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Medical Forum / Diseases and Disorders / Prostate Cancer / December 2004need to rush repeat biopsy?
I am a 61 year-old male. Father had a RP at age of 70 and is still going strong at 86. I have been diagnosed with BHP for years and have had a slightly increasing PSA each year. My PSA last year was 3.68 with 16.3% free. Size was estimated @ 30-35gm. DRE was negative. I had a biopsy and it was negative. This year my PSA (I took a cancellation and the blood work was done ~30 min. after the DRE) was 6.1 with 23.9% free. Size estimate was down to 20 gm. (same Dr.) DRE was negative. The Dr. suggested another PSA to rule out lab error (and in my mind, effects of DRE) As soon as I hung up with the Dr. (6 days after initial test), I went to another lab and had blood drawn. This time the PSA was 5.1. Free PSA was not measured. I had an ejaculation the morning of the 2nd test. What could be the reason for decrease in Prostate size? The Dr. wants to do another biopsy next week. I was very uncomfortable during the latter stages of the 1st biopsy and requested sedation, but the nurse said that this Dr. doesn't provide them. Should I start over? Is there a need to rush this test? Should I wait another month and have a PSA free from effects of DRE & ejaculation and perhaps look for a Dr. that will provide sedation? Will I have to endure a biopsy every year if my PSA continues to rise? Lots of questions - I would appreciate your thoughts! > I am a 61 year-old male. Father had a RP at age of 70 and is still > going strong at 86. I have been diagnosed with BHP for years and have > had a slightly increasing PSA each year. Having a father who developed prostate cancer at age 70 and no other relatives who had it means your risk, while perhaps higher than normal, is not much higher. > My PSA last year was 3.68 with 16.3% free. Size was estimated @ > 30-35gm. DRE was negative. I had a biopsy and it was negative. [quoted text clipped - 6 lines] > lab and had blood drawn. This time the PSA was 5.1. Free PSA was not > measured. I had an ejaculation the morning of the 2nd test. Th ejaculation would explain the increase. > What could be the reason for decrease in Prostate size? > [quoted text clipped - 5 lines] > another month and have a PSA free from effects of DRE & ejaculation > and perhaps look for a Dr. that will provide sedation? I think you should find one doctor you like and stick with him. You may have prostate cancer, but the case for it is not dramatic. Talk to your doctor about how long you should wait for another PSA test and perhaps another biopsy. Your free PSAs don't as yet any reason for panicing, so take your time. Of course, in picking a urologist who may do a biopsy, choosing one who uses a local anesthetic would be an advantage, but even without anesthetic, most men find it tolerable. Are you sure the nurse was referring to local anesthesia? > Will I have to endure a biopsy every year if my PSA continues to rise? This is a judgement your doctor will have to make. Usually, they will several repeat biopsies only in case the free PSA percentage is low. But there could be other factors involved. If you do have prostate cancer, the chances that a well thought out strategy for testing will detect it while it is still confined to the prostate and curable. But to empahsize it again, you really have to talk to a qualified medical expert rather than trying to get information over the internet. > Lots of questions - I would appreciate your thoughts! >> Will I have to endure a biopsy every year if my PSA continues to rise? > > This is a judgement your doctor will have to make. The short answer is that unless you walk away from the whole process, YES. > in picking a urologist who may do a biopsy, > choosing one who uses a local anesthetic would be an advantage, but even > without anesthetic, most men find it tolerable. That's nice for them, but this gentleman has already indicated that he does not. Being in the same category (six cores I can stand, 8 was seriously unpleasant and I shudder to think what 14 would be like), I think it needs pointing out that "most men" doesn't mean much in contexts like this. "Most men" don't have prostate cancer in the first place, but does that mean we probably don't either?. >>in picking a urologist who may do a biopsy, >>choosing one who uses a local anesthetic would be an advantage, but even [quoted text clipped - 6 lines] > like this. "Most men" don't have prostate cancer in the first place, but > does that mean we probably don't either?. If you already know that you find the biopsy procedure very painful, then you should definitely find a urologist who uses an anesthetic. If it is really bad for you, you might see if you can arrage to be sedated during the procedure. My urologist did use anesthesia, and the whole procedure was not quite as bad as common dental procedures. I've had my share of those, both with and without anesthesia, and I can stand them without anesthesia but I am happier with it. > > My PSA last year was 3.68 with 16.3% free. Size was estimated @ > > 30-35gm. DRE was negative. I had a biopsy and it was negative. [quoted text clipped - 8 lines] > > **The ejaculation would explain the increase**. Are you serious? And by what %? Do you have any references concerning this fact? I don't think I saw anything to that effect in Walsh. But I may be mistaken. >>>My PSA last year was 3.68 with 16.3% free. Size was estimated @ >>>30-35gm. DRE was negative. I had a biopsy and it was negative. [quoted text clipped - 14 lines] > I don't think I saw anything to that effect in Walsh. > But I may be mistaken. Your editing gives the mistaken impression that I am the person responsible for the statements. You should be more careful about such things in the future. Nothing in the quoted material originated with me. However, I believe it is common knowledge that ejaculation before a PSA test can raise the values. See Walsh's Guide to Surviving Prostate Cancer, p. 128. It says "Sexual activity can elevate PSA as well: PSA levels can increase by as much as 41 percent in less than an hour after ejaculation. (Thus is is wise to abstain from having sex for two days before you are due to have your PSA tested." On p. 127, the same reference says that PSA values can be increased by a DRE. >> > My PSA last year was 3.68 with 16.3% free. Size was estimated @ >> > 30-35gm. DRE was negative. I had a biopsy and it was negative. [quoted text clipped - 14 lines] >I don't think I saw anything to that effect in Walsh. >But I may be mistaken. Just to throw my .02 in, his PSA rose either 1.42 or 2.42 depending on which test you choose. Seems like too much velocity and too much overall PSA in either case to ignore. In his place I'd consult with the Dr. about the second PSA results and go along with any recommendations about another biopsy. As 'delightful" as these biopsies are, delay is worse if there is a problem. FWIW YMMV DFB (who will likely be getting his second biopsy in January) "When a legislature undertakes to proscribe the exercise of a citizen's constitutional rights it acts lawlessly and the citizen can take matters into his own hands and proceed on the basis that such a law is no law at all." - Justice William O. Douglas >I am a 61 year-old male. Father had a RP at age of 70 and is still >going strong at 86. I have been diagnosed with BHP for years and have [quoted text clipped - 24 lines] > >Lots of questions - I would appreciate your thoughts! I communicated with my Dr. via his nurse and he said it would be OK to have another PSA performed in a month. It will be free of DRE & ejaculation factors, and I'll feel better about dealing with the results. I'm still going to look for a urologist that will administer a sedative, though. My uro told me that there was an anesthetic in the lubricant that they used for the biopsy. Insterting the probe was not painful, but it did hurt when he moved it around in my colon. Once placed there was no pain. The actual biopsy, if memory serves he took ten, did not hurt at all, which did surprise me. No stinging, nothing. I know, however, that other men have reported quite a bit of discomfort when the biopsy specimens were taken. So, again we are all different. No explaining why it hurts for one person and not for another. It only makes sense for you to find a doctor that will take your needs into consideration and give you some sedative during the procedure, expecially if you are going to be subjected to multiple biopsies. Good luck to you. Thank you. David S. >>I am a 61 year-old male. Father had a RP at age of 70 and is still >>going strong at 86. I have been diagnosed with BHP for years and have [quoted text clipped - 30 lines] >results. I'm still going to look for a urologist that will administer >a sedative, though. > I communicated with my Dr. via his nurse and he said it would be OK to > have another PSA performed in a month. It will be free of DRE & > ejaculation factors, and I'll feel better about dealing with the > results. I'm still going to look for a urologist that will administer > a sedative, though. First, I must wonder about the competence of a uro who would have blood drawn for a PSA test immediately after a DRE and/or ejaculation. It was a waste of time and money. Even I know better. Second, I don't know where it is written that a patient must suffer pain when it can be alleviated/prevented. And in the case of a biopsy, it can easily be. I know; I've undergone two prostate biopsies under sedation administered at my request. It appears that the uro is careless of the best interests of his patient, as well as ignorant. In view of what he has done (and failed to do), I'd fire him. I've fired three medics over the years, and will not hesitate to do it again if dissatisfied. The "I am God" attitude of some medics is a disgrace. The patient should never relinquish to anyone his ultimate authority to decide on his treatment. I know that, too, because I have done so and regretted it. Regards, Steve J __ "Never give in--never, never, never, never, in nothing great or small, large or petty, never give in except to convictions of honour and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy.'' --Sir Winston Leonard Spencer Churchill >>I am a 61 year-old male. Father had a RP at age of 70 and is still >>going strong at 86. I have been diagnosed with BHP for years and have [quoted text clipped - 30 lines] >results. I'm still going to look for a urologist that will administer >a sedative, though. Update: Had another PSA (free of DRE & sexual factors) and this time it's 3.5/14%. Dr. says we will wait 6 months and retest. I'm relieved for now and in case I need another biopsy, I have obtained a referral to a Urologist who sedates his patients. Thanks for all your input. Ken > Had another PSA (free of DRE & sexual factors) and this time it's > 3.5/14%. Dr. says we will wait 6 months and retest. I'm relieved for > now and in case I need another biopsy, I have obtained a referral to a > Urologist who sedates his patients. Good luck. I've had five biopsies without anaesthetic or sedation, and they aren't bad. Going to the dentist for filling or root canal is worse. I prefer to avoid any unnecessary medical procedures such as sedation because it's just one more thing that can go wrong. Cheers, Lech If this doctor was doing his job he would be culturing your prostatic fluid and treating you for an infection which is most likely what you have rather than sitting around waiting for this to develop into prostate cancer. I learned about this in Dr. Hennenfent's book. ABSOLUTELY UNBELIEVABLE! Regards, Everett > >>I am a 61 year-old male. Father had a RP at age of 70 and is still > >>going strong at 86. I have been diagnosed with BHP for years and have [quoted text clipped - 41 lines] > > Ken > If this doctor was doing his job he would be culturing your prostatic > fluid and treating you for an infection which is most likely what you > have rather than sitting around waiting for this to develop into > prostate cancer. I learned about this in Dr. Hennenfent's book. There was no evidence that I had an infection, and there was very strong evidence that I had prostate cancer following the biopsy. That was confirmed by the pathologist after the prostate was removed. There are often difficult cases in which a man, often an older man, has an elevated PSA. There are various causes of rises in PSA which are more likely than prostate cancer, including BPH and prostatitis. Good primary care physicians and urologists are well aware of that. Certainly prostatitis is one possibility, and it may be that in some cases it can be detected by culturing the prostatic fluid. I don't know why your urologists didn't want to do that. Perhaps they were incompetent, or perhaps they had a good reason based on their education and clincial experience. I am pretty confident that my urologist knows what he is doing, so i take his advice. If there is something that I've read somewhere or other than is not consistent with what he tells me, I ask him about it. So far he has always satisfied me by his response. But let me note that as I noted previously a biopsy is not really a big deal. You have managed to scare yourself into believing that all sorts of dire things could happen from one, but I don't think that is the case. A biopsy might very well eliminate the possibility of prostate cancer. If my PSA was behaving suspciciously, I would actually be more concerned about the possibility of having prostate cancer than I would be of adverse consequences from a biopsy. I wouldn't want to second guess my doctors by going out a reading some book on a subject I don't have the qualifications to understand appropriately. > cancer. If my PSA was behaving suspciciously, I would actually be more > concerned about the possibility of having prostate cancer than I would > be of adverse consequences from a biopsy. I wouldn't want to second > guess my doctors by going out a reading some book on a subject I don't > have the qualifications to understand appropriately. You pretty much reflect my own thoughts on the matter. Cheers, Lech "Leonard Evens" <len@math.northwestern.edu> wrote in message news:veqdnZKRKYYCfzDcRVn- A biopsy might very well eliminate the possibility of prostate > cancer. You know this is not true Len. Most people here say that 6 cores or whatever is just a small sample. Keep looking and every one of us will have cancer, certainly by 80 and even what is it 8% at age 20-30? > "Leonard Evens" <len@math.northwestern.edu> wrote in message > news:veqdnZKRKYYCfzDcRVn- [quoted text clipped - 4 lines] > > You know this is not true Len. All such statments are relative. Of course, a biopsy can't eliminate the possibility of prostate cancer. If nothing else, cancer can develop at a later point in time. Most biospies are done with 10-12 cores these days and some with more. The 6 core figure is out of date for much current practice. Research studies have estimated the likelihood of a biopsy missing a cancer. I forget what it is, but is is relatively low. In some cases, further biospies are done. As you may know, the probability of missing the cancer on two biopsies, assuming they are independent events, is the square of the probability of missing it on one try, so it is much smaller. Of course, it is possible there is a systematic error because the cancer is not in the usual location near the periphery. But there exist figures on the likelihood of that also. Finally, by using free PSA measurements, it is often possible to distinguish cases where repeated biopsies are merited from those where they are not. So to be precise, a negative biopsy doesn't literally eliminate the possibility of prostate cancer, but it may reduce the likelihood below the level where you feel you need to take it seriously. This is not different from other medical tests. My primary care physician has referred me twice for stress echo cardiograms which came up neagative. Thaat doesn't eliminate the possibility of significant coronary heart disease, but it reduces the likelihood enough that I don't worry about it much. > Most people here say that 6 cores or > whatever is just a small sample. Keep looking and every one of us will have > cancer, certainly by 80 and even what is it 8% at age 20-30? Again you are referring to autopsy data. Men in their 20s are not given PSA tests, and only rarely would such a man be referred for a biopsy because of something like a digital rectal examination finding or some other unusual situation. There is no evidence whatsoever that if biopsies were done on living men in their 20s that 8 percent of them would show evidence of prostate cancer. If you can find any data supporting such a conclusion---which applies to living men and not to autopsies---then give me a reference. Actually, I would like a reference to the 8 percent figure for autopsy data. Biopsies should be rare for men in their 80s unless there are explicit symptoms. But they are done in some cases. I doubt very much that almost all of them show evidence of prostate cancer. Again, if you can find a study which indicates that biopsies in living men over 80 almost always show evidence of prostate cancer, please tell me where to find it. > > "Leonard Evens" <len@math.northwestern.edu> wrote in message > > news:veqdnZKRKYYCfzDcRVn- [quoted text clipped - 37 lines] > Again you are referring to autopsy data. Men in their 20s are not > given PSA tests, But if they were given a biopsy, then cancer would be discovered. Ditto for 60 and so forth. You say that every one of us will have prostate cancer by age 80 and I am in agreement with this but why do you and anyone out there think this is true? Regards, Everett > You know this is not true Len. Most people here say that 6 cores or > whatever is just a small sample. Keep looking and every one of us will have > cancer, certainly by 80 and even what is it 8% at age 20-30? > You say that every one of us will have prostate cancer by age 80 and I > am in agreement with this but why do you and anyone out there think [quoted text clipped - 5 lines] > > whatever is just a small sample. Keep looking and every one of us will have > > cancer, certainly by 80 and even what is it 8% at age 20-30? Autopsy results say it is true. > You say that every one of us will have prostate cancer by age 80 and I > am in agreement with this but why do you and anyone out there think > this is true? Never mind him. Why do YOU agree with the statement? The argument for that position is based on a few autopsy studies which vary widely in their conclusions. Have you looked at any of them? It seems to me that what you can conclude from autopsy studies that most men whose cancer has been discovered by a pathologist after death don't need to have their cancers treated. :-) It doesn't tell us much about whether or not cancer detected in living men needs to be treated. Be that as it may, it does seem true that the incidence of prostate cancer goes up with age. Since prostate cancer generally takes a while to cause problems for the patient, it is almost never appropriate to treat prostate cancer detected in a many over 80 aggressively in an attempt to cure the cancer. For such men, watchful waiting followed by hormone therapy if needed is the appropriate approach. And it is also standard practice in the real world. Radical prostatectomies are almost never performed on men over 80. > Regards, > Everett > >> You know this is not true Len. Most people here say that 6 cores or >>whatever is just a small sample. Keep looking and every one of us will have >>cancer, certainly by 80 and even what is it 8% at age 20-30? > > You say that every one of us will have prostate cancer by age 80 and I > > am in agreement with this but why do you and anyone out there think [quoted text clipped - 9 lines] > need to have their cancers treated. :-) It doesn't tell us much about > whether or not cancer detected in living men needs to be treated. That statement applies to both groups equally. If you look, you find, at any age. >>>You say that every one of us will have prostate cancer by age 80 and I >>>am in agreement with this but why do you and anyone out there think [quoted text clipped - 12 lines] > That statement applies to both groups equally. If you look, you find, > at any age. What does that mean? Do you mean that if you look you always find it, or do you mean that if you look you will sometimes find it. The second alternative is true and not particularly surprising. After all, no one disputes the fact that some men actually have prostate cancer. The first interpretation is just plain wrong. For example, the PTPT study biopsied several thousand men with supposedly "normal" PSAs (below 3 or 4 ng/ml). They did in fact find evidence of prostate cancer in about 15 percent of them. But they didn't find it in 85 percent of them. You ask why I agree with the statement that every one of us will have prostate cancer by age 80. It's quite obvious if you have had any experience with urologists like I have and everyone I have spoke with. If you go into a typical urologist office and the urologist feels you're not a candidate for surgery or some procedure he can bill a nice fee for he will ignore your problem whether it be prostatitis or BPH and will wait until the underlying problem turns into something he can bill for like surgery. I read about this in Dr. Hennenfent's book. With such atrocious behavior from the urology profession is it any wonder that everyone of us will have prostate cancer sooner or later. WAKE-UP!!!! Regards, Everett > > > You say that every one of us will have prostate cancer by age 80 and I > > > am in agreement with this but why do you and anyone out there think > > > this is true? > > > > Never mind him. Why do YOU agree with the statement? > You ask why I agree with the statement that every one of us will have > prostate cancer by age 80. It's quite obvious if you have had any [quoted text clipped - 6 lines] > With such atrocious behavior from the urology profession is it any > wonder that everyone of us will have prostate cancer sooner or later. You seem to have had some unfortunate interactions with your urologist or urologists. I get along fine with my urologist, and I have confidence that he wouldn't recommend something that he didn't feel was necessary. He is not at all mercenary. As I mentioned previously, I referred a friend to him who has a problem with prostatitis, and he didn't recommend a biopsy but treated the prostatitis, as best I can tell successfully. I know several other men who have not been pressured into haven't biopsies by their urologists. Perhaps I am fortunate in my choices of doctors. But none of them seems to be motivated by monetary concerns when ordering tests or treatment. In a couple of cases, my primary care physician wanted me to have some expensive tests I though were unnecessary. In one of those cases, he was right, and I'm sorry I didn't follow his advice immediately. My gallstones would have been diagnosed a year earlier, and I really did have them. That is not in doubt. In the other case he was wrong, but I did follow his advice and the test he ordered was prudent. I didn't have coronary heart disease, but I could have had it and it would have required treatment. However, it should be noted that because of the way HMOs work, it probably cost his group money to order those tests. So if anything, he would have been motivated not to order them. That sort of arrangment is not uncommon. In fact, I'm not sure my urologist actually earned much extra by performing surgery on me. I doubt if he had much monetary motivation for doing extra unneeded surgeries. > WAKE-UP!!!! > Regards, [quoted text clipped - 5 lines] >>> >>>Never mind him. Why do YOU agree with the statement? > > > > You say that every one of us will have prostate cancer by age 80 and I > > > > am in agreement with this but why do you and anyone out there think > > > > this is true? > > > > > > Never mind him. Why do YOU agree with the statement? > You ask why I agree with the statement that every one of us will have > prostate cancer by age 80. It's quite obvious if you have had any [quoted text clipped - 9 lines] > Regards, > Everett Perhaps 'do no harm' is a good idea after all Everett. > But let me note that as I noted previously a biopsy is not really a big > deal. You have managed to scare yourself into believing that all sorts of > dire things could happen from one, but I don't think that is the case. There _are_ all sorts of dire things that can happen from one -- but all the probabilities I've seen associated with sequelae like that have been very small. I myself would (will, I'll need one in 2 years after seeding) unhesitatingly agree to undergo the biopsy to lessen the uncertainty. But people differ. My wife's cardiologist wants an angiogram; 1% of people who have one fail to survive it; she refuses. There has been adequate discussion; hers is an informed choice that I think we have to respect. The key is "informed." There's an awful lot of FUD (fear, uncertainty and doubt, generally lacking justification) out there, and one owes it to onesself to get good information from qualified sources before deciding. | G r e g L o u i s | gpg public key: 0x400B1AA86D9E3E64 | | http://www.bgl.nu/~glouis | (on my website or any keyserver) | | http://wecanstopspam.org in signatures helps fight junk email. | >>But let me note that as I noted previously a biopsy is not really a big >>deal. You have managed to scare yourself into believing that all sorts of [quoted text clipped - 13 lines] > doubt, generally lacking justification) out there, and one owes it to > onesself to get good information from qualified sources before deciding. I agree with you completely about informed choice. I'm surprised about the figure of 1 percent that you give. It seems awfully high too me. I wonder if the death rate from the procedure is related to the degree of coronary heart disease in the patient. If those 1 percent are largely people who are already quite ill and who have a high probability of dying from the disease, then even a high death rate might not be sufficient to suggest avoiding the procedure. Instead of the overall death rate from the procedure, I would want to know an estimate for it for me in my condition and if the procedure is done by my doctor. I would then compare it to the likelihood that I have coronary heart disease and will die of it in the relative short term. You have to do a fairly complex calculation in any individual case to determine if it is worth taking the risk, and that may be why most people just take their doctor's advice. The doctor should have sophisticated tools available to estimate the various likelihoods so he/she can explain them to the patient, but I suspect that they seldom do. For comparison, the likelihood of dying during a radical prostatectomy or shortly afterward is anywhere from half a percent or less to over one percent. But this depends a lot on the patient, the surgeon, and the surgical facility. Most of the patients who do die have some serious medical problem. In my case, I was in quite good health, and I my surgeon had a good record in this respect. So I considered the risk of death from the surgery in my case as being so remote that it wasn't worth thinking about. But I could easily have been scared by a 1 percent figure if I had taken that as appropriate for me. > I'm surprised about the figure of 1 percent that you give. It seems > awfully high too me. I wonder if the death rate from the procedure is > related to the degree of coronary heart disease in the patient. If > those 1 percent are largely people who are already quite ill and who > have a high probability of dying from the disease, then even a high > death rate might not be sufficient to suggest avoiding the procedure. Just so. The cardiologist opines, without the information the angiogram would presumably yield, that the patient has a 1% or greater, but probably not much greater, chance of being too sick to treat with the cardiology equivalent of watchful waiting (which actually involves considerable pharmacological intervention). Since the degree of risk of the procedure for this patient could only be estimated accurately if we knew the results the procedure is to elicit, that overall 1% is about all we have to go on. He advises taking the risk; the patient, however, feels that she would prefer a 2-5% chance of a heart attack down the road to a deliberate 1% risk now.  SignatureGreg |
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