What questions to ask.

icemantoo

My 3000 posts are mainly from the Kidney Cancer board where I am an almost 17 year survivor and mentor the newbies. At age 75 my PSA is 6.5 and has been going up from about 3 to 6.5 in the last 5 years. I have BPH and I am having a retest on my PSA in 90 days.  I have had some blood work which pruports to show I am not a high risk for Prostate Cancer, The URO is contemplating a biopsy if my Psa keeos going up. What questions do I ask? What am I looking at?

 

 

icemantoo

Sw1218

Same Issues

i'm 45 years old. about three years ago, i too had a blood test that put me at a low risk for PCa. as of this past thursday, i was diagnosed with G7 {4+3} PCa. ONLY A BIOPSY CAN DETERMINE PROSTATE CANCER now, there are four different biopsies i know of:

1. the TRUS biopsy,

2. MRI Fusion/Ultrasound guided biopsy

3. MRI In-Bore targeted biopsy

4. Saturation Biopsy

some say the 3rd is the best because it only targets the lesions seen on an MRI.

so if i were you i'd ask my uro about these different biopsies. which ever you decide to do next.

PLEASE do not agree to have a biopsy until you've first had a 3T MRI. this way if there ARE any 

lesions your doctor will know where to find them and there wil be no mistake that you do or don't

have PCa.

Max Former Hodgkins Stage 3

Welcome over here...

I'm a "double boarder" also, iceman.

An increase from 3 to 6.5 over a five year period indicates a slow vector or doubling rate, but 6.5 is a little high, even for a 75 year old, and even with BPH.  The symptoms of BPH are mostly identical to PCa, so it can mask or divert attention away from emerging PCa.

The repeat PSA draw after 90 days is reasonable.  You've already been through the cancer wringer. and while it is certainly unpleasant, a prostate biopsy, if necessary, is no big deal, compared to most of the stuff that cancer patients undergo. It takes maybe 30 minutes, and has no, or few, side effects for the vast majority of men.

There aren't any blood tests that have high reliability in suggesting the presence or absence of PCa, so do not read a huge amount into whatever lab result that was.

max

lighterwood67

Define the issue

In my opinion, your urologist needs to define the issue.  The definitive test for prostate cancer is a biopsy.  I had a 3T MRI prior to the biopsy.  The results of this can be used with the biopsy (fusion) to target suspicious areas.  Then you and your urologist will know exactly what you are dealing with.  Good luck on your journey.

 

Clevelandguy

More tests?

Hi Iceman,

If it was me I would do an MRI next to see if any areas in your Prostate look suspicious, if they do find some suspicious spot then a biopsy would be the next step.  I agree with Lighterwood, the MRI should guide the urologist to where to take the biopsy if needed.  BPH can raise your PSA from what I understand, let’s hope it nothing more than that.

Dave 3+4

 

icemantoo

MRI

My Uro also brought up the possability of an MRI, but is concerned about the contrast because of reduced kidney function as a result of losing one Kidney ro the big C. My omlime search though indicates my kidney function is high enough for contrast.

 

icemantoo

Sw1218

icemantoo said:

MRI

My Uro also brought up the possability of an MRI, but is concerned about the contrast because of reduced kidney function as a result of losing one Kidney ro the big C. My omlime search though indicates my kidney function is high enough for contrast.

 

icemantoo

Find A Way

maybe your doctors can f ind a way around your situation. i just think a MRI would be highly in your favor

VascodaGama

What am I looking at?

Iceman,

Your 17 years of experience in Kidney Cancer will help you in finding the answers to your questions. It follows similar steps in diagnosing, identifying and staging in terms of spreading. However, 17 years ago you were much younger looking for a radical treatment and now at 75 you may need to consider if a palliative approach is a more appropriated option.

The advices from above survivors are pretty good. A biopsy is the ultimate way to diagnose the prostate cancer and I think that you should try to find the reason behind the high PSA, but you need to be attentive to consequences from treatments if you get a positive diagnosis and then want to follow with a treatment. The truth is that PCa takes years to spread and become lethal, in particular if the issue relates to a low aggressive type as Max may be suggesting above due to the long PSA doubling time. The risks in PCa therapies are high and many of us not-so-young PCa patients die from other causes. In fact the NCCN guidelines recommend avoiding radical therapies to guys above 75 yo.

I wonder if your doctor is postponing the biopsy due to your age or due to the past diagnosis of BPH. Such condition, if still existent, would constitute a high portion of that PSA value but one should also consider that several aggressive cancers produce little amounts of PSA for its poorly differentiated type of cells, and this is what you need to know apart from finding if you have or not the cancer. In your shoes I would pursue a biopsy to get a Gleason rate. I also would question your doctor about any concern regarding your age and past interventions.

I have CKD (high creatinine levels) and my nephrologist in 2017 recommended me to avoid the traditional contrasts used in image exams. CT is the worse. MRI can be done with or without contrast so that it is not restrict to CKD patients. You can read this article on the issue from Mayo Clinic;
https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/expert-answers/gadolinium/faq-20057772

In any case, instead of a MRI you can have a PET exam to identify PCa lesions. The Gallium 68 (Ga68) PSMA PET/CT is now considered the standard in PCa diagnosis and it is not nephrotoxic. I am not aware if you can already have this exam in USA but it should be possible because the isotope is easily produced at a local nuclear facility using a generator. In fact the price of this exam is now an half of what used to be one year ago. I had a PET/CT with 18F CHC (choline) in January 2018 and last February 20, 2019, I had a 68Ga PSMA PET with no problems to my kidney issue. You can read about this sort of contrast used in renal diagnosis in here;

https://www.ncbi.nlm.nih.gov/pubmed/27612032

https://www.researchgate.net/publication/307521802_Gallium-68_EDTA_PETCT_for_Renal_Imaging

These links relate to the exam in prostate cancer diagnosis;

https://www.ncbi.nlm.nih.gov/pubmed/29976697

https://www.healthcare.siemens.co.uk/magazine/mso-pet-ct-imaging.html

Here is a past thread that may be of interest to you;

https://csn.cancer.org/node/304417

Best wishes,

VGama

 

 

 

prostatebiopsyblog

Similar situation

My PSA had doubled in a little under 10 years and my Uro suggested another round of diagnostics and possible biopsy as well.  I also have BPH, and a doubling of your PSA level could simply be due to a benign doubling of your prostate volume over time.  High PSA can also a risk factor for PCa of course, so at some point a biopsy may indeed be indicated.

To add to other good suggestions here-

1) Ask about biomarker blood and urine testing before considering a biopsy, or at least investigate what blood work you had (free psa?).  ConfirmMdx, PHI, 4Kscore, PCA3 and others may be relevant to your situation and can help your urologist decide if a biopsy may be indicated now or to continue monitoring.

2) Consider a second opinion before a biopsy is done.  Biopsy IS an invasive procedure and sepsis is an underreported risk of TRUS biopsy, perhaps as often as 5%, and in some cases resistant strains or late treatment can be fatal.  Some docs want to do biopsies right off the bat, others prefer non-invasive testing first to work up a complete risk analysis based on testing, history, etc.

3) If you do have a biopsy, a fusion MRI/TRUS fusion biopsy is probably a good idea as it can help improve detection and biopsy targeting of higher risk cancers, while reducing detection of lower risk cancers (those that wouldn't usually require treatment anyway).  I believe you can have a 3T MRI without contrast if necessary, though it likely isn't as good a predictor as with contrast.  Even so, if a lesion is detected it could still be targeted for biopsy regardless.  <url>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503975/</url&gt;

4) If you must have a biopsy, ask about transperineal biopsy to significantly reduce the risk of infection compared to standard transrectal biopsy.  It may require general anesthesia, but that isn't necessarily a bad thing.  Having a rectal swab culture to look for resistant bacteria before a transrectal biopsy is another question to ask.

Best wishes for your testing and diagnosis.  While a prostate biopsy isn't too bad itself compared to some other procedures, it certainly isn't pleasant either.

ASAdvocate

Two points to add

First point: I recently had an MRI at Johns Hopkins, and was surprised that they did not want to do a blood creatinine test, since they planned on using the contrast. The techs told me that they had received guidance from the medical group whose protocol they followed, that kidney function testing was not longer needed unless the patient was on dialysis.

Second point, there is a new type of biopsy device that JH has helped develop. It is called Precision Point, and takes 12 cores through the perienum. While transperineal biopsies aren't new, this method requires only local anesthesia, and no antibiotics. They have never had an infection from using this device. So, you can add that type of biopsy to the list.

icemantoo

Update

My PSA after 90 days is 6.6. My GFR is up to 65. I am having an MRI with contrast and depending on the result the Uro says he will probably follow up with a biopsy, How much fun is the biopsy?

 

 

 

 

icemantoo

lighterwood67

Lets see

 If you get the biopsy hopefully they will do a fusion biopsy.  Basically they use the MRI to target suspicious areas.  My biopsy was a fusion one.  They gave me a valium around 45 minutes prior to the procedure.  Also, I was given some Cipro to take prior to the biopsy.  They attempt to numb the instrument that goes up your rectum, a needle  penetrates the intestines to get to the prostate gland and then it starts taking samples.  It is not that bad but just a necessary procedure.  Also, my first ejaculant after the biopsy was dark red in color.  As far as fun goes.  Well, you tell me.  Good luck on your journey.

 

Georges Calvez

Prostate biopsy

Hi there,

A prostate biopsy is not as you can imagine a bundle of laughs but it is not that bad.
You lie there with your legs in a set of stirrups, the surgeon puts an ultrasound probe up your bum, injects some local anaesthetic then thwang, thwang and it is all over.
I felt like I had been kicked in the arse afterwards when the anaesthetic wore off and I had blood in my urine for a week and in my semen for a couple of months afterwards.

Best wishes,

Georges