Just completed biopsies
Thank you all for your contributions to this site. I have gleaned consdierable information from the first hand experiences I have read here. My story is just begining. Have a family history of prostate cancer with my father undegoing RP and subsequently radiation therapy for Gleason 4+4. I have had some obstructive symptoms for several years and a PSA of 5.0 (age 56) led to a urologist referal. He repeated the PSA (right afetr the finger wave) which was up to 7.0
Had an ultrasound of the prostate with an estimated size of 47 cc and PSA density of just shy of .15 Urologist identified a couple of hypo-echoic but ill defined areas and had the prostate sampling (12 biopsy specimens) taken under a a local anesthetic (that smarted a bit!)
That was 4 days ago and I am still having a dull ache in the perineum. Although I have already had my biopsies, I am wondering what people think about the course of my evaluation. What do you think of repeating the PSA right after an agressive digital rectal exam and using that value as a predicate for ultrasonography/biopsy? Was the urologist being over agressive? Do most people still have some discomfort several days after the biopsy procedure. (had a little blood in the urine and in the semen (that hurt a bit too))
Comments
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Welcome
Hi Bob, welcome to the forum. As you have already learned, there are a lot of well-informed and helpful folks here. Even though my biopsy was only 6 months ago, I don't remember much about it except that it hurt during but not much afterwards. As far as the PSA test after the digital exam goes, according to Johns Hopkins' Dr. Patrick Walsh, author of Dr. Walsh's Guide to Surviving Prostate Cancer, it should have been the opposite -- PSA first, then digital -- as the digital itself could cause a rise in PSA. He says blood in the semen, sometimes for several months afterward, is normal. He mentions blood in the urine, but says it is normal "immediately after the procedure," and that the bleeding "should" stop the same day or the next day. He says that if there is blood in the urine that is "significant" or "lasts more than a few weeks," you should call your doctor immediately. I would call now to see what he has to say. Let us know the results of the biopsy.
Regards,
Michael
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BobYou got reliable answersMichaelF1002 said:Welcome
Hi Bob, welcome to the forum. As you have already learned, there are a lot of well-informed and helpful folks here. Even though my biopsy was only 6 months ago, I don't remember much about it except that it hurt during but not much afterwards. As far as the PSA test after the digital exam goes, according to Johns Hopkins' Dr. Patrick Walsh, author of Dr. Walsh's Guide to Surviving Prostate Cancer, it should have been the opposite -- PSA first, then digital -- as the digital itself could cause a rise in PSA. He says blood in the semen, sometimes for several months afterward, is normal. He mentions blood in the urine, but says it is normal "immediately after the procedure," and that the bleeding "should" stop the same day or the next day. He says that if there is blood in the urine that is "significant" or "lasts more than a few weeks," you should call your doctor immediately. I would call now to see what he has to say. Let us know the results of the biopsy.
Regards,
Michael
Bob
You got reliable answers from Michael above. The PSA results from blood sampled after DRE cannot be used for diagnosis. Your doctor may be of the group of those that do not believe in the PSA test (and there are many) so that he gave more importance to the DRE results and to your family history with PCa, to consider your status. The PSA test was merely used to complete the initial diagnosis as a high or low result. However, by having a father with cancer one is at threefolds of high risk (150%) for contracting it. Read this;
http://www.cancerresearchuk.org/cancer-info/cancerstats/types/prostate/riskfactors/The biopsy is a simple procedure but painful if it causes inflammation. You can take some pain killers while waiting for the results.
What is surprising is that the size of your prostate is at the high end of normal classification, which could be ruling an existing BPH case. That would also justify your “obstructive symptoms along the years”. The condition could be also behind your high PSA of 5 (ng/ml).
In such a case doctors recommend firstly a protocol of antibiotics and then go through a series of image studies before embarking on a biopsy.
Your doctor by his experience seems to have already considering you a prostate cancer patient.In any case, you have to wait for the biopsy results and should prepare yourself for whatever answer you will receive. Having PCa is not the end of the world. There are many ways to treat it and get cured.
Should the result be positive, you should get second opinions from proper specialists. You should do things coordinately and timely.
Best wishes and luck in your journey.
VGama
Are you a real Cowboy? One of those that ride horses and drive herds along arid fields as the ones we see on the movies?
Riding horses may cause high levels of PSA serum.
Cool
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A year later...CowboyBob said:Biospy Results
The urologist called and let me know that all the biopsies were negative for cancer and he wants to see me again in 6 months. So , good news. Thanks for all the information
So here we are a year later. Had repeat PSA in the spring whihc was less than to post DRE value that prompted the biopsies and had repeat PSA on Halloween. As you can see below in the table below, the PSA is up by2. Was in to see the urologist today for exam and discussion; but, he got called into some procedure and cancelled.
Thoughts on next moves? Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 0 -
State of the artCowboyBob said:A year later...
So here we are a year later. Had repeat PSA in the spring whihc was less than to post DRE value that prompted the biopsies and had repeat PSA on Halloween. As you can see below in the table below, the PSA is up by2. Was in to see the urologist today for exam and discussion; but, he got called into some procedure and cancelled.
Thoughts on next moves? Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 Instead of blind biopsies which most urologist do today, there are now guided biopsies at some institutions and facilities. Basically a multi-parametric mri is done, preferably with tesla 3.0 magnet.Suspicious lesions are determined by a radiololist, and ranked. Then a biopsy is done of these suspicious lesions using the MRI in real time: or by a 3 diminsional biopsy machine that can target these lesions, and targeted cores are taken; aditionally random cores are taken at this time of the biopsy.
The above method is more effective in finding cancer(s) that may exist. You will have a better chance of knowing where you stand.
This method is part of an Active Surveillance program that I am on....click my name for more information.
............
Best
Hopeful
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False negatives in low PSA caseshopeful and optimistic said:State of the art
Instead of blind biopsies which most urologist do today, there are now guided biopsies at some institutions and facilities. Basically a multi-parametric mri is done, preferably with tesla 3.0 magnet.Suspicious lesions are determined by a radiololist, and ranked. Then a biopsy is done of these suspicious lesions using the MRI in real time: or by a 3 diminsional biopsy machine that can target these lesions, and targeted cores are taken; aditionally random cores are taken at this time of the biopsy.
The above method is more effective in finding cancer(s) that may exist. You will have a better chance of knowing where you stand.
This method is part of an Active Surveillance program that I am on....click my name for more information.
............
Best
Hopeful
I would suggest you get an image study of the "grade" above indicated by H&O. The results will provide you peace of mind and move you into WW.
Typical CT or MRI, or bone scans are known to provide false negatives in PSAs of less than 10.
Hope for the best.
VG
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MRI/MRSICowboyBob said:A year later...
So here we are a year later. Had repeat PSA in the spring whihc was less than to post DRE value that prompted the biopsies and had repeat PSA on Halloween. As you can see below in the table below, the PSA is up by2. Was in to see the urologist today for exam and discussion; but, he got called into some procedure and cancelled.
Thoughts on next moves? Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 I had an MRI/MRSI done on my prostate at UCSF a copule of years ago because of fluctuating and rising PSA levels following CK treatment a couple of years earlier.
Not sure if it was a full multi-parametric MRI or not, but it did include the MRSI which is the most important because the spectroscopy focuses on identifying the location and levels of choline (which is a marker for cancer) in the prostate. My screening came up negative for choline concentration in the prostate, despite the elevated PSA levels, which was a relief. The PSA tests later dropped to acceptable levels.
If you're not sure what multi-parametric MRI screening is, take a look at this site: http://radiology.ucsf.edu/patient-care/services/prostate-exam-study.
It's an expensive procedure and I'm not sure if your insurer would approve MRI/MRSI or multi-parametric MRI for a PCa screening w/o some pre-existing evidence of PCa from a DRE &/or biopsy BUT it certainly wouldn't hurt to ask. The fact that your PSA level has almost doubled in the past 18 months should be enough for your urologist to recommend it.
However, the necessary equipment to do the MRI/MRSI is not always available. So, you may have to switch hospitals or providers to get it.
Good luck!
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What Next?CowboyBob said:A year later...
So here we are a year later. Had repeat PSA in the spring whihc was less than to post DRE value that prompted the biopsies and had repeat PSA on Halloween. As you can see below in the table below, the PSA is up by2. Was in to see the urologist today for exam and discussion; but, he got called into some procedure and cancelled.
Thoughts on next moves? Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 "Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?"
Thought it better to address this question separately.
Ultrasound prostate biopsies (UPBs) are crude but are the only way (other than an MRI/MRSI screening) to find out if you "might" have PCa or not. UPBs are not perfect and can entirely miss finding PCa (false negative) but the procedure is cheap and relatively simple to perform in a doctor's office; albeit uncomfortable with possible side effects, such as infection and bleeding, as you already know.
Given the rise in your PSA levels over the past 18 months, you need to find out if this change has been caused by PCa or just an enlarged but benign prostate (BPH). Only way to do this is via a UPB or an MRI/MRSI screening and the only way to know for sure is with the MRI/MRSI screening.
While you could do AS, you'll still not know if you have PCa or not without a future biopsy or MRI/MRSI screening. So, you might as well get that done now. The only quesiton is whether to go w/the UPB or MRI/MRSI. Unless you want to and can pay for it yourself, which method you get will depend a lot on your insurer.
Because of the cost involved and the lack of any other evidence of PCa, my guess is that your insurer would only want to pay for another UPB at this point. If the new UPB comes in positive, you'll know whether you have PCa or not and can act accordingly. However, if the UPB comes back negative, I'd push to have the MRI/MRSI done to rule out a false negative because of your rising PSA levels.
As soon as you find out whether you have PCa or not, you'll then be able to decide what to do next, whether it's AS or someother specific form of treatment.
Good luck!
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Will the urologist wants toSwingshiftworker said:What Next?
"Are repeat blind biopsies in order or should an advanced imaging study be performed, or perhaps watchful waiting?"
Thought it better to address this question separately.
Ultrasound prostate biopsies (UPBs) are crude but are the only way (other than an MRI/MRSI screening) to find out if you "might" have PCa or not. UPBs are not perfect and can entirely miss finding PCa (false negative) but the procedure is cheap and relatively simple to perform in a doctor's office; albeit uncomfortable with possible side effects, such as infection and bleeding, as you already know.
Given the rise in your PSA levels over the past 18 months, you need to find out if this change has been caused by PCa or just an enlarged but benign prostate (BPH). Only way to do this is via a UPB or an MRI/MRSI screening and the only way to know for sure is with the MRI/MRSI screening.
While you could do AS, you'll still not know if you have PCa or not without a future biopsy or MRI/MRSI screening. So, you might as well get that done now. The only quesiton is whether to go w/the UPB or MRI/MRSI. Unless you want to and can pay for it yourself, which method you get will depend a lot on your insurer.
Because of the cost involved and the lack of any other evidence of PCa, my guess is that your insurer would only want to pay for another UPB at this point. If the new UPB comes in positive, you'll know whether you have PCa or not and can act accordingly. However, if the UPB comes back negative, I'd push to have the MRI/MRSI done to rule out a false negative because of your rising PSA levels.
As soon as you find out whether you have PCa or not, you'll then be able to decide what to do next, whether it's AS or someother specific form of treatment.
Good luck!
Will the urologist wants to do a PC3 urine test before the T3 MRI: Apparently he has had better success getting the scan approved by insurance after the PC3...... My reading of the sensitivity and specificty of this test is that it really isn't that good.
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PCA3 Urine Test?CowboyBob said:Will the urologist wants to
Will the urologist wants to do a PC3 urine test before the T3 MRI: Apparently he has had better success getting the scan approved by insurance after the PC3...... My reading of the sensitivity and specificty of this test is that it really isn't that good.
If you doc thinks you have a better chance getting a T3 MRI approved by your insurer, I'd do it even if there is some risk that the pee test will come back w/a negative result. What other choice do you have?
If the pee test comes back negative, you could still opt for a biopsy to followup but, if that comes back negative again, you'd probably be stuck w/o getting the Tesla3 MRI scan unless you can/want to pay for it yourself or UNLESS your PSA continues to skyrocket (think "doubling time"), in which case, I think your doc should be able to make a strong argument for a T3 MRI.
FWIW, I got my MRI/MRSI Tesla scan based only on a rising PSA following CK treatment, but that was based on the knowledge that I had PCa already (confirmed by biospy) and the accepted policy of suspecting recurrence with 3 consistenly rising PSA scores following treatment.
Good luck!
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PCA3CowboyBob said:Will the urologist wants to
Will the urologist wants to do a PC3 urine test before the T3 MRI: Apparently he has had better success getting the scan approved by insurance after the PC3...... My reading of the sensitivity and specificty of this test is that it really isn't that good.
This PCA test is an indicator only.
In my case my PCA3 was low, showing low probablity of PCa, however I have had 4 MRI guided biopsies which are paid via my medicare and a PPO.
In my case, since I have adequate insurance there is no problem in being treated.
Generally a PCA3 test is done as one of the tools to determine if a biopsy is needed. In your case you have a rising PSA, plus a family history of aggrssive PCa. If it were me, I would precede with the best biopsy that I can get.
I am copying a note that I wrote to you on a different thread, so all informaton will be in one thread
The MRI is excellent for identifying suspicious areas. It takes a Guided Biopsy with pathology and second opinion to know what is PCa and what is not a problem.
I suggest that you find a place that does both; a MRI T-3 and three dimensional biopsy capability, or using the same MRI machine in real time to biopsy the suspicious areas.
........................................
"PCA3 test
This test is a new investigational ( only an indicator) urine gene test that is available. The test is a molecular biologic assay. This test has a specificity of 75% and a sensitivity of 57%. (What that means is that among 100 bad tumors, for example, they only can identify 75 of them. And among 100 good tumors, they identify them as bad in 57). The test is done by a doctor who does a DRE and vigorously massages(the fun part...my doc is very experienced, has muscles on his finger, and can make a grown man cry) the prostate; the patient gives urine and the results are sent to Bostwick Laboratories(the only laboratory that does this) for analysis.
So the way the results work, 35 is the magic number, so the less one score is below 35 the better. Mine was 8.3 "Prostatic cells are present but do not over express the PCA3 gene", "value of 35 or greater suggests a high likelihood of prostate cancer"
It is also stated that only a prostate biopsy can diagnose prostate cancer. The test's preformance has been established by Bostwick Laboratories. It should not be used as the sole evidence for or against the diagnosis of prstate cancer. Clinicco-patholological correlation is indicated."0 -
Accuracy of PCA3 Not The Issue!CowboyBob said:Will the urologist wants to
Will the urologist wants to do a PC3 urine test before the T3 MRI: Apparently he has had better success getting the scan approved by insurance after the PC3...... My reading of the sensitivity and specificty of this test is that it really isn't that good.
As I read Cowboy Bob's post, accuracy of the PCA3 pee test is NOT the issue.
His doc just thinks that taking the PCA3 test will improve the likelihood that the insurer will approve Bob for a Tesla 3 MRI. Based on this, I don't see the "harm" in taking the PCA3 test, assuming that his insurer will NOT approve any further testing w/o some indication that PCa is present.
Obviously, if the PCA3 test comes up negative, that doesn't necessarily mean that Bob doesn't have PCa and that further testing would still be adviseable and it would be up to Bob to advocate for further testing -- be it an ultrasound or MRI guided biopsy or Tesla 3.0 MRI scan -- if there's still any doubt about that.
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Agree, good idea to have theSwingshiftworker said:Accuracy of PCA3 Not The Issue!
As I read Cowboy Bob's post, accuracy of the PCA3 pee test is NOT the issue.
His doc just thinks that taking the PCA3 test will improve the likelihood that the insurer will approve Bob for a Tesla 3 MRI. Based on this, I don't see the "harm" in taking the PCA3 test, assuming that his insurer will NOT approve any further testing w/o some indication that PCa is present.
Obviously, if the PCA3 test comes up negative, that doesn't necessarily mean that Bob doesn't have PCa and that further testing would still be adviseable and it would be up to Bob to advocate for further testing -- be it an ultrasound or MRI guided biopsy or Tesla 3.0 MRI scan -- if there's still any doubt about that.
Agree, good idea to have the PCA3 diagnostic test, it is a great indicator for determining if a biopsy is neededT.
Eventhough I had a PCA 3 after I was first diagnosed it is an indicator used in the management of my case. I am glad that I had one...it is not very invasive. (Side note: Additonally, I had several of the PCA3s as part of multi-hospital study...the results of the tests were stored for analysis. I was one of the guini pigs to develop this test, and a similar test)
To be honest, I have not known anyone with sufficient coverage, where the MRI guided or the ulltrasound was refused when there was cause for a biopsy.
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PCA3 assays: no definitive answers!CowboyBob said:Will the urologist wants to
Will the urologist wants to do a PC3 urine test before the T3 MRI: Apparently he has had better success getting the scan approved by insurance after the PC3...... My reading of the sensitivity and specificty of this test is that it really isn't that good.
The PCA3 test results in a number. The number is related to the probability (!) that there is cancer in the prostate. A score of less than 25 indicates a lower probability of cancer and a score higher than 25 a greater probability. In other words, I agree with CowboyBob that the test really isn't that enlightening.
In the CowboyBob scenario, what if the PCA3 assay result ends up in the 'good' range (less than 25)? It seems doubtful that the insurance company would approve paying for the (3T) MRI-guided biopsy with such a result.
Note that even the high-tech MRI can miss cancerous sites ('false negatives').
More importantly, I would like to see the PSA test repeated to make sure the jump to 8 (10/31) wasn't a bounce without clinical significance.
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PCA3 of 8hopeful and optimistic said:Agree, good idea to have the
Agree, good idea to have the PCA3 diagnostic test, it is a great indicator for determining if a biopsy is neededT.
Eventhough I had a PCA 3 after I was first diagnosed it is an indicator used in the management of my case. I am glad that I had one...it is not very invasive. (Side note: Additonally, I had several of the PCA3s as part of multi-hospital study...the results of the tests were stored for analysis. I was one of the guini pigs to develop this test, and a similar test)
To be honest, I have not known anyone with sufficient coverage, where the MRI guided or the ulltrasound was refused when there was cause for a biopsy.
Well the PCA3 test came back quite low (8) and the urologist is comfortable with repeating the PSA and DRE in 6 months. If it rises again we are back to the 3T with guided biopsy. I did not really take much solace in the PCA3 given the low sensativity I have read. Appears that it is not much better than flipping a coin for detecting cancer.........
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confirming your situation and some thoughts.CowboyBob said:PCA3 of 8
Well the PCA3 test came back quite low (8) and the urologist is comfortable with repeating the PSA and DRE in 6 months. If it rises again we are back to the 3T with guided biopsy. I did not really take much solace in the PCA3 given the low sensativity I have read. Appears that it is not much better than flipping a coin for detecting cancer.........
As I understand: your situation:
You have a family history of PCa.
Last year you had a 12 core random biopsy with no cancer found.
I wonder does your doc make any comment about your PSA trend, or high PSA/density of 0.17 .ie, What does he think is the probablity that you may have an infection that needs to be treated....usually one looks for the density to be 0.15 or less. Does he make any comment about the PSA level of 8.0?
The PCA3 test is another indicator. Your low number of 8 is an excellent score. It is the same score as mine. I am on AS almost 6 years now.
What is your age?
............
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Updatehopeful and optimistic said:confirming your situation and some thoughts.
As I understand: your situation:
You have a family history of PCa.
Last year you had a 12 core random biopsy with no cancer found.
I wonder does your doc make any comment about your PSA trend, or high PSA/density of 0.17 .ie, What does he think is the probablity that you may have an infection that needs to be treated....usually one looks for the density to be 0.15 or less. Does he make any comment about the PSA level of 8.0?
The PCA3 test is another indicator. Your low number of 8 is an excellent score. It is the same score as mine. I am on AS almost 6 years now.
What is your age?
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Update. Had another 6 month followup. DRE unchanged. PSA was DOWN to 5.7 with % free at 16. I have copied the chronology below for quick reference. I am surprised at the dramatic fall. Urologist just recommends another PSA in 6 months. Any thoughts on the drop?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 05/14/2015 5.7 0.91 16
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The PSA test is an indcatorCowboyBob said:Update
Update. Had another 6 month followup. DRE unchanged. PSA was DOWN to 5.7 with % free at 16. I have copied the chronology below for quick reference. I am surprised at the dramatic fall. Urologist just recommends another PSA in 6 months. Any thoughts on the drop?
Date Total Free % Free 4/13/2013 5.4 9/16/2013 7 1.3 16.1 4/11/2013 6 1.02 17 10/31/2014 8 1.58 20 05/14/2015 5.7 0.91 16
The PSA test is an indcator only; one needs to look at the trend of the PSA tests, not one observation.
As far as Free PSA the higher the number the more likely that there is not cancer. Here is information from a site that shows likelihood of cancer at different Free PSA levels.
http://www.harvardprostateknowledge.org/what-is-the-difference-between-psa-and-free-psa
At the Sloan Kettering web site, you can track your PSA rate of change.
I think (opinion) that you should just be happy with a lower PSA number this time, good luck in your next test.
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Choiceshopeful and optimistic said:The PSA test is an indcator
The PSA test is an indcator only; one needs to look at the trend of the PSA tests, not one observation.
As far as Free PSA the higher the number the more likely that there is not cancer. Here is information from a site that shows likelihood of cancer at different Free PSA levels.
http://www.harvardprostateknowledge.org/what-is-the-difference-between-psa-and-free-psa
At the Sloan Kettering web site, you can track your PSA rate of change.
I think (opinion) that you should just be happy with a lower PSA number this time, good luck in your next test.
Hi Bob,
I did the MRI with radioactive dye then a Biopsy which detected the cancer. The MRI will direct the doctor where to take the biopsy samples. I chose to go with Robotic surgery with radiation as a back-up if needed. Sounds like you are still going through the diagnosis stage but I feel the biopsy is the definitive tool to your diagnosis. There are a lot of confusing options available for treatment, you will have to sort through them & determine which is best for you. Good luck.
3+4 PSA 5.1
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^ mo followup
Had my 6 mounth followup today and was quite surprised to learn PSA was 33! (I'll update my PSA table later, but that's a rise from 5.7 this time last year. ) Got a lot of questions asking about synmptoms of prostatitis ( which I don't have) and had a negative DRE. Urologist wants to repeat the PSA test and think about a 3T multiparametric MRI with guided biopsies if the PSA is not back down.
I had a flu like illness the week before my PSA was drawn. Can't believe such an impressive jump would be cancer. Maybe it is related to my viral illness. Anyway, looks like I may be headed for more biopsies
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