood in my urine for a few days, but it was expected, and I didn't find it a problem.

Re: Biopsy wisdom

Thanks for all the responses. Seems like there are worse case scenarios - worse then what my friend had. None the less they still seem to be fairly rare.

I am getting a free psa test tomorrow then will get results probably 4 days later. If it is low I will definitely get the biopsies. If it is high - over 25 then I have to decide.

Seems like everything before biopsy is just guessing. Even a low PSA does not really say much I guess. It tells you percentages. Not whether you have something or don't. So biopsy = a much better chance at knowing something solid.
-------------

Probability of finding prostate cancer based on % free PSA in men with a total PSA between 4 ng/ml and 10 ng/ml

% free PSA ---- Probability of prostate cancer
0%–10% ----- 56%
10%–15% ---- 28%
15%–20% ---- 20%
20%–25% ---- 16%
More than 25%--- 8%

SOURCE: Journal of the American Medical Association, May 20, 1998.

16% chance still seems pretty high. 8% chance - hmm - is that worth not doing the biopsies? It could come back under 10% - which then means 56% chance of cancer - then it is a no brainer I think. But 20 to 25% free?

Re: Biopsy wisdom

I'm glad to hear that. On second thought, I decided sooner would be better, and returned to the thread to suggest that, but you beat me to it. Good call.

"I am getting a free psa test tomorrow then will get results probably 4 days later. If it is low I will definitely get the biopsies. If it is high - over 25 then I have to decide."

When I researched it back in 2009, I found that a very low free PSA ratio correlated highly with a higher grade tumor. I don't recall anything about the probability of any tumor, but I might have missed that or forgotten it.

"Even a low PSA does not really say much I guess."

One PSA doesn't say much. But a change from an established baseline is significant. If you've been bumping along between 3.5 and 3.8, 4.7 is a spike above an established baseline. I am less concerned with free PSA ratio than if the 4.7 repeats. If PSA repeats at 4.7, I think a biopsy is probably advisable, regardless of free PSA.

Re: Biopsy wisdom

yes - it seems repeated over 4 and it is time to decide for biopsies.

The repeated psa may be helpful before biopsy - seems half of the psa jumps come down again. But if it doesn't go down - it is time for some real information.

Over all my trend is in one direction - which means probably a biopsy for me soon.

Thanks for the info. Not sure if I am making sense right now.

I think this is a really good site too:

http://www.uptodate.com/contents/screening-for-prostate-cancer

Re: Biopsy wisdom

Brooke - do you know if the free psa includes the total figure? So it might come back free over 25% but total psa of 4.7 again?

By the way I went to high school with Dana Jennings - the guy who chronicled his prostate cancer surgery on the NY Times. No relation I am sure - but had to add that.

Re: Biopsy wisdom

Free PSA came back as 13% = 28 percent chance of cancer. Biopsy scheduled for May 7th.

Re: Biopsy wisdom

Finally got the details

Total PSA went down to 4.3 - from 4.7

Free PSA is 13.7%

Biopsies are May 7th, Results May 14th

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