I Need Understanding With My Results

Samuel,

Although you have not been diagnosed with prostate cancer, you feel threatened, and are having  those depressive feelings that those of us who have been diagnosed exeperience that usually last for a few months.

The PSA is an indicator only, and is affected not only by infection, but by activities before the biopsy such as sex, bike riding, other activities, hard stool. Additionally the PSA is elevated by having a large prostate which can lay on the uretha and elevate the PSA.

There is  a ratio that you might look at between the size of your prostate and the PSA.........an estimate of your prostate size has been noted at your biopsy........you want the ratio to be 0.15 or less.     If you receive an MRI , it will be a more exact description of you prostate size.

I wonder if you have engaged in any of these activities, especially before your last biopsy.

Some docs treat for infection in order to see if the PSA is lowered.

Your free PSA ratio is 8.7%. This is of concern, since the higher the better.

At this point you obviously want to know where you stand.

Your doctor has mentioned having an MRI guided three dimension biopsy........this is the state of the art in biopsies........I , personally have had four of these biopsies......that give a lot more confidence in results than the typical biopsy...........there are only a  few institutions that perform this, generally at  major centers of excellence.

The PCA3 is a urine assay test that is an indicator only.....it is another piece of the puzzle.

I don't know your financial ability, but I would do both the PCA3 and the MRI guided biopsy.........or I would do the mri/ biopsy only.

Feel free to click my name at the right to see what I have been doing in the Active Surveillance protocol that I am following.

It's important for you to aquire knowledge.....read books, attend local prostate cancer support groups........ask questions here..........we are here for you.

Best

More information is what you need and, in your situation, here's what I'd do:

1) I'd submit my biospy slides to Johns Hopkins for a 2nd opinion with special attention to the area noted in the initial biopsy.  Dr. Jonathan Epstein is a recogizned expert in rendering PCa 2nd opinions and I'd ask that he do the reanalysis.  He did the 2nd opinion on mine. Here are links to the 2nd Opinion Service and some info regarding Dr. Epstein:

http://pathology.jhu.edu/department/services/secondopinion.cfm

http://www.hopkinsmedicine.org/hmn/F02/feature2.html

2) As recommended, I'd get the PCA3 test done.  It's a genetic based test which can give you a better indication of whether you have PCa or not but, as noted in your report, it's negative predictive value is only 75%, which means there might be a 25% chance that you still have PCa even given a negative PCA3 result.  For $175, this is a small price to pay for the additional info that it will provide.

3) As also recommended, if the 2nd Opinion and/or PCA3 is positive, I'd get the multiparametric MRI done.  This is a combined MRI/MRSI scan using a contract agent which detects the presence of cholie (a marker for cancer) in or near the prostate.   Normally, this test is only done when there is a postive biospy result or fear of recurrance. 

I had this test done when there was a concern of recurrence during my treatment.  This is the only test that will tell you for certain whether there is any cancer or not but your insurer may be unwilling to pay for it w/o any positive indication of PCa. 

Here's some info about the scan: http://www.radiology.ucsf.edu/patient-care/services/prostate-exam-study#accordion-metabolic-imaging

4) If the 2nd opinion and PCA3 test is negative and your insurer will not authorize a multiparametric MRI, all you can do (unless you can afford to pay for the MRI out of pocket) is to continue to monitor your PSA level.  If you are concerned, I'd ask your doctor to authorize quarterly (instead of semianual) testing which will give you better warning or any significant increases in PSA levels that would warrant taking another biopsy.

Good luck!

Sw1218 said:

hello, VGama.
i must admit

hello, VGama.

i must admit some of the wording you used i didn't quite understand. but, i will answer the questions you asked

1. no, after finding prostatitis and BPH in 2014, there was no recommendations made. the uro simply stated that he was to find reason for the 5.5 PSA.

2. my primary doctor did not perform a DRE before having blood drawn. when i was referred to my urologist,  however, he performed a DRE and didn't find anything. so, he recommended a biopsy. this was all done in 2014. in 2015, i visited my primary doctor, but no DRE was performed, but blood drawn to test my PSA. the results came back 5.9. my uro said because of BPH and inflammatioon, that was to be expected. so, he ordered a fpsa in six months, which was this past thursday.

are you saying i should ask the doctor for some type of antibiotics to treat the inflammed areas and bph?

 

 

SW,

You are learning fast, and asking the right questions. 

Prostate biopsies are known for frequent false negative results; just too little tissue is removed to cover all areas inside the gland where a tiny tumor might be active. MOST biopsies are accurate, but a high enough percentage are false negative to be problematic.  With a personal background in lymphoma before I got prostate cancer, one of the things that struck me about PCa (prostate cancer) is how difficult it is to locate. Although improved forms of imaging now better spot tiny PCa tumors, the imaging in this area is poor compared to most other forms of cancer. And metastatic prostate disease is virtually impossible to track down, at least until tumors become so large as to be painful in the bone, or other locations.  The "gold standards" for viewing lymphoma: the CT and PET scans, are not much used in PCa treatment.

The DRE is of value, but quite limited:  It will tell the doctor if the rear half of the gland has sensible tumors, but tells them nothing about the front half of the gland. So a negative DRE in essence suggests that half of the gland is tumor-free.  

The doctor is correct (of course) that BPH and inflammation could well be the cause of your PSA levels.  I had BHP and chronic prostatitis for years before I got the PCa diagnosis.  In fact, both my biopsy and the pathology report following my prostectomy mentioned, "Chronic inflammatory tissue."  This tissue is usually non-cancerous, but routinely co-exists with cancerous tissue; it is not an issue of one or the other, but possibly both. And to further confuse the issue, many forms of chronic prostatitis, which can persist in a man for decades (it did in me), are non-bacterial, and will not improve on Cipro or other antibiotics. I wish I had a dollar for every 'Cipro Pack' I was given over the years.

I have not read a lot about secondary studies of a biopsy, but do what the guys suggested and have it sent to a better lab. The cost is relatively cheap compared to the other stuff men have done in cancer treatment.   Ask the necessary insurance coverage questions first, however. Pay out of pocket if necessary, if you can afford it.  No good doctor objects to second opinions in these matters.

More important than an absolute or static PSA number is how it is changing, and how fast. This is called yor PSA doubling rate or vector. A faster rate of increase is worse than a slow increasing or static number.

Most men in the US are diagnosed with PCa at the age of 68.  You are quite young for a PSA of over 5, even with inflammation.  The following statement is IMPRESSIONISTIC, and I have no statistics to back it, but some writers suggest that PCA occuring in quite young men (guys in their early 40s or younger) tend toward more aggressive disease.  My cousin's brother-in -law was lost to the disease in his 40s, despite getting his care at M.D. Anderson in Houston, one of the best facilities in the world.  You will hear it said that "PCa is very indolent (slow-moving)."  That is correct, except for the rare cases when it isn't. You will hear, "Men die with PCa, not from it."  True, except when they die from it, and many thousands die from it in the US every year.   Two of my dear friends died from it in the last 7 years, not counting the cousin's relative.  Address prostate issues calmly, intelligently, but with force.

I do not say any of the above to frighten you, and quite likely you do not have PCa.  But I would absolutely demand a PSA every three months until this is figured out -- a very small price to pay to monitor things.

My layman's take of your numbers,

max

Sw1218 said:

Thank you, Max

Thank you, Max. Yes, some of the things you wrote did frighten me a bit. However, what you wrote also had me wondering, if [generally speaking] men my age [42] do in fact have PC, you wrote the tumors would be aggressive. I'm not noticing any symptoms at all what so ever. So, could that mean I don't have it, or am I one of the exceptions? 

Tomorrow, I will reach out to my urologist and ask him some questions 'bout the options he presented to me over email, and ask about the insurance of both. Also, I may look into getting another opinion as well as ask to treat the inflammatioon then test the PSA. My inflammation was never treated.

 

Samuel,

Most times there are no symptoms with early diagnosed prostate cancer.  

As you are probably aware, prostate cancer diagnosis have different levels of aggressiveness. So in your case, even if you are diagnosed with prostate cancer (which you have NOT been) it may be indolent, that is not likely to spread. In fact where I am treated there is a man who was diagnosed in his early 30's about 10 years ago, and has an indolent cancer. He is enrolled in an active surveilance protocol, that is being closely monitored, and is going on with his life.

As discussed you may have an inflamation, that may be treated with a month of cipro or another drug. The downside to this treatment is that you can develop an immunity to the drug.

When you say another opinion, are you referring to a second opinion of the pathology of your biopsy by a world class pathologist.. Determining results of these biopsies are subjective, so the need for a world class pathologist that specializes.

Sw1218 said:

2nd Opinion

I wish I knew a world class pathologist. No, I was going to make an appointment with another urologist, show him/her my history since 2014, and decide where to go from there. This was just a thought.

swingshiftworker recommended a world class pathologist to you,

") I'd submit my biospy slides to Johns Hopkins for a 2nd opinion with special attention to the area noted in the initial biopsy.  Dr. Jonathan Epstein is a recogizned expert in rendering PCa 2nd opinions and I'd ask that he do the reanalysis.  He did the 2nd opinion on mine. Here are links to the 2nd Opinion Service and some info regarding Dr. Epstein:

http://pathology.jhu.edu/department/services/secondopinion.cfm

http://www.hopkinsmedicine.org/hmn/F02/feature2.html"

You can always seek another opinion by a urologist.--I personally would contact my current urologist at this time for more discussion.

 I wonder if the urologist that you are seeing is associated with a center of excellence such as UCLA or NYU. Both of these institutions offer MRI guided biopsies using three dimensional ultrasounds----Samuel, this is a very big deal, probably less than 1/2 of 1  percent of urologists have this capability. ONe of the benefits of this biopsy is that you will have more confidence with the results, and another benefit is,  if there is a spot that is suspicious, you can target, that is, go back to the area of the spot that is suspicious in a follow-up biopsy. You cannot do  this with the standard  two dimensional biopsy that most urologists only have available.

Basically the critical information for type of treatment, or non treatment is the biopsy..........using the MRI guided biopsy is the state of the art................the best.

Hi again,

Inflammation would alter the level of the PSA bounded or not (free) to proteins. In other words, if you have an inflammation you may expect having high levels of both serums, wich would lead to think that the percentage (value) between these should not alter, but nobody could trust in "masked" values.

Surely you need to consider that your chronic prostatitis may render your PSA absolete in any judgement of your status.

Best,

VG

Samuel

When we hear the word “Cancer” we think we are close to death. You and I and the many in this forum experienced that fear. However, prostate cancer is not something that spreads overnight to incapacitate us to such extent that we die.

Firstly, you have not been diagnosed with the disease in your initial biopsy and the data causing you the worries is not trustful. The PSA and the percentage free PSA cannot be used as a statistical measurement to confirm your status. In the future, a guided-biopsy may reveal your real status. Until then you should monitor the problem and enjoy life as usual.

The MRI (multiparametric) will also add information with a better “picture” (a close look) of your prostate gland. It cannot differentiate between benign tissue and cancerous but it can distinguish particulars which when fused with other information (from several ways/pulse-sequences construing the image, including sort of colour Doppler) manages to pinpoint problems that comparing with past experiences, it provide an answer close to a proper diagnosis.
In fact doctors make use of it to attribute a clinical stage to a patient.
In the site of UCSF (prostate cancer specialists) they comment this;

“Multi-parametric MRI prostate cancer imaging exams are performed after a biopsy-proven diagnosis of prostate cancer to provide patients with more detailed information about their disease…”

Here is the link:

https://radiology.ucsf.edu/patient-care/services/prostate-exam-study#accordion-dynamic-contrast-enhanced-(dce)-mri

I sense stress. How about going for that trip you wanted so much to accomplish in the past.

Best wishes,

VG

Sw1218 said:

Where I Live

hello, h.

i live in atlanta, ga. my urologist is dr. peter nieh, md. if anybody knows a good urologist who accepts medicaid, please tell me.

U.S. News and Report publishes an annual hospital ranking be specialty

Emory is ranked 22 for urology

http://health.usnews.com/best-hospitals/rankings/urology?page=3

and, also 22 fdr adult cancer

http://health.usnews.com/best-hospitals/rankings/cancer?page=3