Second biopsy

PIN
Jimmie,

Can you refresh us as to why your doctor performed a second biopsy in such a short period of time?

PIN stands for prostatic intraepithelial neoplasia and is generally classified as being either low or high grade. Since prostate cancer cells do not spontaneously appear where there were none before, most pathologists believe that there is a gradual evolutionary process going on and that PIN is an indication that cells may be transitioning toward prostate cancer although I believe there are many differing views on this within the scientific community. High grade PIN is generally taken to mean that a person is at higher risk for prostate cancer.

Interestingly, there is not a firm correlation between PSA and PIN.

K

JimmieJoe said:

Second biopsy
This is what he found on first biopsy with PSA at 4.9. Two months before it was 5.4, don't know why it went down.

Biopied 12 cores found 1 out of 12 with cancer, involved 1/10 of core
Gleason 3+3=6
T1C
Area he found was only 1mm focus

He said he wanted to do a second biopsy to see where the small might be going. I wonder if he things he missed something and will find more in this biopsy.

Cautious Doctor
Jimmie,

It seems that you have a very cautious doctor. It's not unusual to miss something in a biopsy as only about 1% of the prostate volume is sampled during a biopsy but the first results seem consistent with your PSA readings.

PSA fluctuates quite a bit depending on what you were doing in the 48 hours before the blood was drawn and even during the time of day. Sex before a blood draw, a hard stool, certain OTC medications (like Advil) riding a bicycle can all cause transitory PSA excursions. Other conditions such as BPH, prostititis, a urinary tract infection (even without symptoms) can also cause PSA to elevate.

Many, many men have small amounts of indolent cancer in their prostate that never requires treatment or poses a threat to your health. One of the complaints many prostate cancer specialists have with the PSA test is that many of these indolent cancers are detected only with a PSA rise and biopsy and result in over treatment which has a negative effect on the quality of life of the patient. On the other hand, the PSA tests also enable doctors to discover and treat cancer earlier than otherwise. Whether or not this is saving lives in the long run is debatable as the overall numbers of prostate cancer continue to increase and the death rate is not declining. Men who have been diagnosed through PSA testing and treated, however, tend to feel that early treatment while prostate cancer is at a low risk stage will prolong their life.

In my own case, I was urged to have a biopsy when my PSA went to 4.3. It revealed cancer in 1 of 12 cores with 15% involvement, staged T1c with a Gleason of 3+3=6. So, our initial diagnoses are very similar. I seriously considering following an active surveillance regimen but finally elected to treat my cancer with a hypo-fractionated sterotactic radiation treatment (CyberKnife) in June 2010 when I was 59. The reason I elected treatment was that I figured at some point I would need to deal with the cancer and wanted to minimize any possible adverse side effects. So far, my treatment choice seems to be working as my PSA has plummeted and continues to fall and I have experienced zero side effects associated with the procedure.

Other men with similar diagnosis prefer to have the cancer removed and pursue surgery or some other treatment protocol.

There's really no right or wrong answer about treatment. It's a choice you have to make based on what your expectations and priorities are regarding quality of life, longevity, your present age physical shape, other medical conditions, and so forth. It's not an easy decision because whatever you decide will have some impact on every single day of the rest of your life.

One of the things I've come to learn since my diagnosis last March is that any treatment such as radiation, surgery, HIFU, cyrosurgery, and so forth are really only treating the *symptoms* of prostate cancer. None of these are attacking the root cause of what causes the cancer to grow in the first place. I have chosen to make some lifestyle changes that involve increased exercise levels and the elimination of meat and dairy in my diet which I believe create chemical conditions at the molecular level that encourage cancer to grow. At first I thought these changes would be hard to do but in fact the opposite has happened. I'm surprised at how easy it has been.

Whatever course you decide, I would urge you to consider the potential impact of diet and nutrition and the roles they play in all this. Genetics may also play a role but there's not much you can do about your genes today...but you have complete control over what you put in your mouth and how much you exercise. Populations in Asia, certain parts of Africa, and others where meat and dairy are not part of a regular diet have a tiny fraction of the cancer, heart disease, diabetes, stroke, MS, dementia, rates that we see in the "wealthy" nations.

In any event, you have a challenging road ahead of you as you become educated and forumulate your priorities on what you will do. I wish you the best of luck as you go forward.

Please let us know what your second biopsy results reveal.

K

active surveilance
As one who has been on active surveillance for two years now, and haveclosely studied this treatment type ...let me say that you appear to be an idea candidate for active surveillance...that your cancer is probally indolent, that is not likely to spread.

I personally believe that instead of having another biopsy so early , you would have been better off with a MRI with a spectroscopy...my opinion...well anyway you will get the results of the second test very soon.

Please feel free to click my name and see what I have done.

VascodaGama said:

Cells which are neither “normal” nor cancerous
When I was diagnosed in 2000, I enter into denial, did not believe in the diagnosis given to me and tried to find a reason for the high PSA. I read about prostatic intraepithelial neoplasia (PIN) which led me to think that I had no cancer but cells that were neither “normal” nor cancerous. The papers/researches on PIN at the time were from studies done in 1990th and they explained this type of cells being similar (much closer) to Gleason pattern 1 (and 2 in some aspects).

This made sense to me when diagnosed with micro-metastasis (2001) which was typical of a high PSA (numerous cancerous cells) of a low grade Gleason pattern (2 in my case) therefore of slow growth. The theory on PIN also supports the reason for fixing in 2005 the standards of patterns when in the context of Gleason score by eliminating grade 1 and 2 and instead applying 3 as the norm. This eliminated Gs of 2 to 5, upgrading “low risk” patients to Gs 6.

I was recommended Watchful Waiting (AS) only because of the micro metastasis theory. Today, ten years after, many doctors are advocate of AS. One of them is Dr. Charles "Snufffy" Myers (cited as one of the best oncologists in PCa) who in his paper published at the Prostate Cancer Research Institute (PCRI) recommends "No Immediate Treatment", meaning active surveillance. His standards for AS are six principles:
(1) a Gleason Score < 7;
(2) less than 34% of biopsy cores with cancer;
(3) a PSA level < 10;
(4) a PSA velocity in the previous year that is < 1;
(5) a PSA density (PSA divided by the size of the prostate in cubic centimeters) < 0.15;
(6) a negative Digital Rectal Exam.

He writes: "Waiting is not right for every man with prostate cancer, but it's a good option for men with Low-Risk disease."

Dr. Peter Scardino of Sloan-Kettering, cited as one of the best doctors in the USA (trained in urology and oncology) in his Prostate Book: The Complete Guide to Overcoming Prostate Cancer, Prostatitis and BPH (2005), comments in regards to Watchful Waiting and Active Monitoring that;
"Some tumors will grow, spread, and become incurable despite the most scrupulous state-of-the-art monitoring. This is the major risk in deferred treatment: Once the horse is out of the barn, locking the door won't bring it back inside."

In my case, I believe WW was a palliative way of extending my survival which indeed gave me quality of life during six years.

I wish Jimmie finds a concrete decision for his case.
VGama

PSA Velocity
Vasco,

I'm not quite sure where the PSA velocity you mention in your post above comes from. Most of the literature I have read suggests that a PSA velocity greater than 0.35 ng/ml/year is a worrisome number for men with an absolute PSA value between 4 and 10 as 95 percent of these cases have been shown to result in high risk prostate cancer several years later.

Obviously PSA velocity alone should not be the determinant factor in making a treatment decision but must be taken within the context of other information such as PSA density, DRE, other physical symptoms, age, prostate size, and biopsy results. All the other numbers you cite are consistent with what I have learned, I just don't get the less than 1 number under your note 4 in your post.

K

Kongo said:

PSA Velocity
Vasco,

I'm not quite sure where the PSA velocity you mention in your post above comes from. Most of the literature I have read suggests that a PSA velocity greater than 0.35 ng/ml/year is a worrisome number for men with an absolute PSA value between 4 and 10 as 95 percent of these cases have been shown to result in high risk prostate cancer several years later.

Obviously PSA velocity alone should not be the determinant factor in making a treatment decision but must be taken within the context of other information such as PSA density, DRE, other physical symptoms, age, prostate size, and biopsy results. All the other numbers you cite are consistent with what I have learned, I just don't get the less than 1 number under your note 4 in your post.

K

Here is the paper
Kongo
Here is the paper with regards to Myers suggestions. I believe some of these principles have changed along the years but the data is similar. My opinion is that guys on AS should have a Gleason score of less than or equalt to 6.
http://www.prostate-cancer.org/pcricms/node/262

Regards
VG

Kongo said:

Vasco
Thanks for the feedback. I agree with you on the Gleason. Like your namesake, we often sail through uncharted waters on this journey.

K

You are welcome
Were is the Martini?
Cheers