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the new guy - a candidate

xNTP
Posts: 34
Joined: Oct 2016

Well, I got a high PSA last week, 8+ and some other unfriendly bloodwork.  It's been a few years since last PSA (+1.x?)  A year ago I put on another 25 lbs extra, and I think that was a donut too far.  This year I've been dealing with mild BPH symptoms.

So I got a call from the doctor, and he says take the PSA seriously, a little review of the blood work, gives me a referral to two urology practices.  I take these things probabilistically, and believe in doing the homework.    I see a lot of new test vs biopsy opportunities in the prostate world, like 4K score, PHI, PCA3 etc....  Not too much prior here on 4K score, one of the new marker batteries that can eliminate biopsy in some cases of minor PSA elevation.

I am sorting through the risks, costs, and technologies. I plan to record some of my initial thoughts and experience here.  Total cost is important but I feel that these opening steps are crucial.  I appreciate any comments on experience with the various markers at different points from those a little further along.   I'd like to get useful blood data beyond just PSA for monitoring.  I'd prefer to do ultrasound or MRI targeting before any needle biopsy.   

[Added 8/28] I'm 60.  

Papers:  mpMRI has many flavors and possibilities

Webpages:  

Websites: YANA

Swingshiftworker
Posts: 1013
Joined: Mar 2010

I understand your concern about doing a physical biopsy BUT it's the only method that will give you a practical assessment (at a reasonable cost) of the likelihood that you have prostate cancer.  It possible to get a false negative but that is actually quite rare.

Neither an ultrasound (even w/color doppler) nor a standard MRI will tell you much, if anything, and, even if they are suggestive for PCa, you will still have to get a biopsy anyway to verfiy the diagnosis. 

The only screening method that will tell you for sure if you have PCa or not (without a biopsy) is an MRI/MRSI spectroscopic scan using a Tesla 3T coil inserted in your rectum to detect choline which is a marker for cancer.  This is a very expensive procedure which is seldom (if ever) approved by insurance carriers for initial PCa screening. 

So, if you are self-funding your screening and treatment, you should consider asking how much this would cost and, if the cost is not prohibitive, choose it as the method of screening.  You will get no more dispositive assessment than with an MRI/MRSI.  However, if you are limited to what an insurance will approve, only a biopsy will yield a practical assessment of the probability that you have prostate cancer.

PS: I had a biopsy for initial screening in 2010 (which was positive) and an MRI/MRSI after a worrisome bounce (3 increases in PSA) around 3 years after treatment w/Cyberknife (an advanced form of radiation treatment) which was negative.

 

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3293
Joined: May 2012

I completely agree with all Swing Shift wrote.

There is no reason to turn a very simple process into something complex. The only way to determine if there is cancer is a biopsy.  An academic review of every PSA test on the planet is a meaningless waste of time. They will provide you and the doctors no definitive answers.

A prostate biopsy (in relative medical terms) is cheap, quick, and easy. And the only thing that will answer the big question.  You can have all of this resolved in under an hour....no Doctoral study required.

 

max

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

I would add to your doctor's suggestion that you take prostate cancer (PCa) as much as serious.

From your post I can figure that you have been researching about cancer screening. That is a good approach when someone is found with an high PSA. But when "looking" for cancer one should try methods that assure the result, not just probabilities. I absolutely aggree with above survivors for you to choose biopsy over an image study this time, if in fact you seriously want to know if you have PCa.

The methodologies you describe above, to avoid the inconvenience of a biopsy, are practical in particular cases where the "patient" would get benefits from those probabilities; For instance, when one cannot do a biopsy due to religious restrictions or due to other impossibilities, AS patients that may also benefit from these techniques when judging progression or increased aggressivity, etc. Max sets it rightful:  An academic review of every PSA test

You have not shared details of the problematic BPH. I wonder your age and the symptoms/investigations done that lead to BPH diagnosis. Hyperplasia increases the PSA and so does any massage of the gland before drawing blood for the test (riding a bike tractor, horse, stressful physicals of the abdomen, masturbation, sex, etc). A graphical plotting the PSA histology can guess the cause of the increase. BPH presents a sort of seesaw graph with fast increases and fast decreases. PCa is like a slow slope of constant increases.

Surely you can have an MRI before a biopsy. It will be helpful in future comparison with the findings of another image study, when looking for probabilities of metastatic cancer. This is the sequential exam done after a positive biopsy. Choline based contrast agents in MRI/PET (commented by Swing) are better. However they do not substitute fully the microscopic analysis of a sample of tissue from the gland done by a pathologist.

Your PSA > 8 is three times above normal high significative of cancer if this is the solo element producing the serum. The following markers are also practical for guessing a positive result when one is doubtful of the PSA, but these serve the purposes when compared to previous results:

PSAf (free PSA)
PCa3 (genetic analysis of cells in the urine)
PAP (prostatic acid phosphatase)
CEA (Carcinoembryonic Antigen)
NSE (Neuron Specific Enolase)
CGA (Chromogranin A)

So far you are not considered a member of this exclusive club. I hope you do not.

Best wishes,

VGama

xNTP
Posts: 34
Joined: Oct 2016

Thanks for the insights guys.  I'm processing on several things, I can't exclude that I have other problems going on, too, so I'm lining up on other stuff.   Funding or availability will definitely be an issue on some markers. I am going to do the common inexpensive markers, the higher tech may also be difficult to access in some places.  If I am able to get (and afford) a type of marker, now is the time to start checking them for a baseline for long term surveillance and/or treatment.  

The 4K score brochure lists that it is to be used before a dx (FDA approval restriction?) with several caveats (>4-6 months post biopsy, orgasm/DRE in x hrs, etc), although if the price were right, I'd probably use it as a preferred, occasional or primary marker panel (most complete kallikrein kit).  I'm not getting a good price number yet - a paper said $400, a call to a lab in another state said $1900, and a local urologist's office says visit first (urologist oriented exclusives in states where possible?), a place where an armed robbery is probably a cheaper and better experience.

This brings up another subject.  Operator training, experience, skill or variations on the coring and biopsy pathology, and guided versions.  Thoughts?  My most affordable options will have to consider that.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3293
Joined: May 2012

It seems you misunderstood what was written to you... You need a simple 'test,' not 'processing,' whatever that is.

But we submit insight, not instructions.

max

Old Salt
Posts: 720
Joined: Aug 2014

Several of us (all with prior prostate cancer experiences) agreed that the tests that you are considering aren't useful for your situation. Perhaps we can address why you are so very reluctant to get a biopsy? Perhaps you don't have (sufficient) insurance? You don't trust your urologist? If you would explain, perhaps we can offer suggestions.

PS: Most of us have gotten one (or two) biopsies and we are still here to describe our personal experiences...

xNTP
Posts: 34
Joined: Oct 2016

As one practical matter this late in the year, almost all bills are my personal $ for 2016, the insurance won't be paying much this year. The policy for next year has already gotten worse.  

I have a split situation of place A (one place right now, high cost, low and slow service) or B (in ~2~3 weeks?).  B may be short on some high tech options, like PHI, PCA3, 4Kscore.  In general, skill, available technology and prices can change greatly between offices, and specifically with A/B.

I am interested in what might be best in 2016-7, no tears, vs cost.  I've dealt with a number of medical fubars and a cancer fight in the last 12 years, so I do scratch, sniff, and paw each option carefully, as quickly as I can.  From previous experience, I know that some steps can have price variations over 5-10 fold, the cheapest being technically best but not recognized or standard.  

Sometimes paying for extras gives extra advantage. So in part I'm trying to get the best biopsy sampling (mp-MRI, color doppler US guided) if biopsy proves necessary as is almost certain.  Then I'm trying to establish biomarker baselines beyond PSA, that may be important years out, or near term, gather PCa activity information, and arrange lowest profile treatment for a better monitored, good result.

no MRI vs, mp-MRI at 1.5T vs 3T ?

normal TRUS vs color doppler ?

I hope I am moving at reasonable speed on these steps.   From one office, I understand that I am on the edge of being too early for the 2nd PSA to compare or confirm the first high PSA value.  I have another two blood values that have to be resolved. A consultant this afternoon was pretty excited about one and I am still more worried about the other that would be unusual for prostate cancer origins.  I'm trying to be agnostic and cover several bases at the same time as carefully as I can.  I could be BPH, indolent or aggressive prostate cancer, and/or even cancer something else.  I am hopeful that your experience will help me improve my planning, execution and results as I try to do the very best one can do starting now in 2016-7 with a somewhat cocked situation on a budget.

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

If you want to have the very best as the starter on your investigations, then do the traditional 12~14 cores template biopsy now. This is cheap, quick in providing an answer and the best for a deserved peace of mind on the issue.
You can go through those details of added information you describe above once you become a member of the PCa club, if ever.

Best,

VG

Clevelandguy
Posts: 456
Joined: Jun 2015

Hi,

I did the MRI 1st which help the Urologist pinpoint where to take the biopsy samples.  Even still the biopsy can still be a little hit or mis depending on how good the Urologist is at taking the samples.  I would find the best hospital & doctors that you can afford to get the basic info on what's going on inside of your prostate. 

If you have a general MD that you are seeing they might be able to help you finding good doctors.  Good luck..............

xNTP
Posts: 34
Joined: Oct 2016

Thanks, I'd love to hear more of your experience step by step getting that MRI before dx and any technical details about which MRI and parameters.   There are not many details written here on mpMRI that I've found yet. I'm sure many could benefit from your perspective, too.  

My normal, occasional MD is 1-2 weeks away...

Clevelandguy
Posts: 456
Joined: Jun 2015

Hi,

 

if you are talking about me Private message me and I can tell you as much as I know about how my MRI/Biopsy was done.

hopeful and opt...
Posts: 2224
Joined: Apr 2009

you may wish to explore this.

I wonder what your age is and where do you live? There are differences in care in various parts of the the USA, of which some of us are familiar can direct you to a place of excellence if you wish.

The only test will indicate if you have prostate cancer or not is a biopsy. There are various types of biopsies. The one that vasco recommended is the most common. It is a stratified random test, taking 12 cores.

There are also more sophisticated tests; an MRI guided biopsy, that is a T3 MRI that locates suspicious lesions, then targets these lesions with a 3 dimensional biopsy machine that can lock into these lesions and sample them

You mentioned other tests that perk your interest...however with a PSA of 8, you need to have a biopsy now....the results of these tests will not change your need for a biopsy (do you have any historical PSA readings?)

xNTP
Posts: 34
Joined: Oct 2016

60 yo.  I think it was 3-5 years ago, incidental to some other blood data 1.x (fugitive paperwork).  AFAIK no one has had PCa in my family. Some paternal side GI cancer disposition in there though...

I'm pretty much headed out to Asia, already 2/3rds  there, some insurance there, and as  far as I'm concerned, ACA already failed in my state.  If the butterside lands down, one can become a tourist to find sites e.g. protons in one place, CK others.  The US connection becomes specialized tests and supplies.

hopeful and opt...
Posts: 2224
Joined: Apr 2009

There is a relationship between prostate size and PSA. An enlarged prostate secrets greater amount of PSA, since there is pressure on the prostate from the uretha. You mentioned that you have BPH....so you need to ask the doc to determine the size of the prostate. 

Additionally there are factors such as sex before, bike riding and even a hard stool that may cause the PSA reading to rise.

It would be great if you can find out what your previous psa was, for rate of change.....or in my layman's opinion have a repeat PSA test9 include a free PSA test).

In all probability a biopsy will be a necessary evil for you.

Good idea to eat heart healthy; health healthy is prostate healthy....and as you know heart disease is at epidemic proportion, and we are more likely to die from heart disease than prostate cancer.

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