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High PSA but Negative Biopsy, questions

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Posted 1/15/2014 5:21 AM (GMT 0)
Hi All,

Last year, my friend had his PSA go from 4 - 10 and he was subsequently diagnosed with Stage 4 PCa at 58, although a medium grade and the doc expect hormones alone to stop it for 5-8 years, with many more treatments available after that (and new ones in the pipeline). But it scared me enough to get a PSA test, and it was 3.5.

I'm 50 yrs old now. My PSA was last checked in 2009, and it was 2 then. Then last summer it was 3.5 and my GP doc figured I have BPH/Prostatitis. I asked what we could do besides wait a year and he said we could recheck in 3 months or so after I take some anti-inflammatories. I really didnt take them religiously but got tested anyway 4 months later this fall, and it was 7 (about 4 months after the 3.5). Also, a urine test for infection came out negative.

Got sent to a board certified and experienced urologist, who said since my father had PCa (cured) at 65, we should do the trus 12 point biopsy. The result, thankfully, was negative with signs of chronic and acute inflammation showing in several samples. Also the ultrasound had showed enlargement, but nothing looked abnormal of what could be seen. Normal DRE as well.

Urologist was not interested in fPSA, PCA3, or a new test "ConfirmMDx" I found in a major news site that tests the biopsy samples for markers and (supposedly) can find cancer not only in the biopsy but nearby.

He wanted me to come back in a year, but gave me the option to be a little more proactive and come back in 6 months for another basic PSA test. He feels that I have prostatitis, and routine PSA tests will tell us if/when another crack at a biopsy is called for. He said if he sees a steady general trend upward, we'll do another biopsy. But what I have now is more like the kind of spike he has often seen with prostatitis.

He also noted that he has many patients with high baseline PSA levels due to benign conditions, and statistically, he is right. A PSA of 7 is only cancer 25% of the time. HOWEVER, biopsy has a false negative of 20%. He said that is the percent of ALL first biopsies. I'm hoping the biopsy and anxious long wait did more than reduce my chances of having PCa from 25% to 20%!

Sooooo.... he feels like we have it covered but I am still unnerved about the situation. These tests are not that great at detecting from what I've read here.

I am wondering what to think... confused

Any thoughts or suggestions greatly appreciated.

Post Edited (JustStarting) : 1/14/2014 10:32:47 PM (GMT-7)

Posted 1/15/2014 5:30 AM (GMT 0)
Your psa has been explained by infection. As your Uro said you have symptoms of prostitis and this is the most likely cause of your high psa.
Posted 1/15/2014 5:50 AM (GMT 0)
Welcome to HW, sorry you need to be talking to us.

BPH and prostatitis both can explain the high PSA. Were you given any medication to treat either?

The fact that there was signs of inflammation in the biopsy would make the URO not that interested in looking for PC. Likely you don't have it.

I think you've got a very smart doc there and wait and do the retest. If it comes in around 7 or lower, you're off the hook.

My brother's URO said the same thing about high PSA. My brother's was 8 when he was first tested and we were told that could be normal because of BPH and other issues. On retesting my brother had a steadily rising PSA and at 10 a biopsy was done which resulted in a DX of PC. Then he did brachy and today is just fine with a PSA dropping very fast. From first PSA to treatment was about 9 months - that was a bit fast tracking it.

Hang in there and keep us updated on your progress.
Andrew
Posted 1/15/2014 6:07 AM (GMT 0)
Hi Andrew, thanks for the reply. Now is my time to get up to speed on this matter since the monitoring will now be ongoing. I was prescribed no medication. My symptoms (weak urine sometimes) are mild. I kind of prefer to go au natural, because some meds can artificially lower the PSA. If I needed them of course I'd do it, but he didnt even suggest it. I have a copy of the biopsy lab report, it shows "Focal Mild Chronic Inflammation" in 3 of 12 samples, and a 4th shows "Focal Mild Acute and Chronic Inflammation" and the others, one was unreadable, two said "benign prostate tissue. CK903 and P63 show patchy staining for basal cells consistent with a benign diagnosis. control tissues stain appropriately" and the rest just say benign prostate tissue.

I guess I would have felt better with a fPSA test (and will ask for that next visit). These other tests are interesting especially the new ConfirmMDX test (although it's not mentioned by the major maintstream sites yet that I could find).

There are quite a few testimonials on this great site about numerous neg biopsys then finally finding the problem.
Posted 1/15/2014 6:10 AM (GMT 0)
It seems to me a free-PSA and for sure a PCA-3 test would be very useful in your situation.

Is there a University medical center nearby?

Yes, it could be BPH, but why not do the other tests; they might provide some reassurance anyway

Mel

Posted 1/15/2014 6:12 AM (GMT 0)
Hi Mel, he didnt want to do them. So maybe I can just ask my GP whom I know a lot better to order those? I agree, why not. I'd even pay myself if I had to.
Posted 1/15/2014 1:30 PM (GMT 0)
Unfortunately, you're going to have to put up with some uncertainty. Biopsies miss stuff and all the blood tests give merely probabilistic results. On the plus side prostate cancer usually grows slowly so you have time to watch it and, being cancer, it will grow and the PSA trajectory is fairly distinctive so it can't hide forever.

And, if it helps, you did your math wrong with your probabilities. 20 percent of 25 percent is 5 percent. It's still one chance in twenty but it's better than one in five.
Posted 1/15/2014 1:59 PM (GMT 0)
Inflammation can sure cause increased PSA. It can also give really low fPSA. PCA3 would be more specific, but it's a little expensive and wouldn't be done unless the uro's pretty suspicious of PCa. Your uro sounds duly cautious.

Try not to let it get your knickers in a twist. The mind game is just too painful.

I had 3 biopsies over about 18 months for almost exactly the same scenario, with nothing ever but inflammation. My PSA eventually came back down, settling below 2.0 for 3 years in a row. We just had annual checks then, and I finally put off having it checked again.

But..... I do recommend continuing annual PSA checks. Even though now it may only be inflammation, things can happen later, as they can with anyone. The annual trend could alert you early if something does kick up.

In my case I decided the annual PSA anxiety wasn't worth it, and waited four years until I turned 55 to get it checked again. Unfortunately, something unpleasant had in fact developed, and I'll never know if annual checks could have alerted me earlier. Mine was just over my age-adjusted alert level of 4 even then, but the PSA trend might have been indicative.
Posted 1/15/2014 2:54 PM (GMT 0)
Welcome aboard JustStarting! Hopefully you are just visiting us for now.

I had a similar situation around 2000-2004. My PSA was all over the place from 3 to 9 and back down. 2 biopsies and antibiotics turned up nothing.

THEN........... In 2012, after no PSA test for 8 years, it went to 18.5 and a positive for PCa biopsy.

You maybe joining us at later day but maybe not at this time.
Word of advice, keeping having you PSA tested on a regular basis. I went 8 years without a test because I was tired of getting poked, in more ways than one, and coming up with nothing. If I had waited 1 more year before DX, my stats below could have been different.

Keep a log of your PSA results but keep getting tested regularly.

Bill from Florida cool
Posted 1/15/2014 5:43 PM (GMT 0)
Than you guys for the replies. I'm not as reassured as informed. Even though my GP assures me that 50-something PCa is "very rare", I have read far too many cases as well as heard about a good number from asking around of just that. This is also a top occurring cancer for men. This information has convinced me to get PSA every 6 months (its cheap test) and make that a fPSA (why the hell not??). If it stays elevated I might throw in a PCA3 and whatever else there is/will be.

I still realize the majority of elevated PSA cases are not cancer but a sizeable percent in fact IS. Also, as we've seen here, one can have inflammation/BPH PSA issues AND catch cancer too at any point. Since my father was a case at 65 (he's 80 and remains cancer free), all the more risk.

IF I do end up with another biopsy, I'm interested in that "confirmMDX" test http://www.mdxhealth.com/products-and-technology/products/confirmmdx-for-prostate-cancer

With all that being said, prostate cancer is usually caught early and almost 90% of the time can be cured. In the rest of the cases, treatments are getting VERY good at dragging it into an almost chronic condition. My friend (stage 4) was told that just in 2013, a half dozen new drugs have been approved for this, and more treatments are very much in the pipeline. Target RT is getting much more precise as well to zap troublemaker areas, adding to the options. If I catch this, I would rather it be early. Even with all the encouraging treatment progress (as well as miraculous things happening with other cancers using gene therapies, protein science and so on).

Peter, as to the math, that's what I though which is why I asked the specific question of my uro, and he said that its 20% of *all biopsies* that end up missing a cancer that's there. That doesnt sound like 20% of the 25% which would have it statistically at a PSA of 7. That still doesnt sound totally right to me however, but it is what he said. I'll see if I can research it to clarify.

Finally, I'm not afraid of the chance of this disease, actually. Just afraid of not taking a step and later wishing I had. But after reading these replies, etc looks like the 6 month sPSA test regime is a good start. A year is a long time even for what is usually a very slow cancer, when a test like that is so cheap anyway.

Have a great day guys!
Posted 1/15/2014 7:03 PM (GMT 0)
Just,

What he might have been talking about is that additional biopsies do worse and worse at finding cancers that were missed the first time around. That is because there are places in the prostate that are hard to hit with a biopsy gun. So you can't multiply together a bunch of biopsies to get a tiny little risk. Cancers you miss the first time are statistically more likely to be missed the second time, etc.. But since PSA doesn't have much to do with how easy a cancer is to hit with a biopsy needle the two probabilities are reasonably orthogonal and you can multiply the probabilities.

But, like the guys said, get out there and have yourself a life. Don't worry about prostate cancer -- except for once every year or so when you have your PSA checked so it doesn't have time to sneak up on you.
Posted 1/15/2014 7:18 PM (GMT 0)
Just Starting -

I think you have a really good urologist.

You have a clear Dx after your biopsy - prostatitis with BPH, and your PSA pattern is consistent with that. Only a small percentage of chronic prostatitis is curable with antibiotics, but you can try that route. It may take over a month and you may have to try different ones. As for the BPH - 5aris (Proscar and Avodart) should handle that. Even better, they will reset your PSA to a new baseline that will make it more useful for determining if PCa is causing it to rise - although it will still be subject to the peaks and valleys of your relapsing and remitting prostatitis. The other benefit of 5aris is that it is the only medicine proven to prevent PCa.

The other tests (% free PSA and PCA3) may be useful if you didn't have other things going on that are known to cause PSA to rise. The genetic tests are only useful after a positive biopsy, if you are on the fence about AS. There are no biochemical tests that accurately detect PCa before a positive biopsy - they only suggest risk (and not very well at that).

- Allen
Posted 1/16/2014 2:33 AM (GMT 0)
Just Starting -

I read your posts with great interest because I am in the very same situation.

In December, my PSA came in at 5.2, more than two times what it was a year ago (2.3), and my free PSA was less than 10%. I was certain that I have PCa, but I had a biopsy the day after Christmas and the results were negative.

The pathology report noted chronic prostatitis and "foci of mucinous metaplasia" (whatever that is) but no PCa. My Urological oncologist says to come back for another PSA test in six months. We may do the PSA3 test then too.

I'm not sure what else can be done because I understand that the biopsy wrecked havoc with the prostate, so that a couple of months need to pass before any additional testing can be done. In the meantime, I, like you, am stressing out.

I suppose we should relax and enjoy the good news, but that is hard to do given the fairly high false negative rates of biopsies.

Please keep us informed about what you learn and do. Thanks for posting.

Rich
Posted 1/16/2014 3:00 AM (GMT 0)
Hi Rich,

Regarding what can elevate the PSA temporarily such as the biopsy, here I found solid information on what raises it, by how much, and how long it takes to fall back to your real level. For example a biopsy can affect PSA for 2 - 4 weeks before fully falling back. Even a TURP operation's effect lasts only 3 weeks according to this site:

http://www.uptodate.com/contents/screening-for-prostate-cancer



My own research with the nice folks here, and also on the web indicates that first - stay on top of it with the usual PSA tests etc. Second, most (85%) of prostate cancer is caught early when it's curable. Third, both you and I have a low probability of even having it. But it is (while low %) VERY possible. It also could occur later. It can also occur side by side with other issues that raise and lower the PSA, making it harder to figure out. Below is a link with what I think is great info about the various tests they use at NYU, including new imaging etc., and when they use them. (Not for you or me at this point, btw). Also, keep in mind that treatments have much improved and new ones are continuing to appear.

http://prostate-cancer.med.nyu.edu/faqs/faqs-screening-biopsy
Posted 1/16/2014 3:02 AM (GMT 0)
You can order a free psa lab without your doctor's prescription. Just search for online lab tests or something like that. You select the test you want, pay with credit card, and they email you req for labcorp. You go to labcorp and hand them the paper, they draw blood, and you get results in a day or 2.

PCA3 requires special handling, so you have to do that through a doctor. If your doctor is willing to read the instructions and follow them, he just needs to do an "aggressive" dre exam before you provide a urine sample. But the instructions have to be followed exactly or the sample will be rejected.

If I was in your shoes, I would have an MRI if my insurance would pay for it. IMO, a trus biopsy is old technology. Why go in blind when technology is available to target probable cancer locations?
Posted 1/16/2014 3:08 AM (GMT 0)
Please, take your high PSA seriously. I had my first ever PSA test come back at 11.7. The DRE revealed a normal feeling and sized gland. What was thought to just be prostatitis and then chronic prostatitis turned into a dx of PCa, but my biopsy wasn't negative and confirmed it after 3 high ones.

I was dead set against having cancer. A maximum antioxidant consumer, I thought it impossible at age 45 for me to have it. I was wrong. A tough thing to get my head around.

My wish for you is you have a case of prostatitis that can be eradicted with antibiotics. Many men suffer a nasty bout and are just fine. Glad to hear your biopsy was negative.

Here's hoping your next PSA shows a dramatic drop.
Posted 1/16/2014 3:35 AM (GMT 0)
Thanks guys. All good information. I will keep you posted and I hope JustStarting does the same.

Best wishes to everyone on this site.
Posted 1/18/2014 12:56 PM (GMT 0)
I had a similar problem. PSA was 3.8. Subsequent biopsy was negative. 6 months later PSA was 18! No symptoms except decreased semen. Tx with antibiotics. PSA was still 17. Went to major cancer center ....PSA was 8, had MRI and another bx. Negative, some inflammation. So 26 cores over 9 months and no cancer.... 1 year later my PSA is 7. Uro thinks my prostate has been sampled enough, for now.
PSA screening is difficult to do in men with prostatitis.
Posted 1/18/2014 7:54 PM (GMT 0)

starr15 said...
I had a similar problem. PSA was 3.8. Subsequent biopsy was negative. 6 months later PSA was 18! No symptoms except decreased semen. Tx with antibiotics. PSA was still 17. Went to major cancer center ....PSA was 8, had MRI and another bx. Negative, some inflammation. So 26 cores over 9 months and no cancer.... 1 year later my PSA is 7. Uro thinks my prostate has been sampled enough, for now.
PSA screening is difficult to do in men with prostatitis.

I had same problem as you. AS I have chronic prostatitis, the PSA's bounce all over. Two biopsies a couple years ago were negative. Antibiotics are useless against prostatitis. They come when they want to come and they leave when they want to leave. MY urologist put me on Cipro for six months and I got an infection while I was taking it. I also have prostadynia. I rely a lot on my urologists talented finger.Maybe I should have an MRI-What do you guys think?
Posted 1/23/2014 9:42 PM (GMT 0)
I'm 62. Diet, health, nutrition, exercise have been important to me for 25 years. I have had BPH for 15 years but have never had prostate inflammation, prostatitis, no family history, etc. My urine and blood tests are all in range except PSA, which has dribbled higher each year by one, two, three points to 27.5, putting me in the 70% cancer category. I've had 3 biopsies, the last one 6 years ago. All negative. My urinary symptoms have basically disappeared over the years, but I do take 8mg Cardura at night.

My new urologist prescribed a PSA test with %free PSA. The test came back showing 23% free PSA, putting me in the less than 10% cancer category. He said no need for a biopsy. The doctor went so far as to say that I had a healthier prostate than most men my age, the best words I've heard on my health in my adult life, seriously.

PSA can be a head scratcher, even for the doctors. He suggested that perhaps I have a naturally large prostate. I've often thought my problem may be diet oriented. So, starting over a year ago I intake only organic meats and most vegs to eliminate any chemical antagonist. I have also tripled down on my dietary anti-oxidant intake. Maybe that will help the cause.

If anyone has feedback, feel free.
Posted 11/18/2015 4:59 PM (GMT 0)
Hi Rick HHH;
Im in a similar situation. 3Tmri fusion biopsy at UCLA showed chronic and acute inflammation. Prostate large.
Free%=21. How are you doing?

Thanks,

Markom3
Posted 10/5/2016 8:58 PM (GMT 0)
57-year-old

I've had 2 biopsies (both negative) in 2010 and 2011. PSA has increased slightly from 4.3 in 2010 to 5.0 this year. Scheduled to see urologist in a week.
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