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Medical Forum / Diseases and Disorders / Prostate BPH / September 2003Growing PSA, negative biopsies
My father, who is 66 now, has the following history: 09/94 PSA = 4.9 10/97 PSA = 8.0 11/97 PSA = 12.0 11/97 Negative biopsy 08/99 PSA = 12.6, free PSA = 7.1% (low!) 10/99 Negative biopsy 05/00 PSA = 15.9 01/01 PSA = 13.0 06/01 PSA = 12.4 03/02 PSA = 14.0 10/02 PSA = 20.0, free PSA = 15% 10/02 Negative biopsy 11/02 PSA = 17.8 08/03 PSA = 21.9 All 3 biopsies were done by the same urologist, each with 8 cores. We are getting mixed messages from doctors. Does anybody have a similar history, or know somebody who did ? Any help will be highly appreciated. -Alex Does your father have bph? My PSA went from 4 to 17 over a period of years prior to having a TURP at age 68. I had two negative biopsies along the way. My uro said that it was not uncommon in people with enlarged prostates to have elevated PSA readings. After my TURP the PSA dropped back to 4 and has been there since. Don > My father, who is 66 now, has the following history: > [quoted text clipped - 20 lines] > > -Alex > Does your father have bph? Yes, his prostate is markedly enlarged, 7cm x 6cm x 5.5cm according to a CTScan last year. At this point he would rather prefer to have his prostate removed completely, even without a positive biopsy, if it is possible. -Alex > > My father, who is 66 now, has the following history: > > [quoted text clipped - 20 lines] > > > > -Alex Very similar to my own case. Over a period of about 4-5 years my PSA rose from 5.5 to 17.9, during which time I had 3 biopsies, (8-10 cores), all negative. I'm 72 years old, with BPH. My prostate volume is 110ccs. My PSA then fell to 7.9, and I now have a PSA test at 6 monthly intervals. It is believed that the rise in my PSA level coincided with inflammation of the prostate, accompanied by some discomfort/pain, which has now subsided. Will > My father, who is 66 now, has the following history: > [quoted text clipped - 20 lines] > > -Alex I'd be a bit worried too with a PSA around 20 and a fairly low free PSA - but a radical prostatectomy is nasty, and only a prospect of likely cure for proven cancer would make me even consider it. I'd suggest joining p2p, a forum monitored by PCa specialist doctors, and asking the same question there. The URL is http://www.pcri.org/mailists/p2pindex.html I suspect they will suggest a biopsy by a real expert, plus perhaps a couple of other tests. That way Alex's father will either get a positive diagnosis or peace of mind - hopefully the latter. Richard Slessor > I'd be a bit worried too with a PSA around 20 and a fairly low free > PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 10 lines] > > Richard Slessor Or they will find someone else who wants to do a biopsy forever and forever and forever. > I'd be a bit worried too with a PSA around 20 and a fairly low free > PSA - but a radical prostatectomy is nasty, and only a prospect of > likely cure for proven cancer would make me even consider it. It is not really possible to estimate the likelihood of a cure in a case like that without a biopsy. A biopsy is a relatively simple and safe procedure. Also, radical prostatectomy is not the only possible treatment. In many cases, radiation is an appropriate alternative. Many statements you see in the media overestimate the occurence and seriousness of side effects and underestimate the likelihood of a cure. It is important to have up to date information and to realize that results can depend significantly on the competence of the doctor. Unfortunately, there has only been one truly randomized study comparing radical prostatectomy to waiting (followed by hormone therapy). It did show a signficantly reduced death rate from prostate cancer for those treated by RP, but there was no significant overall difference in death rates. But this study was limited in time and done in Sweden where urological practice is quite different than in the US. One can't overgeneralize from its results. There is a similar study going on at present in the US, but the results aren't in yet. Moreover, it is important to realize that overall results can be misleading. It could easily be true that overall RP confers no significant benefit but that for certain diagnostic classes it does confer such a benefit. So right now you have to go with the best available evidence. Most of this is somewhat indirect but it does generally support the conclusion that in many cases treatment of early prostate cancer is curative and that the side effects can be dealt with. > I'd suggest joining p2p, a forum monitored by PCa specialist doctors, > and asking the same question there. The URL is [quoted text clipped - 6 lines] > > Richard Slessor  SignatureLeonard Evens len@math.northwestern.edu 847-491-5537 Dept. of Mathematics, Northwestern Univ., Evanston, IL 60208 > > I'd be a bit worried too with a PSA around 20 and a fairly low free > > PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 26 lines] > that in many cases treatment of early prostate cancer is curative and > that the side effects can be dealt with. Of course, NPR reported on one American study which showed no differences after 8 years, but the study continues. You are the only person I have ever heard call a biopsy a safe and easy procedure. Stories do circulate among men who have other things to say. >>>I'd be a bit worried too with a PSA around 20 and a fairly low free >>>PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 31 lines] > heard call a biopsy a safe and easy procedure. Stories do circulate among > men who have other things to say. My doctor told me that if done properly biopsy is a relatively safe and easy procedure. I checked up on the incidence of complications, and although I don't remember the figures now, I found that he was right. The main complication is infection, but that is controlled by use of antibiotics. Different men react differently to the procedure as to any medical procedure, but most men find it unpleasant but not unbearably so. It is roughly comparable to a typical dental procedure for most of us. If you look at the reports in alt.support.cancer.prostate, you will find lots of anecdotal information supporting what I just said, though of course anecdotal information is always suspect. Many other common medical procedures, in my experience, are much worse, but are still routinely performed. Here is a list of some I've experienced: flexible sigmoidoscopy, endoscopy, MRI of lower back, nerve conduction tests (a real killer). air contrast barium enema Xray of colon, and many others I've forgotten. Note that George Conklin's personal ignorance about the procedure is not evidence of anything. Stories of course circulate about practically everything, but that isn't evidence. For any man who has reason to believe he may have prostate cancer, let me say again. In the great bulk of cases, if done by a competent urologist, the procedure is safe and while not pleasant, far from unbearable. There is no reason to be afraid of it. SignatureLeonard Evens len@math.northwestern.edu 847-491-5537 Dept. of Mathematics, Northwestern Univ., Evanston, IL 60208 > >>>I'd be a bit worried too with a PSA around 20 and a fairly low free > >>>PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 34 lines] > My doctor told me that if done properly biopsy is a relatively safe and > easy procedure. As in, "You don't feel pain. You just feel PRESSURE." >>>>>I'd be a bit worried too with a PSA around 20 and a fairly low free >>>>>PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 45 lines] > > As in, "You don't feel pain. You just feel PRESSURE." I felt a sharp pain when he injected an anesthetic, much like what I feel when my dentist inject novocaine. After that I felt something when each sample was taken. It wasn't particularly pleasant, but I wouldn't describe it as pain. After he had taken 12 samples, I was happy that he was done. Afterwards, I had some soreness because the procedure excacerbated my hemmorhoids, but that receded pretty quickly. All told I would rate the discomfort on a scale of about 3. On the other other hand, the flexible sigmoidoscopies I've had I would rate at 10 plus. Men of course may differ in how they react to different procedures. Anecdotal evidence from many men who have reported their experiences in alt.support.cancer.prostate is that my experience was fairly typical. The whole thing is no big deal. There are a few men who find it very unpleasant. Such men would probably be better off having it done under sedation. I'm not sure what the purpose of your continuing this discussion is. It is just not true that biopsy is either o a dangerous or particularly painful procedure. The "danger" that most opponents of PSA testing see in biopsies is that the biopsy may be positive and hence invariably lead to invasive treatment, the effectiveness of which they question. SignatureLeonard Evens len@math.northwestern.edu 847-491-5537 Dept. of Mathematics, Northwestern Univ., Evanston, IL 60208 I have performed my last 25 prostate biopsies under local anesthesia with 1% lidocaine. Patients have tolerated them pretty well, and they don't remember the procedure as a trully painful event. Under these conditions me and my collegues at the hospital are taking as many samples as necessary to obtain 100 mm of core at least. We haven't seen important side effect, exept for a patient who has an acute urinary retention (he had severe obstructive symptoms before the procedure). I'm not sure about how much a doppler ultrasound can help. What is clear among urologists is that the sensivity of prostate biopsy depends on the amount of tissue (cores) and in the > > > I'd be a bit worried too with a PSA around 20 and a fairly low free > > > PSA - but a radical prostatectomy is nasty, and only a prospect of [quoted text clipped - 31 lines] > heard call a biopsy a safe and easy procedure. Stories do circulate among > men who have other things to say. "Manuel Díaz" <mdiazcSINESTO2000@hotmail.com> wrote in message news:<bkic61$fht$1@news1.nivel5.cl>... snip...I'm not sure about how much a doppler ultrasound can help...snip Color doppler identifies regions of higher vascularity (e.g. tumors). This allows the practitioner to direct the biopsy needle at these suspicious areas, rather than just randomly sample prostate tissue. Peer reviewed articles in medical journals demonstrate the statistically improved efficacy of color doppler at identifying prostate tumors during biopsy...Ron the evidence is strong enough to make it the standard of care?? i know what a color doppler is, and why it would be suitable to "see" the tumors in order to improve biopsy accuracy. I wonder if you can post the references of such a dramatic statement. > "Manuel D?az" <mdiazcSINESTO2000@hotmail.com> wrote in message news:<bkic61$fht$1@news1.nivel5.cl>... > snip...I'm not sure about how much a doppler ultrasound can > help...snip [quoted text clipped - 5 lines] > statistically improved efficacy of color doppler at identifying > prostate tumors during biopsy...Ron "Manuel Díaz" <mdiazcSINESTO2000@hotmail.com> wrote in message news:<bkl178$dbp$1@news1.nivel5.cl>... > the evidence is strong enough to make it the standard of care?? i know what > a color doppler is, and why it would be suitable to "see" the tumors in > order to improve biopsy accuracy. I wonder if you can post the references of > such a dramatic statement. Hi Manuel...Here is a reference that makes the point. At present, color doppler is only practiced by a few clinicians such as Drs. Bahn, Dattoli, Lee and a few others. I suspect that it is not more widely practiced at this time because 1) it is relatively new, 2) it is relatively expensive, 3) like all technologies it continues to evolve (for example, I've heard that in europe it is now being practiced with some iron nano particles [think I got that right] that further enhance contrast) making purchase of current generation equipment even more questionable from a cost recovery basis and 4) it requires considerable training to use it as intended. Journal article aside, I've read a number of posts where men with elevated PSAs have had repeated (2-3) negative biopsies. They then have a color doppler with Fred Lee or one of the other experts and the PCa is located...Ron Eur Urol 2003 Jul;44(1):21-31 Value of Power Doppler and 3D Vascular Sonography as a Method for Diagnosis and Staging of Prostate Cancer. Sauvain JL, Palascak P, Bourscheid D, Chabi C, Atassi A, Bremon JM, Palascak R Medical Imaging Center, 6 passage Jules Didier, 70000, Vesoul, France [Medline record in process] OBJECTIVES: To compare the value of Power Doppler Sonography (PDS) and B mode sonography in the diagnosis of prostate cancer and to assess the value of PDS to specify capsular effraction of the cancer. PATIENTS AND METHODS: 323 patients were investigated: 41 control subjects allowed the establishment of normal vascular semiology and 282 patients with suspected cancer (PSA >4ng/ml). Power Doppler Sonography with 3D reconstruction was used to describe Power Doppler Sonography features of normal or abnormal vessels. Three types of blood supply(a: regular avascular posterior peripheral margin, b: irregular avascular posterior peripheral margin, c: vessels crossing the posterior peripheral margin) were described as a function of the presumed stage of cancer (a: intraprostatic, b: undetermined, c: extraprostatic). Comparison with histology was performed on random biopsies without Doppler (282 cases) (median PSA level = 15.8ng/ml), on second biopsies indicated with PDS (72 cases), and radical prostatectomy specimens (63 cases). RESULTS: A cancer was diagnosed in 157 of the 282 patients (55.7%) with suspected cancer. The overall sensitivity of PDS in the initial diagnosis of prostatic cancer was 92.4% and its specificity was 72% (versus 87.9% and 57.6% for sonography alone respectively). The negative predictive value of PDS was elevated to 80.6% (p<0.0001). Targeting area presenting abnormal blood flow in any part of the prostate was useful to detect isoechoic or lesions in patients with first negative biopsy results (in 41 of 72 targeted patients with first negative biopsies with PDS a cancer was diagnosed: 58% of these cancers had less than 3 positive biopsies and 34% only one positive biopsy). The 3 vascular types a, b, c were evaluated prospectively in the detection of capsular effraction. The presence or absence of vessels crossing the capsule to determine an extracapsular extension was a significant sign (p<0.0001). Capsular effraction was detected in 3 of the 27 cases (11%) of type a cancer and in 16 of the 18 cases (87%) of type c cancer. CONCLUSION: PDS improves the accuracy of echographic imaging in the diagnosis of cancer. Combining first sextant biopsies and targeted areas presenting abnormal blood flow using PDS can increase cancer detection with an optimized number of biopsy cores. The risk of extracapsular involvement can be evaluated by the presence of vessels perforating the capsule. I have read a few articles about it, and i agree that it is a promising tool, but still far from being the standard. A much more dramatic role plays a "good" biopsy, in terms of representing the peripheral zone and having a high number of cores (100 mm at least), what should be done under local anesthesia, which is easy and cheap. In our experience, with an average sample of 135 mm (obtained with an average of 26 cores) we have detected prostate adenocarcinoma in 48% of patients with PSA of 4 ng/dl and over. That is dramatic. > "Manuel D?az" <mdiazcSINESTO2000@hotmail.com> wrote in message news:<bkl178$dbp$1@news1.nivel5.cl>... > > the evidence is strong enough to make it the standard of care?? i know what > > a color doppler is, and why it would be suitable to "see" the tumors in [quoted text clipped - 74 lines] > number of biopsy cores. The risk of extracapsular involvement can be > evaluated by the presence of vessels perforating the capsule. > My father, who is 66 now, has the following history: > [quoted text clipped - 20 lines] > > -Alex Alex...I've read of a number of people in a similar situation (e.g. rising PSA, but negative biopsies). One thing that seems to be commonly recommended as a next step is to have a color doppler ultrasound performed. Dr. Fred Lee, Dr. Dattoli, Dr. Bahn and others are among the practicioners of this art. Do a Google search on "color doppler ultrasound" for starters. If color doppler doesn't show anything, then people generally have it repeated every 6-12 months...Good luck, Ron > Alex...I've read of a number of people in a similar situation (e.g. > rising PSA, but negative biopsies). One thing that seems to be > commonly recommended as a next step is to have a color doppler > ultrasound performed. Dr. Fred Lee, Dr. Dattoli, Dr. Bahn I can personally attest to having a color doppler done by Dr. Bahn after 2 biopsies 6 months apart by my local urologist were negative. Dr. Bahn found nothing suspicious. Believe me a 12 sample biopsy while not painful is no fun. Dr. Bahn charges less than $300 for ultrasound and less than $300 for biopsy if needed. My local uro was charging my insurance $1000 and me $100 each time. Dr. Bahn is in Ventura, Calif. Dr. Lee is in Michigan outside Detroit. Dr. Dattoli is in Florida. Size of prostate has much to do with PSA numbers. Normal prostate is 30cc. A 60 cc prostate can put out twice the PSA as a normal one. You need to know the size of your prostate to know if the PSA is elevated above the acceptable limit. Vern PSA in June was 6.6, July 13.0 and August 10.5 Ron wrote: > Alex...I've read of a number of people in a similar situation (e.g. > rising PSA, but negative biopsies). One thing that seems to be [quoted text clipped - 4 lines] > anything, then people generally have it repeated every 6-12 > months... Yes, I suspect that is what the doctors on p2p would recommend. By the way, just in case there was any misunderstanding, I wasn't saying that Alex's father should give up on biopsies - only that the next one should be done by an expert such as Fred Lee, probably together with the doppler. I also wasn't decrying RP in the right context - but having one when you weren't even sure you had PCa definitely wouldn't be the right context! Richard Slessor > Ron wrote: > [quoted text clipped - 20 lines] > > Richard Slessor There is a procedure called an open prostatectomy which is sometimes used to treat BPH. It is not the same as a radical prostatectomy which is used to treat prostate cancer. So it is possible we are talking about apples and oranges here. SignatureLeonard Evens len@math.northwestern.edu 847-491-5537 Dept. of Mathematics, Northwestern Univ., Evanston, IL 60208 |
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