High PSA

tall floridian · August 2015

VascodaGama said:
Coding in Medical Records is meaningful
Tall,

I think your case being the typical diagnosis process in prostate cancer occurrences. High PSA leads to a biopsy that identifies the presence of cancer. My note here is for those reading your posts that may not be aware of the terminology used by the pathologist/laboratory that analysed your specimens. The coding of 790.93 stands for “Elevated PSA” and the percentage of PTI may regard the amount of the oncogene PTI 1 found in your prostatic carcinoma. The clinical stage of T1c is erroneous if in fact they found cancer in both lobes of the prostate (T2c).

At first glance you would be classified in the group of low risk for metastases because of the low grade of Gleason s-6 found in the 3 out of 12 cores. However, this is not enough to set you in such group and your doctor is requesting additional information from image studies. He wants to certify that cancer is in fact contained which would provide the possibility for the surgery option. As commented above by Hopeful these typical exams “cat scan plus bone scan” are not very effective and commonly provide false negatives. The MRI 3.0 Tesla provides better images but it may also not complete the diagnosis process.

The worrisome items in the pathologist report goes to the high PSA at 19.3 (ng/ml) which also has shown a fast doubling (PSADT) of less than 14 months, in any case, the PTI-1 gene may be the “baddy” in the story because it rules out the existence of hyperplasia (a cause in enlarged glands), and because it is typically found in extracapsular extension cases. I wonder about the DRE (digital rectum exam). Was it performed? Did they find any particular extruding bumps in the biopsy’s ultrasound?

My PCa case is similar to yours regarding the elevated PSA in a low Gleason score. I was PSA=22.4 and Gleason 6. This was confirmed at separate laboratories (second opinion) which gave me more power in the decisions ahead.
At your age and with other health issues you may confront limitations in future treatments and medications. You need extra vigilance and need to be more cautious, but you do not need to rush. I would recommend you to get second opinions from other specialists. Urologists typically recommend surgery as much as radiologists recommend radiotherapy. All treatments are subjected to risks and side effects that you should be aware in advance. The final decision is yours. They will request you to sign an agreement relieving the doctor (and the facilities) from any wrong outcome.

Here are links regarding the PTI 1 Human Prostatic Carcinoma Oncogene;

http://www.ncbi.nlm.nih.gov/pubmed/8988032

http://www.cumc.columbia.edu/psjournal/archive/archives/jour_v17n2_0005.html

Regarding the Coding in Medical Records is here;

www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf

For PCa;
https://www.supercoder.com/coding-newsletters/my-oncology-hematology-coding-alert/reader-questions-79093-describes-elevated-psa-article

Best wishes and luck in your journey.

VGama

High PSA

What did you decide for your treatment and how are you doing now? My primary care physician did a digital rectum exam and his words were "irregular' - urologist did also and said "I feel a hard spot". Also what age are you? I know age's a factor in my case- I'll be 74 in november. I thank you for responding and like you say will proceed cautiously and slowly.

VascodaGama · August 2015

tall floridian said:
High PSA
What did you decide for your treatment and how are you doing now? My primary care physician did a digital rectum exam and his words were "irregular' - urologist did also and said "I feel a hard spot". Also what age are you? I know age's a factor in my case- I'll be 74 in november. I thank you for responding and like you say will proceed cautiously and slowly.

DRE; The missing piece of information

Tall

I am 65 (66 in October) and was 50 years old when diagnosed with PCa. “Backwards” calculations indicate that the cancer may have expressed its intent to spread at the age of 46.
You can read my PCa history in these threads and their links;
http://csn.cancer.org/user/133775
http://csn.cancer.org/forum/126/search?body=vgama&title=

The positive DRE you describe here is very significant in your diagnosis and reinforces my above comments. Even the clinical staging increases in class because of the meaning that such finding could bring to the real status of your case. If in fact extra capsular extensions become apparent than the case would be graded up to T3 which relates to advanced localized status. This is a class that may rule out the success of a surgery.

http://www.psa-rising.com/prostatecancer/staging.htm

Your doctors comments regarding the bumps ("irregular' - urologist did also said "I feel a hard spot") indicate that either; they touched calcium deposits or tumours. Moreover, these formations can be felt at the capsule of the gland therefore with high probabilities of spread in the outer surface of the gland.
I wonder if your biopsy used an automate gun or the conventional gun method. These are different and the later obliges the doctor to be attentive at the image in the ultrasound when directing each needle. With this method they can analyse those bumps and certify its contents. Is the cancer contained or does it exist away from the gland?

Where does these all lead us is to the decision on a treatment. Either one looks for curative intent or just a palliative way to handle the matter. At 74 you are in the limit age for a therapy with curative intent, as recommended in the NCCN guidelines. However, many do try cure through a radical (surgery or radiation) and are successful. Some do surgery just with the intent of debulking the big tumour giving them long years of survivorship but not cure.

Radiation therapy can accomplish the job as much as surgery. The choice goes to the fact of owns preferences and believes. Both treatments got risks and side effects. Incontinence issues are common in surgery executions. Bowell issues are common in radiation executions. A palliative way to control the advance of the cancer would be hormonal manipulations which therapy can be executed intermittently, providing the patient with periods of relief from the drugs side effects. This causes conditions of menopause (hypogonadism) with its traditional symptoms (hot flashes, fatigue, irritability, etc). Some guys experience mild effects and some unbearable nasty conditions. The good is that one can stop the treatment whenever he wants and return to normalcy status.

I would recommend you to get educated on each treatment, their risks and side effects and discuss the matter with your family before deciding on anything.

Here are some reading materials that may help you in your decisions;

https://books.google.co.uk/books?id=16TbQ6as4uAC&pg=PA1&lpg=PA1&
dq=choosing+the+right+treatment+for+your+prostate+cancer+johns+hopkins&
source=bl&ots=RUO2tcFIuM&sig=KdfOBDSchbX6w12IDUn8JqvrZRE&hl=en&sa=X&
ei=bZ4GVaOdMsWsUfq5hFA&ved=0CC4Q6AEwAA#v=onepage&q=choosing%20the%20
right%20treatment%20for%20your%20prostate%20cancer%20johns%20hopkins&f=false

Books which contents may be biased by their author’s profession;

“Guide to Surviving Prostate Cancer” by Dr. Patrick Walsh (third edition); on options between surgery and radiation.

"Beating Prostate Cancer: Hormonal Therapy & Diet" by Dr. Charles “Snuffy” Myers; which informs on “patient’s language” all about hormonal manipulations.

Try getting second opinions on the suggestions of your physician and prepare a list of questions to expose to them when consulting. Here are some ideas to your list;
http://www.cancer.net/navigating-cancer-care/diagnosing-cancer/questions-ask-doctor

http://csn.cancer.org/node/224280

A copy of the NCCN Guidelines;
http://www.nccn.org/patients/guidelines/prostate/

Hope for the best,

VGama

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

stoniphi · August 2015

VascodaGama said:
DRE; The missing piece of information
Tall

I am 65 (66 in October) and was 50 years old when diagnosed with PCa. “Backwards” calculations indicate that the cancer may have expressed its intent to spread at the age of 46.
You can read my PCa history in these threads and their links;
http://csn.cancer.org/user/133775
http://csn.cancer.org/forum/126/search?body=vgama&title=

The positive DRE you describe here is very significant in your diagnosis and reinforces my above comments. Even the clinical staging increases in class because of the meaning that such finding could bring to the real status of your case. If in fact extra capsular extensions become apparent than the case would be graded up to T3 which relates to advanced localized status. This is a class that may rule out the success of a surgery.

http://www.psa-rising.com/prostatecancer/staging.htm

Your doctors comments regarding the bumps ("irregular' - urologist did also said "I feel a hard spot") indicate that either; they touched calcium deposits or tumours. Moreover, these formations can be felt at the capsule of the gland therefore with high probabilities of spread in the outer surface of the gland.
I wonder if your biopsy used an automate gun or the conventional gun method. These are different and the later obliges the doctor to be attentive at the image in the ultrasound when directing each needle. With this method they can analyse those bumps and certify its contents. Is the cancer contained or does it exist away from the gland?

Where does these all lead us is to the decision on a treatment. Either one looks for curative intent or just a palliative way to handle the matter. At 74 you are in the limit age for a therapy with curative intent, as recommended in the NCCN guidelines. However, many do try cure through a radical (surgery or radiation) and are successful. Some do surgery just with the intent of debulking the big tumour giving them long years of survivorship but not cure.

Radiation therapy can accomplish the job as much as surgery. The choice goes to the fact of owns preferences and believes. Both treatments got risks and side effects. Incontinence issues are common in surgery executions. Bowell issues are common in radiation executions. A palliative way to control the advance of the cancer would be hormonal manipulations which therapy can be executed intermittently, providing the patient with periods of relief from the drugs side effects. This causes conditions of menopause (hypogonadism) with its traditional symptoms (hot flashes, fatigue, irritability, etc). Some guys experience mild effects and some unbearable nasty conditions. The good is that one can stop the treatment whenever he wants and return to normalcy status.

I would recommend you to get educated on each treatment, their risks and side effects and discuss the matter with your family before deciding on anything.

Here are some reading materials that may help you in your decisions;

https://books.google.co.uk/books?id=16TbQ6as4uAC&pg=PA1&lpg=PA1&
dq=choosing+the+right+treatment+for+your+prostate+cancer+johns+hopkins&
source=bl&ots=RUO2tcFIuM&sig=KdfOBDSchbX6w12IDUn8JqvrZRE&hl=en&sa=X&
ei=bZ4GVaOdMsWsUfq5hFA&ved=0CC4Q6AEwAA#v=onepage&q=choosing%20the%20
right%20treatment%20for%20your%20prostate%20cancer%20johns%20hopkins&f=false

Books which contents may be biased by their author’s profession;

“Guide to Surviving Prostate Cancer” by Dr. Patrick Walsh (third edition); on options between surgery and radiation.

"Beating Prostate Cancer: Hormonal Therapy & Diet" by Dr. Charles “Snuffy” Myers; which informs on “patient’s language” all about hormonal manipulations.

Try getting second opinions on the suggestions of your physician and prepare a list of questions to expose to them when consulting. Here are some ideas to your list;
http://www.cancer.net/navigating-cancer-care/diagnosing-cancer/questions-ask-doctor

http://csn.cancer.org/node/224280

A copy of the NCCN Guidelines;
http://www.nccn.org/patients/guidelines/prostate/

Hope for the best,

VGama

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

I must add here...

...that the 2 extracapsular extentions my T3c cancer had put out were clearly visioned with the cat scan I received along with that pesky bone scan which showed no (large enough to see) mets and lots of arthritis.

Get more info as best you can before making a decision and weight the docs advice heavier than ours here. We are patients like you and highly motivated, but not doctors.

CC52 · August 2015

SLOW!!!

Tall,

I want to echo the advice of several here that advise avoiding surgery. The factors of your situation indicate two favorable options, as have been mentioned:

#1 - Active Surveillance. Although 3/12 positive cores may disqualify you for AS, the combined Gleason 3+3=6 along with your age could be to your advantage. (Note: I had 3 of 18 cores positive at age 61 with a Gleason of 3+4=7, and AS was not an option for me).

#2 - Radiation. I had Cyberknife (SBRT) 10 months ago, and so far very positive results. It is a very precise administration of high doses of radiation over 3-5 treatment sessions, each lasting about 30-45 minutes. After much study on the various types of radiation treatments available, I choose CK because results indicate it is THE most effective in treating PCa with minimal side effects. It does require the placement of markers (fiducials) into the prostate that provide the CK technicians the ability to "see" the prostate during treatment. The procedure to place the markers is painless (it is called surgery, but the markers are placed with needles through the perinenum with no incision). From start to finish, about 4 weeks.

No matter what, take your time. And before you make any decision about treatment you have to get a 2nd or even 3rd pathology review from other labs. Bostwick and Johns Hopkins are known to be the most reliable.

Best wishes - CC

hopeful and optimistic · August 2015

tall floridian said:
Test results from biopsy's in
Final diagnosis from my biopsy came in - I'm looking at 3&3=6 Gleason score with 3 of 12 specimens submitted highest PTI=30%,PSA at 19.3 which is high so uroligist's set up a cat scan plus bone scan for August 12th. If it shows clear and not spreading he then recommends removing prostate in Venice, FL where a specialist he recommends works out of Venice Hospital and is rated the best in the area. Looks like my cancer's in both the left and right side-clinical stage=T1c. Also says tumor involves 5% of the total biopsy length. I'm new to this so I'm just leaning on my doctor's advice for now and moving slowly, he says "no rush".

Proper Diagnostic test; No rush, if qualified AS; NO SURGERY

First a " cat scan plus bone scan " does not provide very much definition, and WILL NOT determine extracapular extention. . They are not effective tests. Additionally the American Urological Association does not recommend a bone scan for patients who have a Gleason under 8.

The tests that this doc referred youto is not appropriate for proper evaluation....

An MRI T3 will do the job for you.

here are some studies from pubmed about mri's and a high tech pet scan

multiparametric mri t3

The impact of Magnetic Resonance Imaging on prediction of extraprostatic extension and prostatectomy outcome in low-, intermediate- and high-risk Prostate Cancer Patients. Try to find a standard.

http://www.ncbi.nlm.nih.gov/pubmed/26154571

The impact of multiparametric pelvic magnetic resonance imaging on risk stratification in patients with localized prostate cancer.

http://www.ncbi.nlm.nih.gov/pubmed/24785987

Preoperative 3-Tesla multiparametric endorectal magnetic resonance imaging findings and the odds of upgrading and upstaging at radical prostatectomy in men with clinically localized prostate cancer.

http://www.ncbi.nlm.nih.gov/pubmed/23040223

...........................

Here is one that

Detection of recurrent prostate cancer after radical prostatectomy: comparison of 11C-choline PET/CT with pelvic multiparametric MR imaging with endorectal coil.

http://www.ncbi.nlm.nih.gov/pubmed/24434294

This above comparason is looks at a high tech PET/Ct.

The MRI scan for prostate cancer that is very effective in indicating if there is any nodule involvement, if there is involvement in one or two lobes, will show size of prostate, may show evidence of extracapular extension, will stage the disease. An MRI with the 3.0 Tesla magnet, is the gold standard. It provides a very fine definition. Major hospitals that have MRI machines with a 3.0 Tesla magnet.

In my layman’s opinion it is advisable to have such a test before any treatment. If the cancer is outside the prostate you may wish to reconsider a treatment decision.

................................................

Second, the criteria for Active Surveillance at Johns Hopkins is two cores or less Gleason 6, with less than 50 percent involvement in each...it is more relaxed for men who are over 70, you are within these guidelines.....PSA 10 or less......( by the way I wonder what the size of your prostate is, since the larger the prostate, the more PSA is secreted, and effects the PSA numbe, which may be your case.....one looks for a ratio of prostate size to PSA of 0.15 or less...please let us know the size of your prostate, it should be in the biopsy report).....................normal or slight bump on the prostate...........

Active surveillance is the prefered treatment decision, if you are eligible....which appears that you are.

...................................

Surgery is the very worse choice that you can make.....the side effects for a man of 73 are more likely to happen.....additionally there is a difference between surgeons.....generally local surgeons do not have as good results as nationally known surgeons.

................................

With your numbers , you are in no rush at all to make any decision at this time.

Do research, attend support groups, read book, post here, a source for support groups is USTOO.org....which lists local support groups, and information about prostate cancer; see the "hot sheet" that they publish.

Best