Biopsys

Arrowhead · February 2011

I am a 65 yr old man with 3 biopsy in the last 6 years. In 2006 Clean,in 2008 hot w/gleason score of 6 in 2010 clean. One Dr. says sugery one says I should watch and wait.My PSA has been stable over the past two years from 3 to 4. Anyone out there with a neg. reading after a posative.

hopeful and optimistic · February 2011

me
I am doing active surveillance...........it looks like you have indolent cancer, not likely to spread........chick my name to read about my numbers and tests taken.

Kongo · February 2011

Tough Questions
Hi, Arrowhead. Welcome to the forum. You seem to be facing a difficult decision as you can go one way or another.

When the do a biopsy less than 1% of the gland volume typically ends up on a biopsy slide. As my urologist told me when I had my biopsy: "If you have a slow growing, indolent cancer it can very easily be missed on a biopsy."

As Hopeful and Optimistic suggests, since your PSA has been stable between 3-4 for the past few years, it may be very likely that you have one of those indolent forms of prostate cancer that more than 50% of men in their 60s have and may never require any treatment. Since your PSA is not increasing and you have a positive biopsy followed by a negative biopsy you may very well fall into this category where watchful waiting (also known as active surveillance) is a very viable option for you.

Just curious...what prompted you to get a biopsy to begin with? Was there an abnormal DRE or some other symptom that caused your doctors to suggest a biopsy?

This is a tough decision to sort out but I think you have plenty of time to do your research and sort out your options. Active surveillance may be perfect for you and there are other options as well that include the surgery one of your doctors recommended as well as several modern radiation treatments. I hope you take the time to research potential side effects of each of the many options open to you.

Best wishes as you sort this tough situation out.

K

hopeful and optimistic · February 2011

Kongo said:
Tough Questions
Hi, Arrowhead. Welcome to the forum. You seem to be facing a difficult decision as you can go one way or another.

When the do a biopsy less than 1% of the gland volume typically ends up on a biopsy slide. As my urologist told me when I had my biopsy: "If you have a slow growing, indolent cancer it can very easily be missed on a biopsy."

As Hopeful and Optimistic suggests, since your PSA has been stable between 3-4 for the past few years, it may be very likely that you have one of those indolent forms of prostate cancer that more than 50% of men in their 60s have and may never require any treatment. Since your PSA is not increasing and you have a positive biopsy followed by a negative biopsy you may very well fall into this category where watchful waiting (also known as active surveillance) is a very viable option for you.

Just curious...what prompted you to get a biopsy to begin with? Was there an abnormal DRE or some other symptom that caused your doctors to suggest a biopsy?

This is a tough decision to sort out but I think you have plenty of time to do your research and sort out your options. Active surveillance may be perfect for you and there are other options as well that include the surgery one of your doctors recommended as well as several modern radiation treatments. I hope you take the time to research potential side effects of each of the many options open to you.

Best wishes as you sort this tough situation out.

K

Some more input
You mention that more than 50 of men with prostate cancer have an indolent form.......I'm thinking that includes men who have been diagnosd with more aggressive forms, for example with higher gleason scores, etc who have had to have aggressive treatment up front.........so in Arrowhead's situation, who has been on Active surveillance for six years, with a steady PSA, with 3 biopsies, and in the last there was no cancer discovered, his chances would be significantly more than 50 percent that he does not have an aggressive form, and in fact he does has an indolent form.....if you you at the Klotz study, that is in "about me" folder, you will see that his numbers confirm this.

Just more input

Kongo · February 2011

hopeful and optimistic said:
Some more input
You mention that more than 50 of men with prostate cancer have an indolent form.......I'm thinking that includes men who have been diagnosd with more aggressive forms, for example with higher gleason scores, etc who have had to have aggressive treatment up front.........so in Arrowhead's situation, who has been on Active surveillance for six years, with a steady PSA, with 3 biopsies, and in the last there was no cancer discovered, his chances would be significantly more than 50 percent that he does not have an aggressive form, and in fact he does has an indolent form.....if you you at the Klotz study, that is in "about me" folder, you will see that his numbers confirm this.

Just more input

Good Point
Ira, excellent point. I was just referring to studies that have shown that autopsies of men who died without a cancer diagnosis did in fact have some form of prostate cancer.

K

hopeful and optimistic · February 2011

Kongo said:
Good Point
Ira, excellent point. I was just referring to studies that have shown that autopsies of men who died without a cancer diagnosis did in fact have some form of prostate cancer.

K

I agree
...there are many men , when autopsied, did not have a prostate cancer diagnosis, but died with the disease, not because of it....this is key reason why men do Active Surveilance now a days

By the way , like you I think that it would be a good idea and informative for Arrowhead to answer the questions that you posed.

Klemon · February 2011

biopsies
Welcome :>) I think prostate cancer is the craziest thing. It is so personal for each man and never seems to act particularly the same for any two men. my husband's (age 64) history

PSA
2006 2.5
2007 3.7 told to watch and test again in 6-12 months
2008 4.5 recc biopsy- 12 cores negative
2009 6.1 second biopsy, 12 cores negative
2009 6 mnths later up to 6.9- watch and wait
2009 3 mnths later to 7.2 - watch and wait
2010 3 months later to 8.0 third biopsy, 1 core postive at 3+3=6

all DRE's normal, had pelvic MRI normal

Told we had "years to make a curative decision", discussed radiation, seeds and surgical RP and they also suggested he was a good candidate for watchful waiting. Very healthy, very active. Father age 90 with prostate cancer being treated with Lupron

Final diagnosis was slow growing, low volume of cancer likely.

June 2010 we got a second opinion along with a surgery consultation, and they recommended a saturation biopsy 30 cores. turns out approx 13 cores positive at 3+3=6, 3+4=7 and 4+4 =8. CT scan normal. We decided on surgery.

Elected for Davinci RP and extended lymph node dissection= all nodes negative, final post op path report was a 3 cm x 1 cm x 1 cm mass (not palpable nor visible to the naked eye).. covered both sides of the prostate. T2c. 3+4=7 final Gleason Score. PSA at 3 and 6 months undetectible. Surgery confined to the prostate, nerves bundles in tack, two margins involved at 1 mm.- did not break the capsule

Like Kongo said, the core punch biopsies take such a small sample that they are really doing their best ..but taking shots in the dark to get a representative sample if they don't have an abnormality to focus on.

Hoping you are also one of the lucky ones, stay on top of it and I am sure you will decide what is best for you.

jminnj · February 2011

Klemon said:
biopsies
Welcome :>) I think prostate cancer is the craziest thing. It is so personal for each man and never seems to act particularly the same for any two men. my husband's (age 64) history

PSA
2006 2.5
2007 3.7 told to watch and test again in 6-12 months
2008 4.5 recc biopsy- 12 cores negative
2009 6.1 second biopsy, 12 cores negative
2009 6 mnths later up to 6.9- watch and wait
2009 3 mnths later to 7.2 - watch and wait
2010 3 months later to 8.0 third biopsy, 1 core postive at 3+3=6

all DRE's normal, had pelvic MRI normal

Told we had "years to make a curative decision", discussed radiation, seeds and surgical RP and they also suggested he was a good candidate for watchful waiting. Very healthy, very active. Father age 90 with prostate cancer being treated with Lupron

Final diagnosis was slow growing, low volume of cancer likely.

June 2010 we got a second opinion along with a surgery consultation, and they recommended a saturation biopsy 30 cores. turns out approx 13 cores positive at 3+3=6, 3+4=7 and 4+4 =8. CT scan normal. We decided on surgery.

Elected for Davinci RP and extended lymph node dissection= all nodes negative, final post op path report was a 3 cm x 1 cm x 1 cm mass (not palpable nor visible to the naked eye).. covered both sides of the prostate. T2c. 3+4=7 final Gleason Score. PSA at 3 and 6 months undetectible. Surgery confined to the prostate, nerves bundles in tack, two margins involved at 1 mm.- did not break the capsule

Like Kongo said, the core punch biopsies take such a small sample that they are really doing their best ..but taking shots in the dark to get a representative sample if they don't have an abnormality to focus on.

Hoping you are also one of the lucky ones, stay on top of it and I am sure you will decide what is best for you.

Agree
Klemon, agree completely about it being and acting differently in each man which is why it is so hard to figure out what to do. Take a look at my situation

Age 45 - PSA was 1.7
Age 46 - PSA was 2.2
Age 47 - PSA was 2.9 still not at the 4+ range but doc was concerned about trend

Biopsy - one core at 10% positive.

Went for second opinion, did a lot of research and thinking (could I mentally handle AS). I decided to have surgery 2 months after diagnosis. While the cancer was contained to the gland, over 35% of the gland had been impacted. Based on the low numbers I would not have guessed that type of result.

In the end I felt I did (as you said above) what was best for me and my peace of mind. That is a big part of coping with this, we need to feel comfortable with the choice we make.

To all, I wish you all well in taking whatever steps you need to take to beat this disease.

Joe

VascodaGama · March 2011

jminnj said:
Agree
Klemon, agree completely about it being and acting differently in each man which is why it is so hard to figure out what to do. Take a look at my situation

Age 45 - PSA was 1.7
Age 46 - PSA was 2.2
Age 47 - PSA was 2.9 still not at the 4+ range but doc was concerned about trend

Biopsy - one core at 10% positive.

Went for second opinion, did a lot of research and thinking (could I mentally handle AS). I decided to have surgery 2 months after diagnosis. While the cancer was contained to the gland, over 35% of the gland had been impacted. Based on the low numbers I would not have guessed that type of result.

In the end I felt I did (as you said above) what was best for me and my peace of mind. That is a big part of coping with this, we need to feel comfortable with the choice we make.

To all, I wish you all well in taking whatever steps you need to take to beat this disease.

Joe

Arrowhead; Rise in PSA may signal cancer proggress
Arrowhead

If infection is ruled out, your latest rise in PSA could be a signal of uncontrolled cancer progress.
Gleason score 6 equals to patterns 2 and 4 or most probable 3 and 3. Gleason specifications have changed since 2005 eliminating patterns of 1 and 2 from the score in clinical diagnosis, and moving up to 3. Your cancer aggressivity could well be pattern 2 (Gleason score 2+2=4) which is low (indolent) enough to continue your WW (from 2006).
The PSA, however, in my opinion is high for an indolent cancer. And the rise, with no infection present, indicates a progressive form out of control.

Negative biopsies as expressed in Klemon’ husband case is typical and prevalent particularly in sextant cores. If that was your case, the PSA maybe a better mark to analyse your status and another increase would be a trigger to “act now”.
I would suggest you having a PSA and PAP test done three month from your last.

Surgery is not the only treatment in cases similar to yours. New types of radiation done under the latest precision equipment have shown successful results in survival free progression with lesser side effects. The side effects must be taken into consideration before deciding on the type of treatment and you should have a “deep” understanding of their causes. You could take the time to educate yourself on the matter. Google this sentence and you get many sites to read “Side Effects of Prostate Cancer Treatments”.

If in good health, at your age (65) a radical treatment may be the best choice. You could also avail of hormonal therapy proven to hold the cancer “at bay” for long periods of time over 15 years, before committing to a second line of HT with immunotherapy drugs such as Provenge (read this site (http://news.bbc.co.uk/2/hi/health/8654039.stm) or other drugs in the pipeline (things have changed in my ten years of survival too).
HT is a palliative treatment that can be done intermittently, so that you can have a relief from the drugs side effects (symptoms similar to menopause) in cycles of 12 month on-drug and 2 or more years on off-drug.

I hope that you actually get a lower PSA so that you can continue on your WW.

Wishing you the best.
VGama

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