PSA from 6 to 25 over 2 years; shall I have initial biopsy or skip to mp mri?

maallyn

I just got PSA of 25 last week. My previouis was 2 years ago at about 6 or 7.

The Urologist (Bellingham Uralogists in Bellingham, Washington) wants to do standard TRUS biopsy, which I understand is normal for this PSA.

The finger test by both my primary and the urologist show now bumps but prostate is enlarged (I am under meds for enarged prostate with frequent nighttime urination).

The one kink is that I am an avid bicyclist and kayaker and work out in the gym. All these activites were within days of the PSA draw; in fact the 2 mile trip tot he PSA draw was on a bicycle (flat with tiny hills). I did vigourus paddle on my kayak the privious day as well as a longer bicycle ride.

Reading up on-line, I hear that the standard TRUS is notorious for inacurate results and some suggest to skip it and find a MP MRI for the initial screen post PSA instead as it is also less invasive than the TRUS.

I have another motivation to consider skipping TRUS and opting for MP MRI is that I understand that I  may have to refrain fom bicycling for a week or so after the TRUS.

My questions are,

1. Is it adisiable to skiip TRUS with PSA read at 25 and opt for MP MRI?

2. What has experience here been regarding biking after TRUS? If I have to forgo bicycing, can I at least walk? I don not have car; biking and walking are my means of getting around.

3. Does anyone know of a place for MP MRI in Bellingham or if not that in Seattle? I am assuming that my insurance (CIGNA HDHP) will not cover anything in Vancouver BC, which is closer to me than Seattle.

This is my first posing here, I hope it is appropriate for the CSN public forum, or shall I move it over to the chats?

Thanks you

Mark Allyn

Bellingham, Washington

GeorgeG

MP MRI especially with 3T ER

MP MRI especially with 3T ER is one of the best imaging capabilities that we have and it will give useful information about location and the extent of any suspicious areas with some indication as to its characteristics. All of this is very useful but it will not give you all of the information required for an informed decision. Eventually a biopsy (made more accurate by the MRI) will be needed for the entire picture. Additionally, no major institution will treat you based only on an MRI. There are both false negatives and positives with PSA when you still have a prostate and there are factors like infection that can change its value but those numbers should get proper follow up, even the baseline of 6.

George

 

maallyn

GeorgeG said:

MP MRI especially with 3T ER

MP MRI especially with 3T ER is one of the best imaging capabilities that we have and it will give useful information about location and the extent of any suspicious areas with some indication as to its characteristics. All of this is very useful but it will not give you all of the information required for an informed decision. Eventually a biopsy (made more accurate by the MRI) will be needed for the entire picture. Additionally, no major institution will treat you based only on an MRI. There are both false negatives and positives with PSA when you still have a prostate and there are factors like infection that can change its value but those numbers should get proper follow up, even the baseline of 6.

George

 

Then should I start with MP-MRI and then have Biopsy?

Currently, the urogolist wants the biopsy first. But would it be better to insist on MP-MRI first so that urogolist knows more prior do doing the first biopsy? Would having MP MRI reduce the need of a 2nd biopsy if it is done first? Or does insurance require the biopsy before any MP MRI is done? I don't want to have to repeat biopsy if possible . . .

VascodaGama

Quality of Life in jeopardy

Mark,

Welcome to the board. In my opinion George suggestion is the best. Get the mpMRI (3tesla machine in preference) and follow it with a biopsy. It seems to me that your urologist is not very confident in image studies as a piece in the diagnosis process, or he is trying to save you the cost of an unneeded MRI if you in fact have no cancer. However, in a positive case, an image study is always required to provide a clinical stage.
Surely only the biopsy can diagnose cancer so that adding to the traditional standard number (14 needles) some cores of the areas identified by the MRI will provide you a much truthful result.

I wonder if you had any symptom apart from the high PSA. In any case, your doctor may also be thinking that your bicycling life style is the cause of the high PSA so that starting with a biopsy (to diagnose the case) is logical. Even the initial 6 or 7 ng/ml you comment above could have been influenced by the constant massaging of the gland. One cannot make any judgment on your high levels of the serum if you do not stop vigorous bicycling (or paddling) at least 5 days in advance of drawing blood for the test.
One should have in mind that the MRI will not diagnose the cancer but simply provide the view of a lesion. Not only cancer but calculi or BPH (benign tissue) would be seen on such an image.

The only exams that can identify a cancerous cell among the many in a benign tissue are nuclear images that use specific targets that make part of the components of a cancer cell. In regards to PCa (prostate cancer) this is the PSMA PET scan. Some PET images are done using other tracers like choline or glucose but these could erroneously be positive for other cancers or reasons (not PCa related). These tracers are suitable for patients that have been already diagnosed with PCa by other means.

In your shoes I would continue bicycling (giving preferences to your quality of life) and have a biopsy for peace of mind. Or stop bicycling during 5 days, test the PSA two times (3 month interval) and if this is found to be above the 2.6 ng.ml, then have a MRI plus a biopsy.

I wonder how your case develops in the future but I wish you a negative to cancer result.

Best,

VGama

maallyn

MP-MRI in Seattle or Bellingham?

VGama:

Thank you for the suggestion.

I went ahead and asked in another posting on this board regarding MP-MRI in Seattle, but I was suggested to keep all of my questions here instead of doing a separate thread for each one.

One of the replies I got was to consider having an MP-MRI directed biopsy using a special biopsy machine called an Artemis Biopsy system. There is one facility in Seattle that has it (Polyclinic Madison).

However I have not heard from anyone where I can get the MP-MRI itself in Seattle (or better yet, Bellingham). What should I ask for, simply MP-MRI for prostate?

Here is another question; insurance.

I am under HDHP from my former employer until December. I will be old enough for Medicare in May. I don't know what I will do for insurance for January through April of next year as I will be on my own on what is left of Obamacare.

My current HDHP policy requires a decuctable of $2500 for the year (only about 300 used up so far)

Would I be better off financially if I wait until I am on Medicare with appropraite medigap before having these tests done? Do any of you know if Medicare/Medigap will cover MP-MRI and an MP-MRI directory biopsy or will they only cover the standard TRUS biopsy after a high PSA result?

Old Salt

Get the test(s) done ASAP

And use your current insurance. The cost of those will be (considerably) more than your deductible. Then go from there. We can hope that no treatment will be necessary, although with a PSA that high, I doubt that.

hopeful and optimistic

Polyclinic Madison

This center will either have a T3 MRI at their facility or use one local to them. you can call them. By the way, personnel who administer an mri, and the radiologist have to be very skilled . You also might want to check if this is a high volume center.

To be honest, I am not familiar with this organization. It is a private institution, not a teaching hospital.

Mark, there are support groups worldwide which are a great source of information, especially locally. There is a an organization called USTOO that sponsors support groups worldwide. I suggest that you google them to find out if there is a group near you.

Best

VascodaGama

Call and inquire and let us know the results

The Overlake medical center does mp MIR. I just Google the site which you can try to get more places. You can inquire there about the insurance coverage and ask for their prices. The traditional mri costs about 500$. The multi parametric exam is usually done by a pca  expert radiologist which charges could had another 500$. You may request help in the matter from a local support group commented by hopeful. 

In any case, you need to consider less biking while on this period of investigation. Pca is a serious affair that can prejudice greatly you love for bycicle.

VG

maallyn

Folks; Thanks for the note on

Folks; Thanks for the note on USTOO. I never heard of them. I just joined. I do wonder, though; shall I use both them and their on-line forums instead of here or shall I double-post (both here and at ustoo)?

 

To VG: As bicycling is my only transportation instead of walking, do you know if I switched to a recumbant bicycle, would that be better or shall I assume that I will have to resort to walking and leave and ease off all pedaling? I do not have a car. Another option may be to get an eliptical such as one of these http://www.elliptigo.com/shop/elliptical-bikes/ or make my own?

 

Also, when you say 'high volume center, is that a sign of hope or caution?

 

Mark

hopeful and optimistic

.

Mark,

I think that the skills of personnel are generally better at a high volume center.

Did you see if ustoo sponsors any support groups near where you live?

There are half dozen or so on line support groups for prostate cancer. I for the most part post only here, but if you wish to post elsewhere as well or instead, this is your decision.

Mark, in my opinion you may  faced with a cronic life threatening disease. The results of your PSA's tests will be affected by this bike riding, and provide inaccurate information that can affect your treatment decision. I strongly recommend that you give this bike riding a rest at the appropriate time(s), and uber it. .additionally it will be best to place your effort on finding the best places and diagnostic tools, as well exploring possible treatment decisions and not focus on bike riding as you are.

maallyn

I think that I understand

I think that I understand your point about bicycel riding as that presses up against the prostate as I normally ride an upright bike. What I am thinking about is switching to either a recumbant bike or just walking. I can get around Bellingham by walking and the bus (slower than biking). Besides, walking is exercise and I am told all the time that exercise is always healthy. I just have temper it around the crotch.

I did check with USTOO and the nearest group is in Seattle. I sent them an email and they told me that there was a group here in Bellingham but it disbanded years ago. I do not see myself going to seattle for the meetings as that would require staying over night since I rely on Amtrak or Bolt bus. So, for now I will have to rely on on-line support or try to start a group here in Bellingham.

hopeful and optimistic

maallyn said:

I think that I understand

I think that I understand your point about bicycel riding as that presses up against the prostate as I normally ride an upright bike. What I am thinking about is switching to either a recumbant bike or just walking. I can get around Bellingham by walking and the bus (slower than biking). Besides, walking is exercise and I am told all the time that exercise is always healthy. I just have temper it around the crotch.

I did check with USTOO and the nearest group is in Seattle. I sent them an email and they told me that there was a group here in Bellingham but it disbanded years ago. I do not see myself going to seattle for the meetings as that would require staying over night since I rely on Amtrak or Bolt bus. So, for now I will have to rely on on-line support or try to start a group here in Bellingham.

.

You can ride a century, twice, every day, but just don't ride for a few days before your biopsy, that includes upright, recumbant, extensive walking....one time before one of my biopsies, I forgot not to ride (a recumbant) before the PSA test...my PSA was up about two points...i did another PSA.

Try calling the american cancer society 800 telephone number...hopefully they might be able to provide a volunteer to drive you to your medical appointments.

here is a google that may help

https://www.google.com/search?authuser=0&q=bellingham+wa+medical+center+prostate+cancer+support+groups&oq=bellingham+wa+medical+center,+prostate+cancer+support+group&gs_l=psy-ab.1.0.33i21k1.18944.40664.0.44340.31.31.0.0.0.0.133.3279.13j18.31.0....0...1.1.64.psy-ab..0.28.2978...0i22i30k1j33i160k1j33i22i29i30k1.MFPTcgxo9Fo

 

VascodaGama

Inquire at a bicycle club

I do not bicycle so that I do not know much about their differences and causing effects. You may join a bicycle club on line to inquire from participants with the same problem.

I think hopeful above is giving you great advice.

VG

SPT

Take it slow

An MRI is almost zero risk.  No ionizing radiation, no dangerous drugs, just an hour or so in a somewhat claustraphobic tube.

A biopsy can hurt you.  There is ample evidence from breast cancer studies (women organize better than men, and a lot more is spent on breast cancer research) showing that biopsies spread the cancer.  Think about it - you hope that you have the cancer contained in the prostate.  The urologist proposes to puncture the capsule by shooting 12-18 fine needles into it, from the large intestine.  Bleeding and infection are certain - they'll give antibiotics to control it.  Now the cancer has a path to the rest of the body, while the prostate is a bloody mess with a large healing response required - not exactly what you want with cancer about!

Take your time.  If there is anything good about prostate cancer, it is that it is slow.  Take 2-3 months to get the MRI, talk to several different docs, read, and make a decision.  Don't rush it; many of the choices you will be offered will change your life forever, and not for the better.  Be careful.

Good luck!

hopeful and optimistic

.

There is no medical research that indicates that biopsies spread cancer.

SPT

hopeful and optimistic said:

.

There is no medical research that indicates that biopsies spread cancer.

Medical research that biopsies spread cancer

Manipulation of the primary breast tumor and the incidence of sentinel node metastases from invasive breast cancer

https://www.ncbi.nlm.nih.gov/pubmed/15197090

"Manipulation of an intact tumor by FNA or large-gauge needle core biopsy is associated with an increase in the incidence of SN metastases, perhaps due in part to the mechanical disruption of the tumor by the needle."

FNA - fine needle aspiration, a type of biopsy

SN = sentinal nodes, lymph nodes that were more likely be cancerous if a biopsy had been performed

The incresed risk for cancer in the lymph  nodes was 50% higher for women who had biopsies instead of lumpectomies.  So there is medical research that indicates biopsies spread cancer.  The implications of this study are significant, since patients with cancer in their lymph nodes are automatically classified at a higher stage and therefore face much more extensive treatment (and fewer treatment options) than those who have organ-confined tumors.

hopeful and optimistic

.

Thank you for your response.

The study that you provide is a population study of the difference of after effects of various size needles for BREAST CANCER, not PROSTATE CANCER. The conclusion of this study done among patients was written in 2004 for patients treated between 1995 to 1999.

One of the conclusions of that study.

"The clinical significance of this phenomenon is unclear."

my opinion is that this study is dated, inconclusive, and limited in scope.  

SPT

So find a better study. I

So find a better study. I refuted a bald claim:  "There is no medical research that indicates that biopsies spread cancer."  That was false, I provided an example of medical research indicating that biopsies spread cancer.  It's fair to critique the paper but the original claim is proven false.

Whether this result applies to prostate cancers is a fair question.  As far as I can tell no one has looked.  Absence of evidence is not evidence of absence.  It might be unwelcome news to many people to question the safety of biopsies, but that doesn't mean the questions shouldn't be asked.

Women are much, much better at organizing themselves than men.  Even though the incidence of breast and prostate cancers are roughly equivalent, the funding for breast cancer is about 7 times higher than prostate cancer.  Breast cancer research looks into things that prostate can't afford, and breast cancer research has much to teach prostate cancer patients and doctors.  This is probably one of those lessons.

There are many similarities between the two cancers.  Both are sexual execratory organs, both cancers tend to be hormone sensitive, both are more common in older people, etc.  The mets like to go to the bone.

If biopsies have been demonstrated to spread cancer cells in breast cancer, what evidence or argument is there that this does not occur with prostate biopsies?

When I have evidence that is more convincing than bluster from a surgeon who pockets $1000 for every biopsy, I'll cite it.  Until then, no more biopsies for me.

Old Salt

The chance of track seeding is quite small

and may be clinically irrelevant with respect to prostate cancer. Here is a link to a review that appears to be well balanced:

http://sperlingprostatecenter.com/truth-biopsy-track-seeding/

 

PS: Very often, medicine is a game of statistics, not of absolutes. Almost everything that relates to prostate cancer (diagnosis and treatment) involves probabilities. No certainties 

 

RobLee

maallyn said:

Then should I start with MP-MRI and then have Biopsy?

Currently, the urogolist wants the biopsy first. But would it be better to insist on MP-MRI first so that urogolist knows more prior do doing the first biopsy? Would having MP MRI reduce the need of a 2nd biopsy if it is done first? Or does insurance require the biopsy before any MP MRI is done? I don't want to have to repeat biopsy if possible . . .

My PSA rose from 4 in 2013 to 25 in 2016

I will try to touch on a couple points brought up here. My PSA rose from 4 in 2013 to 25 in 2016, doubling annually. A TRUS biopsy in 2014 was a terrible experience and results were negative. Because DRE's were consistently negative as well, my Uro continued to treat it as a recurrent infection. When questioned about an MRI he said that he does not do MRI's.

I changed Uro's, had an MRI fusion biopsy that revealed a G8(4+4) tumor which upon RP found that it had invaded the SV. Currently I am midway thru adjuvant radiation. I wish I had known as much then as I do now, as I would have jumped ship much sooner. Part of this can be blamed on arcane insurance requirements and part on misguidance issued by some government panel. Part was me trusting my Uro and his unwillingness to educate and inform me, the patient.

I was on my employer insurance at time of the TRUS but by the time of the RP was on medicare + supplemental and they covered everything. During the brief period following retirement my wife was on Obamacare and was diagnosed with stage 4 lymphoma. We paid $10K OOP for that but was worth it. There is no sense being cheap when it comes to a potentially fatal disease. My insurance had been "cheap" insisting on a blind biopsy, disragarding PSA's and depending primarily upon DRE's. What a crazy system.

BTW I do frequent the chatroom here on CSN and have never, EVER bumped into anyone from the prostate forum. The chat is most active between 9-12PM, though some are on during the day and some very late night who have difficulty sleeping. Chat has more women than men, slightly more BC, LC, CR and H&N and AFAIK I am the only PCa survivor. I looked into USTOO some months ago and the nearest support group is two hours away. But I live in a seniors community with the highest concentration of individuals on medicare in the nation.  Another WTF situation.  Sometimes I feel like this must be the twilight zone.

I don't bike and have two bad knees. When the PCa is over I need to do something about that. One step at a time. Please do not think me blunt when I say get your priorities straight and do whatever you need to do to get your prostate situation taken care of. And good luck going forward!

GeorgeG

Old Salt is right, this is a

Old Salt is right, this is a game of probabilities, not absolutes and every treatment/intervention carries risk. People can have life threatening liver damage from tylenol as an example so we should be informed and make our decisions with the risk/benefit well understood. I dont take any medication and I have no medical issues including blood pressure, cholesterol, blood sugar etc - except PC of course. It was not an easy decision but I have had many images and treatments so far because sometimes it's the right time for intervention.

Regarding biopsies leading to tracking and spreading. I read a lot on that and can tell you that there is evidence/thinking on both sides of that argument as there usually is. On most subjects you see studies drawing competing conclusions both bashing the other one claiming flawed study parameters etc. That is why a biopsy should not be undertaken lightly and should be appropriate. All the scans we do, same thing especially with the contrast agents etc. But if you are in trouble and want the best care possible, most of these things make sense. On the biopsy, I discussed this at length with my doctor and he acknowledged the potential risks but pointed out that I would not get treated at a mainstream facility without it and with a PSA doubling time measured in single digit months, it was time to get on with it. I did not do any of this when my PSA firsts started climbing though to avoid all of this. Thats a personal decision. I know guys that dove in at a PSA of 2,5, others at a PSA of 125. Others have done nothing. I opted for a fusion biopsy based on a 3T ER MP dynamic image with contrast and without sedative.

Since then - Biopsy, scans/contrast, RP, ADT, SRT so I am in full bore and I'm the organic bean sprout guy. Hopefully I am done with this but if I find myself still on this journey in the future I will be making more personal decisions regarding my care, some of which may not be the typical choice. Again, it's an informed personal choice.

It's not about the hand your dealt, it's about how well you play the one you get.

George