Need Help-Biopsy Decission

Hi Everyone,

I am new here and I really could use some help. My husband kind of skipped a few steps and I am a little freaked out. He has not been to a doctor forever and has no prmary care which I have been begging for years for him to get. Because he just lost two family members in the last 3 months it opened his eyes a little. Because of not having a primary care, he would drive by a prostate center everyday on the way home. This prompeted him to go online and check it out and proceed to make an appointment online. I did not know about any of this until after he went. He also felt it necesarry not to tell me that he has been having frequent urination for a long time. He ended up in a great place, just usually referred by a urologist to this center(more of a cancer center,but very well known). He met with the director of the Center Dr. Brian Moran, who did do a PSA and DRE of course. His PSA of 5 was not good and his DRE was abnormal (felt a hard srea on right side), so a biopsy was reccomended espcially with family history. I totally agree with this and propaby any urologist would as well

This is where things get a little tricky. This center specializes in STRP or steotatical tranperinial biopsy(saturation biopsy) not the standard 12 core. From what I have read this is normally done afte 1 or 2 negative biopsy's with rising PSA. This is not the standard but is it more definitive as to not have to leapfrog from one to another?  I did call and talk to his nurse who said that yes it is used more for hidden cancers after a negative, but feels this will be more standardarized in the future. Less infection and more mapping of locations(but a lot more cores 30-40). Dr. Moran is very nice and very open to questions, he is just out of town for a few days. 

They want to do this type of biopsy in 2-3 weeks and I am tyring to get my husband to at least see a urologist to get an opinion about the type of biopsy. I realize that 99% of urologist stick with the 12 core TRUS? I talked to a cancer survivor whos urologist used the transrectal but took 24 cores which was very interesting to me, but his doctor was out of the area. Seems that the saturation biopsy in not indicated. Ultimately I want my husband to choose what he is most comforable with. I think he feels like this will be more difinitve, but I can not find any research that it is for an" initial" biopsy. Although nobody likes to go through multiple biopsy's maybe he is afraid of the false negative %. Someone on this site used Dr. Cornfields name , so I called and they where so nice, even wanted to get him in before his other biopsy appointment. I am sure this Dr. does the standard 12 core, but at least we get another opinion. Going to check with my husband to see if he will go.

Sorry for such a long post, just tyring to get answers fast since my husband has the blinders on and is moving full steam ahead. Of course the goal is to figure out what we are dealing with, which will hopefully happen no matte which one is done. Any and all information is welcome

LAN

Any help on this would be so appreciated. I saw some older posts with people who used Dr Moran

Thank Ausboy,

Except for the fact that the doc reccomending saturation was a radiation oncologist and not Uro, little concern of this being a little biased because of the center.

Nosywife

nosywife, don't feel like your husband is an exception about not seeing a doctor. I was and am very similar to him. I hadn't seen a doctor for many years and what I thought was a high blood pressure problem turned into quadruple heart bypass surgery and a 5.2 on a PSA test eventually led to a prostate cancer diagnosis. A couple months after the bypass surgery, I went to a urologist to get the PSA reading investigated and had a suspicious DRE so that with the elevated PSA led to an ultrasound and 12 core biopsy. The ultrasound revealed a badly enlarged prostate and the biopsy showed 1 of 12 cores positive for G6 cancer. I don't think that in your husband's case a 12 or 24 core biopsy would make a lot of difference in determining what is going on but a 24 or more core biopsy would probably help the oncologist by more accurately locating areas of cancer if cancer is found.

Would a positive DRE and PSA of 5 warrant a biopsy? Yes, it surely would. The lump on the DRE is the decisive factor in it. If it happens that the biopsy shows cancer, then any treatment from that part forward will be in the hands of another doctor, unless that urologist is a surgeon also. Not all uro's are surgeons. So, if it is positive you will have to move to either a surgeon, a radiation oncologist, or even a mdeical oncologist for really advanced cases. You'll want to do both, in your decision making process. A non-surgeon uro's is ok for the referrals and the after care, once whatever treatment is chosen. The only problem with bypassing the uro and being dealing directly with the rad. onco first is if he/she pushes their treatment above others and won't give referrals onward.

However, every older man and woman should have a urologist in their line of specialist doctors, with or without cancer. Our plumbing ages also, and we may need one for something else. Since your husband has neglected this for so long, having a uro that he can trust will fit into his new, more aware health plan. So, there's no reason not to engage the uro, keep the rad. guy and continue. IF IT WERE ME, I wouldn't worry so much about which biopsy, rather make sure insurance will cover it, and that the rad guy is open minded enough to help with referrals in the decision making process, in the meantime I'd be interviewing some uro's to get a 'handler' for my future decisions and care. Just my opinion........

Noisy wife,
You did not mention your husband's age. A psa of 5 is abnormal, but fairly common in a lot of men without PC. Also a hard DRE is very subjective. If the doctor felt a nodule then it would be an entirely different matter. The symptoms your husband is experiencing are very common and consistant with BPH.
You are correct about the saturation biopsy. It is an excellent tool, but is costly and has more probability of negative side effects. It is normally given after several negative biopsies with a continued rising psa or as a staging tool for someone considering Active Survelience or focal therapy for low risk cancer. For a first biopsy it may be overkill. There is no question that it is more accurrate than a standard 12 core biopsy.
Before a biopsy many knowledgable doctors give a free psa test and a PCA3 test and calculate a psa density. If these are abnormal then a biopsy is given. If normal, a biopsy is given only after futher psa tests that show psa continuing to climb.
Many doctors are too quick to pull the biopsy trigger, as is evidenced by the over 1 million biopsies given annually. 75% of these are negative.
I'm not at all anti biopsy as I have had 13, including a saturation biopsy. A biopsy should be given only after other tests such as a free psa and a PCA3 and a psa density have eliminated the most common causes of a high psa which is BPH or a minor infection. A consistant rising psa over time is a red flag that must be fully investigated. A one time slightly abnormal psa without any other confirming information should be closely monitored.
You should also be aware that with a saturation biopsy the chance of finding an indolant cancer is about the same % as his age. Most men over 50 have this type of cancer and it will never hurt you, so you have to be prepared to address this issue and you should do it before the biopsy when you are not affected emotionally by the finding of an indolant cancer.
In the end it is your decision, but you should at least have all the information both pro and con in order to make that decision.
JohnT

The following article "What Every Doctor Treating Male Patients Should Know" by Dr Strum is an excellent article on how to tell prostate cancer from BPH.

http://www.prostate-cancer.org/pcricms/node/119

"Invasion of the Prostate Snatchers" by Dr Mark Scholz has an excellent chapter on when to get a biopsy and when not to.

Both will give you more information and questions to address with your doctor before making a decision.

Good luck

JohnT

My husband didn't have a PSA number to start with either, and it was 5 when he was sent to uro. He recommended the 12 core biopsy also, DRE showed one small hard area on prostate.
He had only one out of 12 positive but it was a Gleason 9, even on 2nd and 3rd slides sent to Bostwick labs. The cancer had invaded the seminal vessel and margins. robotically removed, HT therapy, shots and pills, then radiation, then chemo, now Zytiga.
Mets to spine and tailbone, a real pain In the butt..litterally..
Get Dr. Patrick Walsh's book and read....read...then re..read. Great advise. Wishing you and your husband the best. Hang in there, as a caregiver, it's been very difficult, thank god for my daughters to support us.
LuAn

even though a biopsy is warrented would it still be a good idea to see this Dr. cornfield who is a surgical urologist or other urologist not only for a seond opinion on a first time biopsy being Saturation or STRP? Also would it not be a good idea like you said to get the free psa and other tests first before any biopsy , which ever biopy he chooses? is going on DRE and PSA good enough? You already know that if he went the regular course of family doctor to uro we wouldn't be having this conversation, knowing uro would do 12 core(standard). We do plan to ask the radiologist oncologist these questions as well. He is open minded and am sure would give referrals but since his specialty is Bracheatherapy(sp?) I was assuming he might be staging and also that is why they do this type of biopsy over the other. By the way, 13 biopsys? I have never heard of that many, please tell me if I am crossing the line, but can I ask why so many. Here we are worried about one!

John T,

Great info. Is this done with the biopsy or instead of? I have not heard of anything replacing a biopsy all together as far as diagnosing. Do I ask the urologist doing the biopsy if they offer this and of course is it covered by insurance?

Nosy Wife,
No question is crossing the line on this forum. We are here to help and nothing is off limits if it relates to PC. In response to your question My psa kept rising for 10 years until it got to 40. After 12 biopsies and an MRIS which were all negative I finally got a color doppler ultrasound that showed a suspicious area in the anterior. Anteriors are extremely hard to biopsy. I had another CDU from an expert that had the skill to biopsy that area and he found the tumor. My 12th biopsy had discovered indolant cancer and my 13th, which was the CDU, found the real culprit of the high psa.
The CDU can be with a biopsy or without. If a suspicious area is seen it will be biopsied. Some interventional radiologists will take a small random biopsy and others will only biopsy if they see something. It depends on the radiologist.
I don't know where you are located, but Dr Fred Lee in Rochester MN, Dr Duke Bahn in Ventura Ca, or the Dattoli Center in Sarasota are the best places to get a CDU. There may be others more local, but the skill of the radiologist are very important and these three Drs have proven to be some of the most skilled in this area.

PSA 5 is usually a trigger for a biopsy but not a saturation biopsy. Biopsy's are relatively safe but not risk-free and it stands to reason that any risk must increase with the amount of cores taken. I would not get such a biopsy over a 12 core biopsy without a very good reason. It wouldn't hurt to get a second opinion.

Bohemond,

Thanks for the support. I am so glad to see that you are doing so well. Of course the big fear is if it is there is it contained. That is very scary because you see people with very high Gleason with no spreading and some low that has, so it is confusing.

John T: Thanks for the info. I will ask, but doubt that we will get CDU the first time out. I can't believe you went that long with that high of a PSA and couldn't find the bugger till CDU. What does Combidex Clear mean? I see you went with seed(Brach?). The Radiology Oncologist that wants to do a steostatic transperinial biopsy, that is his specialty.

Dreamerboy: Thanks, that is why this is so hard. It is not idicated, but as you can see from 142's response you never know. I do have an appointment with Dr Cornfields office for Friday, so I hope to get some more answers there.

142: This is what I am talking about. When I read your post to my husband, I am sure he would pick the stauration biopsy and say" see, this would be better". How did you find the Gleason 9 if your 12 core revealed 8?
Here is another twist for everyone. If you tests showed Geason 7, but didn't know you had 9, your treatment options might change drastically. Don't your considerations for your type of treatment rely on those numbers?
More cores might be the standard soon. It already changed from 6 to 12 with the % of false negatives. I really hope they can come up with a diagnositc tool that is even better than what they have now. If you where in my husbands shoes knowing what you know now, would you have done a saturation biopsy out of gate? Of couse in your case if was the difference between 6 and 12, but still?

Everyone: You all have been so helpful and the Biopsy question needs to be explored more. The only URO wanting to get my husband in ASAP is Dr. Cornfield. He is a top doc of 2012 and patients award winner 2011, but his expertise in very much like Catalona and is open surgery. Hard to believe open surgery for an option this day and age, when there is DiVinci? He is a surgen, but I am hoping he can spread some light on the biopsy question. Doubt my husband would ever want open surgery if a treatment is needed, but good to get info anyway.

I could use all of your help if you don't mind, that would be to give me a list of biopsy questions to ask the doctor who wants to perform STRP and for Dr. Corfield, who I suspecct goes the standard 12 core. Again, just because it is not warrented, does it mean its not better? Let's assume that our insurance covers both. My head is spinning and if some of the great questions I know I can get here are in writing, I can take it with us to our appt. I am really not trying to sway my husban either way, again I would never forgive myself if he chose something different because of me and something worse was never detected. Just want him to hear another side from a URO and then decide. Maybe the URO splits the difference with 24 cores:). Let the questions begin. Thanks again

John T

If you are still out there. Did you do the saturation biopsy as part of staging only? Did the Saturation biopsy show anything, or was that negative as well? Is a Saturation or STRP biopsy going to be necessary anyway if Bracheatherapy might be choice of treatment?

I guess what I am getting at and will probably ask the URO that we are seeing for a second opinoin on the biopsy, is if you do the standard 12 core and it is positve, then you decide on seeds for treatment, will you then have to have saturation done anyway? Just wondering

I have heard of some URO's doing more than 12 cores, sometimes as many as 20, but not 40-50 like STRP. I know this is still done transrectally and not transperinial that is completely under. Why do some Uro's decide this and when might that be Indicated? I was assuming that would be with more than one negative 12 core and rising psa as well? Too many variables here. Thanks again