Elevated PSA result-Urologist Unconcerned

A close relative of mine (69 yrs old) has had PSA results above 4.0 the last 3 years at annual visit to primary doctor.  Each time, he was given antibiotics for 30 days.  The previous 2 years, the PSA went down to 4.0 after the 30 days and doctor told him to return in 1 year; however, this year, it did not.  His PSA was 4.4 and after 30 days on antibiotics, PSA rose to 5.5.  Finally, his doctor referred him to a urologist.  He went and the urologist said he wasn't concerned until PSA was 10.0 or above since his DRE was normal.  He told him to come back in 1 year.  He didn't even request another PSA test.  We were all surprised.

Also, what possibly could cause the PSA to rise that much (4.4 to 5.5) after being on antibiotics for 30 days?

After my husband's experience with prostate cancer, I know that waiting another year can be dangerous for some.  I am trying to convince him to get another opinion and hopefully, get a biopsy. 

Is this the usual opinion of urologists when the patient is close to 70 years of age?  I know from our experience, that our urologist was not too concerned with my husband's biopsy results as he said that if you were to get cancer, that this was the kind to get.  He even said that knowing that my husband's gleason score was a 7 (4+3).  We decided to change doctors as we didn't want to wait another month to have the cancer talk. 

I agree with Bud and with your concerns.

I do not understand why the urologist would be content to wait a year.

I'd get a second opinion.

Dave

Be concerned. Definitely time for a second opinion and maybe a new urologist. I was initially sent to a urologist several years ago because my PSA went from 1.8 to 4.0. After 3 months, it went down to 2.5 without any antibiotics. He sent me home. A year later, it was back at 4.3. My primary care physician sent me back to my urologist who, upon seeing me, quipped, "We have to go through the motions again, but I'm sure I won't make any money off of you." He gave me an antibiotic this time and told me to return in 4 weeks. In 4 weeks, it was at 4.1. Without hesitation, he scheduled me for a biopsy insisting though that there was probably nothing there since the DRE was fine and I had gone through this before. Lo and behold, the rest is history. Moral of the story, in this particular case, you have to follow up with another doctor even though the DRE was normal. I had no symptoms at all other than the slightly risen PSA, and I ended up having PC.

My GP did the first PSA, and was concerned enough that he asked for a free-PSA. In my case the lab still had the blood sample, so could do it immediately.

It sounds like the urologist is not terribly concerned with the results. I don't see comment about a DRE, which I would have expected from the urologist as a matter of course. 

You likely can get the PSA and free-PSA through your GP/ family doctor.

Sorry, missed the DRE normal comment.

The uro may simply not believe in aggressive testing. This is the other side of the over-treatment discussion. It sounds like a repeat PSA & free PSA after three months might be a good idea at the least, while a different uro also has merit.

This all goes back to some things we repeat often:

- the DRE only feels one part of the prostate

- PSA can be high without cancer, and low with cancer

Post Edited (142) : 3/10/2012 1:31:38 PM (GMT-7)

Frankly, you folks are too nice.

It would seem this borders on malpractice.

Not following up is certainly NOT the standard of care.

4.0 to 5.5 is a red flag.

At least do a Free PSA and then possibly a PCA-3 test

Mel

The PCA-3 test is easy -- do the DRE and then pee into the cup.

It is a genetic test for PC. It is MUCH more accurate than the PSA tests.

I had it done at Umich. a few years ago and it was recently approved by the FDA. It is worth asking about.

Mel

Compiler, I had the PCA-3 test in January. I felt it was an unnecessary detour. Curious what others think of the test. My PSA had been up, and I was ready for a Bx, but uro suggested the PCA-3.

My test was more than just a DRE followed by peeing. It was a vigorous prostate massage of uncomfortable nature. 20 strokes on the right, 20 strokes on the left, and 20 strokes on the bottom, all the while feeling as if you're going to lose it an pee.

And in the end, the test was "inconclusive," which meant "Time for a biopsy."

I realize everyone's experience is different. I'm just reporting mine!

A PCA3 test is pretty close to having a DRE; uncomfortable but not that bad, and definately much better than a biopsy. It is just one piece of information and along with a DRE, psa, free psa, psa velocity, psa density, and psa doubling time can provide a much better picture of your overall situation.
In Mel's case a high PCA3 indicated an agressive strain of PC. In my case a PCA3 of 41 was slightly above normal and even with a psa of 40 indicated a non-agressive strain which was one indicator that a less agressive treatment was in order. It is commonly used to indicate the need for a biopsy when psa and free psa are borderline.
JT

Purgatory, since the PCA3 involves massaging the prostate, and yours is gone, I'd say it's too late... (I believe the test measures certain cells that are shed from the prostate into the urine following a DRE...)

David:

No, it is no longer possible as it requires massaging of the prostate.

Besides, the main use is to determine the probability that you have cancer, which it does very well. But as you said THAT horse has long since fled the barn.

The question as to whether or not it indicates the aggressiveness of the cancer is still an open question although recent studies indicate that the higher the number the more aggressive the cancer. (Unforunately, I seem to be a case in point).

Mel