Dr. Brooks at Stanford and Dr. Carroll at UCSF are two of the best
prostate cancer surgeons around but you are far from needing to seek
second opinions from these guys since all you want to know is if your
husband should get a biopsy.  I would get a second opinion since your
uro seems too eager to "immediately" get it done unless he knows a
whole lot more than you've indicated such as a pattern of rapidly
rising PSA values.  As for getting a second opinion, anyone at
Stanford or UCSF would be a good bet as would be any private
experienced uro in the area.  The local newspapers in the Bay Area
occasionally put out a list of doctors who are recommended by other
doctors responding to "Who would you go to for ---?" although I
haven't seen that in a couple of years.  I found a great dermatologist
that way.

There are some things you should know and ask about no matter what
doctor you see.  First off, a Free PSA blood test might offer a clue
as to whether the high PSA is due to cancer or not.  Be aware though
that this can only decrease the odds the PSA is due to cancer, it
won't eliminate the possibility.  Secondly, how many PSA tests has
your husband had, what were their values, when were they taken?  A
pattern of rapidly increasing PSA values over a period of months/years
will greatly increase the odds of there being cancer.  One lone test
doesn't say a lot since PSA values can change from day to day.
Thirdly, does your husband have an enlarged prostate, another source
of higher PSA though BPH and prostate cancer sometimes co-exist, both
contributing to higher PSA values.  Fourthly, a PSA in this range can
be caused by an infection.  A round of antibiotics followed by another
PSA might indicate a possible infectious cause, not cancer.  Notice
that nothing I've said here or anything anyone else will say will
exclude the need for a biopsy unless your husband is in his eighties
and will most likely die of something else besides prostate cancer or
if there is a significant drop in your husband's next PSA.

Most importantly, if all the second opinions and blood tests indicate
a biopsy is in order, tell your husband it's not that big a deal, most
guys say it's virtually painless.  I was so scared I could hardly walk
into the room but it turned out to be nothing.  Do, however, insist on
a numbing agent before the samples are taken, there are no prizes for
being tough, and make sure the doc takes a minimum of 12 samples - the
more the better.  Since prostate cancer is often multi-focal, finding
it is like stabbing for raisins in raisin bread by poking the loaf
with straws.  You can poke a bunch of straws in and never hit a
raisin.

Good luck with all this and maybe, just maybe, that high PSA was an
anomaly or even a lab error but be prepared for whatever comes.
Finally, read, read. read.  The more you know the better off you and
spouse are.  Good luck.
Dave Perry

Maxine,

There is more to a diagnosis than PSA.  What is the size of your husband's
prostate?  What were the results of the digital rectal exam.  When a man
goes over 4.1 PSA, especially if he is young (less than 60), especially if
his DRE comes up with palpable areas on the prostate, the next step is the
harmless biopsy.

I would not, at this point, consider a second opinion.

I do not have any knowledge of Oakland referrals.

Hello Maxine.
Dr. James D. Brooks is the Dr. who was my surgeon in 1999 for Prostate
Cancer.
He is a Urologist/Professor/and Surgeon.
Wonderful man, and very experienced.
John Loomis

As others have said, there are things to do before the biopsy, and a
good urologist would have you go through a few things.  Before I got
to the biopsy stage, I had:

1.  My first PSA and DRE (digital rectal exam) done by my primary care
physician (PCP),  who referred me to a urologist (April-May, 2006)

2.  A DRE at the uro's office.

3.  A Cipro series of antibiotics, in June 2006, followed by second
PSA .

My PSA before Cipro was 5.2, and after was 5.1.  SInce I was 50 years
old at the time, that's abnormallly high -- age matters.  The second
DRE revealed a suspicious bump on the left side.  I then had a 10-core
needle biopsy in July 2006.  (I agree that 12 or more is better -- and
I agree that a numbing agent is a very good idea.  Different men react
differently to the biopsy; mine was pretty uncomfortable.  The
discomfort was gone in a day.  I was 'lucky' in that 10 cores was
enough to find my tumor.)

The sequence that my urologist put me through leading up the the
biopsy made a lot of sense to me.  We eliminated the possibility of an
infection before doing anything more invasive.

--charlie

I am reading in imagined words from my own case, which were not said here in
your case, but it sounds like some primary physican giving a routine physical
exam detected the 4.1 PSA and then referred him to the urologist for the
express purpose of having the biopsy done. Why else would he send him to the
urologist?  What else could the urologist do?  4.0 is that trigger point.
Biopsy is why we go to the urologist with PSA >4.0. My point is that you
already have that second opinion, from your primary doctor.  

In my case, the urologist first gave me a second confirming PSA test, which
included a more specialized Free PSA test, and then he immediately
recommended a biopsy. The urologist/surgeon recommended by my trusted primary
doctor turned out well for me.  Perhaps none of this is your issue, perhaps
you simply want a different urologist to do the biopsy?

But if it is prostate cancer, we need to know early, while adequate early
treatment is possible. Biopsy is the way that we know if it is cancer.  

My PSA increased annually, 2.25 at age 60, to 3.01, 3.13, 3.9, 3.7, 4.3, and
that 4.3 casued my doctor to get me to the urologist in less than two weeks.  
My doctor didnt say the word biopsy, or I might not have gone. :)  But that
is obviously the only point of going to the urologist.

Early in the game, biopsy does seem a big deal, but it is definitely the
trivial part of prostate cancer.  The biopsy is uncomfortable during the few
minutes, not so painful, just very uncomfortable, and not fun at all, but we
all easily live through it.   My biopsy result said cancer, and the biopsy's
second opinion said cancer, Gleason 3+3.  This early decection is of course
the purpose of the PSA test, and the purpose of the biopsy.  My cancer was
detected eary, while still contained, and RP surgery removed it, and I feel
very cancer-free now.   That is a huge plus.  Seems much better than the
alternative.

 I can see a 2nd opinion when picking your surgeon, if needed, but not
necessarily for a biopsy.  Am I reading between the lines that you don't
like this guy? I'd start by asking your GP for a referral, then try your
biggest local good hospital or cancer center for a list. By all means
interview them to see who you like, but you can get the biopsy from anyone.

Dear Maxine,

I have some general tips for finding/researching doctors which I have
accumulated in the last two years based on my experiences with my
husband's illness.  Resources vary from state to state.

Ama-assn.org -- basic info about doctors

* Castle Connolly's "America's Best Doctors for Cancer".  2nd edition
came out recently. The best thing since sliced bread.  Lists 2,000
docs in 16 sub-specialties.  Go to castleconnolly.com or you can find
it in the library.

* Also check out "America's Top Doctors" (castleconnolly.com, local
editions avail. for NY and Chicago.)  There is also checkbook.org,
website of Consumer's Union, a nonprofit group which publishes books
of recommended doctors and hospitals. Also, sometimes local newspapers
will publish doctor reviews.  (Here, NY Mag. does a yearly feature on
this.  Search "best doctors" and your area).

* Try to find a doctor who is associated with a good teaching
hospital.  In your case, there's UCSF and Stanford.  Have a look at
the Urology Dept Faculty.

* Check local PC advocacy orgs.  You might want to ask if they know
any docs.

* Medbdca.gov. [or your state prof'l licensing board.] Check doctor's
licensing, malpractice history, etc.

* State Physician Profile.  Provides extensive info about a particular
doctor.  This is mandated by law in certain states, such as NY.
Unfortunately, CA doesn't have it.

** Hospital -- critical decision.  Don't just go to the nearest one.
Be wary of small community hospitals.  *Look at the US News
(usnews.com) or other hospital rankings. Try to go to a center of
excellence for Urology (or if you have PC, cancer) even if it means
travelling somewhere.  Of the Top 50 hospitals listed in US News for
Urology, # 11 is UCSF and # 12 is Stanford.  You can go to the
usnews.com and look up the details.  Don't rely on your general
impression of a hospital.  One may be good for one thing and bad for
another.  Example:  MSK and NY Presb are both first-rate hospitals in
NYC.  However, MSK is rated #1 in the country for the treatment of
cancer; NY Presb is #24.

** Convenience should not be high on your list of priorities.  Your
goal is getting the best treatment for the problem you have.  With
PC:  Don't fixate on any single option such as robotic surgery (which
seems to be robotically prescribed for everybody, regardless of the
situation).  Do not rule out open surgery or any other treatment
before you have found out more about it.  Research the pros and cons
carefully. *You might want to consult a medical oncologist for a
different viewpoint (e.g., radiation, hormone therapy).  Urologists
mostly recommend surgery

** Go see the best general-purpose urologist in your area, somebody
who has absolutely no use for you.  By that I mean he doesn't need
your money, to practice on you, to accumulate another statistic or to
add another surgery to the list.  A person with many years of
experience and an established reputation.  Such a doctor is more
likely to give you the truth.  If you can, go see several.  If you
have to pay out-of-pocket it's worth it.  Don't just go to the people
your doctor refers you to.  They are probably his golfing buddies.

* Go to prostate-help.org and read the chapter for the "Newly
Diagnosed" and pay special attn to the part about selecting docs.
It's like boot camp.

* For general info about a doctor you can do a basic google search.
Personal details can make a difference.  Once I chose a gyn because he
was listed online as giving a lot of money to a particular charity
(was a tie-breaker).  For info about a doctor's scholarly output, try
googlescholar.com.

* Many people here admire Dr. Stephen Strum for his long-time
dedication to the PC community, even though some of his ideas are not
mainstream.  I would go to pcri.org and have a look at Dr. Strum's
list of recommended doctors.

* Read Scardino's "Prostate Book".  Also Strum's "Primer on Prostate
Cancer", the most detailed book ever written about this subject (but
keep in mind the caveat above).  Both are available on Amazon.

* For objective info on PC go to endotext.org.  This site has
comprehensive info for practicing doctors but it is also
understandable to laypeople.  Has won awards for quality of content
and clarity.

* Ask for recommendations from people in online forums such as this (I
belong to 10 PC ones) and from people you know.  If you have a doctor
you trust absolutely, ask him or her for some names.  But patient
referrals are the best.  Also, you can search the archives of these
groups for accumulated wisdom.

Hope this helps.

Good luck,

Leah