Totally New Guy - Biopsy or MRI

Mstoriop,

I agree with Will's opinion above. Both are good starters and complement each other in the diagnosis of cancer. Taking the MRI firstly is better as it may locate abnormalities that can be aimed during the biopsy. A negative MRI result would not mean that cancer is not existent. Prostate cancer of tiny sizes may not be detected by this scan. A biopsy (investigation on prostate tissues under the microscopy) is always the way to diagnose a positive case.

The PSA can be increased due to several means but prostate cancer (PCa) typically relates to constant increases of PSA serum. BPH (benign hyperplasia) typically represents a graph of sharp increases followed by sharp declines (seesaw). Your info regarding the PSA velocity indicates a slow growing value which, if related to cancer, could signify an indolent type of PCa. The free PSA with a ratio of 0.20 has only 24% percent probability of finding prostate cancer. This is a good marker but alone it is not truthful. You need to find what is behind the PSA increase or just follow your doctor's advice in doing nothing and postponing the diagnoses, but never beyond the "gray zone" as you name it.

Here is a comprehensive link on PSA;

http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/81944

Best wishes and a Merry Christmas to you too.

VGama

Welcome to you, mstoriop. I'm sorry you are grappling with these questions in the Christmas Season.

It seems to me you are to some degree dancing around the issue of getting a biopsy, wanting to know what is "most reasonable" at this point.

What is most reasonable and clinically advisable is a biopsy.  Only a biopsy will determine PCa, and give a Gleason Score. No MRI, no PET, no form of blood work can or will substitute for a biopsy, as everyone above has noted.  Plus, the biopsy is cheaper, and has no radiation (MRIs of course have no radiation either, but PET scans and CTs do).  This is a no-brainer, like "Which is healthier ?  The grilled salmon, or the platter of fried chicken ?"   The biopsy is the test that is most important.

Your vector is not radical, but neither is it static.  A negative DRE, while better than a positive one, tells the doctor nothng about the front of the gland, since a DRE only feels the bottom portion of the gland.  It for certain is not an "insurance issue", since, as I noted, a biopsy is cheaper than many forms of scanning, not more expensive.  An insurance rep would advise you to get every scan known to medicine first if they were in charge.

There is no reason to not get a biopsy, but many reasons to get one. Then supplement the biopsy with these other, more expensive tests, if necessary.

max

I believe that mp-MRI first could become standard, a standard option or a more insurance accepted option in 2017.  

First, I did get approved for mp-MRI first, in December, with a resonably respected urologist's support.  Second a paper referenced in the latest 2016 NCCN guidelines shows that biopsy based cancer detection (AUC) was best from biopsies guided with software based fusion of the mp-MRI, better than the ca 12 core biopsy that is standard in many places today.   

I think that two steps need more AUA or medical oncology support:  better molecular profiling of prostate cancer, both as available tissue and blood work; and second, active surveillence combined with milder treatments of biologically based agents and regimens, before being forced by circumstance to the more drastic decisions. 

Not all locations have the automated fusion software available on a regular basis right now.   I am somewhat affected by installed availablity for 1st half 2017.

hopeful and optimistic said:

PCA3

PCA3 test
This test is a  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.

Just so no one is confused, a sensitivity of 57% means that of 100 prostate cancers, only 57 were positive on the test. A specificity of 75% means that of 100 specimens from people who don't have cancer, only 75 would be read as negative on the test (That means 35 would be false positive!)..,,

To put it into perspective, let's say we test men who we think might have prostate cancer. For arguments sake, let's say we test 200 people and 1 in 4 has prostate cancer. Of those 50 people with prostate cancer, (1/4 of 200)  29 will be positive on the test (57% x 50). These are the true positives. Of the 150 people without prostate cancer ~ 113 will be negative on the test( 75% x 150). These are the true negatives. The 37 people who don't have prostate cancer, but the test is positive are the false positives. In this example the false positives (37) are more the the true positives (29).

This test is no better then flipping a coin.  

mstoriop said:

Update

Hello to all.  Hope you all had a very Happy New Year.  For anyone that may find my update of interest I did undergo a 12 core biopsy December 21st.  For anyone contemplating biopsy or not as I was in my first post I can say that for me the whole ordeal and after effects were virtually pain free.  The shots in both butt cheeks were the only discomfort at all and not in any way what I would consider painful. 

on 12/29 I got a relatively non urgent call to check in with the Urologist.  As it turned out the Urologist that performed my biopsy has just retired and I will be switching over to another doctor in this group.  The PA I talked to said I had a bit of a problem and would need to consult with the new Urologist with appointment set for 3 weeks out.  She said she had no information that she could give but with a bit of prodding/respectfully asking have found out with no other technical info that 8 of 12 samples had no issues and 4 of 12 were 3+4=7.  Obviously I was hoping to be in the majority who come out clean with the measurables I had prior to biopsy. 

Luckily I am not an extreme worrier and will wait until my consultation but as with my original post above any comments/opinions/similar situations that anyone has experienced would be very highly appreciated.  From what I have read so far without knowing more I may not be a candidated for active surveillance which was the hope in my mind before biopsy should a condition be found.  Thanks to all         

mstoriop,

I'm thankful the biopsy was not painful for you.

At least you got some info from the NP. A three week wait to get more information from the urologist is irrelevant, and won't affect anything.

The "3=4=7" number, as you seem to know, is your Gleason, and it means that those cores do have a bit of PCa in them.  Roughly 1/3 of the samples pulled.

A Gleason of 7 is regarded as mild to intermediate in aggressivity, and the volume (area with positive tumors detected) is not terrible.

Continue to read and study while you wait, and use whatever relaxation techniques or activities you know.    While you so far have only limited information, things certainly do not sound terrible at this early juncture.  Very likely, like most men, you will achieve a full and permanent cure by whatever treatment you choose.

I do not think you are in the common parameters for Active Survellance, but Hopeful and Optimistic and some others are the experts in that area, and probably will write.

max

There are reasons to NOT get a biopsy (mainly the possibility of infection, which is why you usually hae to take a dose of cirpo beforehand) BUT, even though false negatives are possible, without a biospy you  will not know with reasonable certainty whether you have PCa or not. 

An MRI before a biopsy "could" target the location of possible tumors but I doubt a medical insurer would approve an MRI before an biospy is done because of the costs and because it is contrary from long standing medical practice. 

The more likely procedure would be to follow a positive biopsy would be an MRI/MRSI (aka 3T MRI) scan w/a which could more precisely locate and determine the extent of the cancerf that would probably be approved following a positive biospy determination.

I am sorry for the positive diagnosis. I believe you have been researching on matters of PCa so that you got an idea about the next steps. Your doctor will discuss about that too but it is better that you prepare a list of educated questions in advance for better comprehension on the conversation. The risks of treatments are high and you need to know details before any commitment. The options and decision need to be based on all the info gathered and the clinical stage. The higher the level of information/data the better option is chosen and the best outcomes are provided. These include the best guessing of cancer location, extent of the disease and expected side effects of treatment.

 I would suggest you to get second opinions, make a judgement on the recommendations and discuss them with your family.

Best wishes in your journey and a good 2017.

VGama

At first glance from the above data you describe indicates that the cancer involves the whole right lobe with extensions at mid area to the left lobe. This is a voluminous case that one could think it producing higher PSA levels, probably higher than the 4.5 you indicate above. Your Gleason is also subjective and I think you doing it well in requesting a second look on the biopsy cores at JH. If G7 is 4+3 represents a worsen status that should be considered in the treatment. Negative DRE could mean it to be contained or that the cancer is sort of micro colonies not forming an aggregated mass tumours. In other words, my lay opinion is that it could be close to or at the outer shell.

The PSA is lower than the recommended to assure a true positive result in image studies but you should get one done (higher sophisticated types) at a reliable facilities. Multiparametric analysis MRI should be the minimum acceptable. Micrometastases are difficult of being detectable so that a choline contrast may provide better results. Bone scan makes also part of the protocol. With the collected data the doctor will then provide you a clinical stage (now at T1c, probably T2c) in which you can base your decision on a treatment choice.

Aggressive type of cancers should be aggressively tackled. You need to consider the risks and side effects involving each treatment option. Try researching on the matter now so that you can discuss with your doctor in your next consultation. Typically it takes about 2 to 2.5 months between diagnosis and treatment. There is no reason to speed up things but one should not sleep while waiting. Read, read, read. Second opinions on suggested treatments should be part of your last investigations before deciding.

Here are links that may help you;

http://www.lef.org/Protocols/Cancer/Prostate-Cancer-Prevention/Page-01

http://www.ccjm.org/index.php?id=105745&tx_ttnews[tt_news]=365457&cHash=b0ba623513502d3944c80bc1935e0958

http://csn.cancer.org/node/224280

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

http://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html

A JH book "Choosing the right treatment for your prostate";

https://books.google.co.uk/books?id=16TbQ6as4uAC&pg=PA1&lpg=PA1&dq=choosing+the+right+treatment+for+your+prostate+cancer+johns+hopkins&source=bl&ots=RUO2tcFIuM&sig=KdfOBDSchbX6w12IDUn8JqvrZRE&hl=en&sa=X&ei=bZ4GVaOdMsWsUfq5hFA&ved=0CC4Q6AEwAA#v=onepage&q=choosing%20the%20right%20treatment%20for%20your%20prostate%20cancer%20johns%20hopkins&f=false

Best wishes and luck in your journey,

VGama

The result from JH lowers your risk for metastatic disease. At first look, CK may be enough in your case and you could schedule it definitively after receiving that final confirmation with the 3T MRI. I cannot see the point in extending the time to treat once you got the details in hand.

While waiting, you may investigate on the benefits you could gain from a combination of HT plus S8RT. In such a case you should start HT at least two months prior to RT.

Best,

VG