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Posted 7/2/2014 2:53 AM (GMT 0)
I was recently referred to a urologist because I had a PSA score 4.1 (my free PSA was 18%). He instructed me to have an MRI to be used for a guided biopsy. The MRI came back ambiguous (MRI score of 3) with the radiologist stating that there were several "patchy" responses that she attributed to prostasis or scarring but although unlikely could be caused by the presence of prostate cancer. She measured the dimensions of my prostate and it was quite large - 71 cc. My question is does anyone know how common it is to have prostate cancer when your psa density is as low as mine (0.058)? When I input my numbers (psa density and free psa) into some of the nomograms in the cancer literature I'm coming up with a risk of prostate cancer of around 8%. Obviously I will be talking about this with my urologist. Just wondering if anyone knows of anyone with a cancer diagnosis with numbers similar to mine.
Posted 7/2/2014 3:49 AM (GMT 0)
Drchemy: Wish you did not have to post here but welcome nonetheless. There are others who are brilliant folks that will want to know more info like:
1. What type of MRI did you have?
2. How old are you?
3. What nomograms did you use?
4. What was your previous PSA history? Previous readings and how far apart were they?

Creating a signature like you see many others have done is very helpful.
rest assured you have come to the right place for excellent advice. I wish you the very best.
Posted 7/2/2014 4:20 AM (GMT 0)
How old are you? Does your BPH cause any urinary problems? Is this your first PSA test? As the PSA density revealed, your PSA level is not bad for a man with a 71 gram prostate gland..Having a PSA test every 4 months for a while will establish PSA velocity, how quickly your PSA is rising, an important indicator as to what is going on with your prostate..
Posted 7/2/2014 6:04 PM (GMT 0)
drchemy,

You're right that PSA density is more prognostic of PC, and yours is about a third of normal, so it's looking good. I assume too that your DRE was normal. Since you obviously have BPH, perhaps you can discuss with your doctor taking Proscar or Avodart for about 6 months and retesting. It should lower your PSA by about half (and improve your peeing by shrinking your prostate). Then the PSA becomes a more accurate indicator of PC. It's also been known to regress insignificant amounts of PC, and definitely prevents low grade PC.

MRIs are often indecisive, and two readers may come to very different conclusions. They are much better at detecting high grade aggressive PC, and not all that good at finding insignificant, indolent cancers. That's a good thing because it can help prevent overdetection and overtreatment.

There is a new blood test you can get called PHI that is less affected by BPH. Here's the link.

I think it's always a good idea to eliminate more likely sources of PSA before resorting to biopsy.

- Allen
Posted 7/2/2014 7:38 PM (GMT 0)
Thanks for input everyone. A little more info on my condition. I'm 58. I've had 3 PSA measurements and 3 DRE's (all normal) in the last 6 years
3/2008 2.6
9/2010 3.2
5/2014 4.1 Free PSA of 18%



MRI was done on a 3T magnet with a pelvic coil. Did the usual measurements (T1, T2 and DCE) . Score was a 3 and my prostate measured 71 cc. The nomogram I used was from a journal article ( I can track down the reference if you are really interested) - it was the only nomogram I could find that attempted to incorporate both free PSA and PSA density into a calculation.
The SWOP calculation using only PSA and PSA density I believe yielded a probability of prostate cancer of 12%
Posted 7/4/2014 11:14 PM (GMT 0)
Link to nomogram that calculates risk of prostate cancer using PSA, PSAD and free psa

http://jkms.org/DOIx.php?id=10.3346/jkms.2014.29.3.338
Posted 7/5/2014 12:38 AM (GMT 0)
OK: With your numbers; I would say that your chances are closer to between 25-30% (based on Free and Total PSA). Those were my chances at the time. In my case, my prostate was 67 grams (measured after surgery) and my PSA was 3.3 immediately prior to RP.  My free PSA was 21% and the density was even less than yours at 0.049.  All DRE's were normal.  I had cancer (Gleason 3+4= 7) at biopsy (1 core of 12 positive) but was downgraded to 3+3=6 after surgery (patological results) but cancer was in both lobes.  I was 58 at the time and had been carefully watching my PSA from age 50 slowly rise from 1.5 to 2.6 (at age 58) .  Then once it hit 3.3, I had the biopsy. I had the daVinci RP procedure here in NJ. I had immediate urinary control and it took about 1-1/2 years to get erections good enough for intercourse.  At 3 years (next week) my PSA is < 0.015 and I can have good sex without any drugs at all. Orgasms are the same.  Life is good.  Please remeber, that even if you get diagnosed with PCa, life can still be great.  Catch it sooner rather than later!  But your urologist should prescribe a course in antibiotics to rule out any infection before going any further.  You must be proactive. Good luck. 

Bill K. from NJ

 

Posted 7/5/2014 3:10 AM (GMT 0)
Thanks for the encouragement Z06dude. If I could have the outcome you had I would almost welcome having a low grade tumor. I'm beginning to find some of the symptoms of an enlarged prostate a little annoying and would not mind having it removed if the there was no risk of ED or incontinence. My PSA has grown slowly over the years so I don't thing the recent reading is due to an infection. I do think that many people with PSAD's as low as yours or mine do have prostate cancer but since the volume of the cancer tissue is so small they are never found. Just curious did they ever measure the total volume of the cancer tissue in your prostate after it was removed?


______________________________________________________________________________________

58. 3 PSA measurements and 3 DRE's (all normal) in the last 6 years
3/2008 2.6
9/2010 3.2
5/2014 4.1 Free PSA of 18%
Posted 7/5/2014 4:23 AM (GMT 0)
Dr. Chemy:

If you are interested; here is my story for comparison:

My cancer was 10% of my prostate and as I mentioned it was in both lobes. So even though it turned out be a Gleason 6, I am sure glad that it was found in time and was removed.  During my biopsy, they found 1 of 12 cores positive and that single core was 30%.  I did a tremendous amount of reading on PCa during my 8 years of watching my PSA climb and found that Dr. William Catalona (inventor of the PSA test) was my best guidance during this time.  Reading his many articles on the internet pushed me to be proactive to an extent far greater than my urologist.  As an engineer, I actually plotted each 6 month PSA test to show my urologist the increasing trend and PSA velocity on a graph. According to Dr. Catalona; a PSA of 2.5 should be the number that triggers action. And I was around that for about 4 years.  And he has often said that a man in his 50's should be at about 1.0 PSA maximum. Maybe a little higher for an enlarged organ.

 I believed that my urologist secretly scoffed at me by my worrying and plotting my numbers as well as quoting Dr. Catalona. My wife thought that I was blowing things out of proprtion and that I was obsessed with this.  But in the end, I did have PCa.  I had many things in my favor...a very low density, neg. DRE's, and even the ultrasound guidance during the biopsy showed a uniform prostate- most likely cancer free.  But it was there anyway.

I don't know your age or how much sex means to you.  Sex was very important to me. So I calculated that in order to remove the cancer and still spare as many nerves as possible, having surgery at that time was important.  And a found an experienced surgeon with a good record for maintaining erections.  I was lucky and had immediate urinary control as soon as the catheter was removed. Never used one pad or had even one accident!  I had ED for over a year and simply used 5 mg. daily of generic Cialis, a vacuum pump (2 times a day). I was a quite discouraged with the ED, since I expected to be 100% in about 2 months.  But there is much trauma in the area and it usually takes quite a bit longer.  But at age 61- 1/2 now, my sex life is 95% of what it was when I was 58 and that is perfect if you figure the natural aging process.

I am by no means any type of medical professional. But someone who understands probability and statistics and spent a considerable amount of time reading about PSA / free PSA.  I guess I could have gone the Active Surveilance route, but that is not in my mental nature. I am glad that my prostate is out...nomograms show that after 3 years of being cancer free with my stats; I have a 98+% chance of being cured. I do not get up at night to urinate, and I can pee with the force of a firehouse ( a 6 foot stream!).  Finally, I was very depressed and scared upon finding out that I had PCa.  But I look back now and the ordeal (including the surgery) wasn't bad at all!  You will find that this forum is a great place to get first hand information.  It helped me greatly!

Bill K. from NJ

 

Posted 7/5/2014 4:58 AM (GMT 0)
I've done a lot of math concerning the issue too. My confusion is that a heathy prostate typically excretes about 0.05 ng of psa for every 1 cc of prostate volume. The average prostate at my age has a volume of around 24 cc hence one would expect a PSA reading of about 1.2 for a typical prostate (which is the average reading for an age of 58) . You had a large prostate as do I so one would expect our PSA readings to be quite high. What puzzles me is how so may people can have a PSAD of 0.1 or 0.15 and not have any observable cancer and then someone like yourself (and possibly me) could have such a low PSAD and still have it.
Posted 7/5/2014 5:53 AM (GMT 0)
dr chemy: I can't remember what nomogram that I used to get my figure of 25% PCa probabiltiy, but I remember that I did that calculation. Also my PSA / free PSA blood test stated right on the report print-out that my probabilty was 25%. That was when my PSA was 3.3 and the free PSA was 21%. Years earlier, when my my numbers where in the neighborhood of 2.4 and 33% (free PSA), I remember the probabilty being < 10%. My guess is that your urologist will eventually perform a full biopsy. Reading your previous posts more carefully, I see that you are 58..same as I was. I understand that we both have (had) large prostates and that explains some of the elevation. But you, just like I did, show a troubling upward trend. 4.1 is too high and 18% is too low to simply sit back and FULLY relax in my opinion.

One thing that I didn't mention, is that in my case, my maternal grandfather died at age 67 of PCa. That family history made me follow my PSA numbers even closer. Perhaps that factor explains my situation. This may be where your path and mine diverge! So with that, I hope that you dodge this bullet.

Finally, I can't figure out if you had a biopsy yet. If you have to get one, ask to be "put under". You don't have to be a hero. I was "knocked out" and it was a pleasant sleep with no issues what-so- ever.

Good Luck.
Bill K.
Posted 7/5/2014 5:30 PM (GMT 0)
I'm hoping to get a biopsy in the next month with the trus biopsy system they just got in Austin Texas where they overlay the MRI images onto the TRUS screen so that the urologist can precisely sample suspicious areas seen in the MRI. My reason for asking so many questions about risk factors is that when and MRI is labelled ambiguous the chance of detecting a tumor on the biopsy is about 25% and only 60% of the cancers are detected in the "suspicious" areas . Because my tumor (if it exists) most likely has a small volume ( and hence has a greater likelihood of being missed ) I am just trying to calculate ahead of time whether I should have a second biopsy if the first is negative. Your information has been a help in this regard. I'm finding that people who have cancer with low PSAD's are most likely to have a cancer with a low gleason score.

By the way did you have a TRUS measured volume of your prostate before your surgery? The reference below indicates the volume determined with TRUS tends to be 70% of the actual surgical weight of the prostate. TRUS volumes have typically been used to calculate most of the PSAD values in the literature

http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11049.x/full
Posted 7/5/2014 5:57 PM (GMT 0)
The nice thing about the mpMRI/US fusion biopsy is that it's pretty good at detecting higher grade tumors, and not so good at detecting the insignificant, indolent kinds that we really don't want to detect. Unless you're obsessed with knowing about every last insignificant PC cell, a negative biopsy is good news until you have some other reason for suspecting PC growth.

- Allen
Posted 7/5/2014 8:40 PM (GMT 0)
dr chemy: My prostate was estimated at 50 grams (twice the normal weight) the time of my biopsy and that plus the fact that nothing abnormal was detected with the ultrasound guidance gave me hope (although false) for about 2 weeks while I waited for the results. As mentioned, after surgery, it was physically weighed at 67 grams. I was of the mindset that even if my first biopsy came back negative; I was "not out of the woods". I knew based upon statements that I read from Dr. Catalona that higher PSA's (like ours in our 50's) usually eventually lead to finding PCa. So there would have been many more 3 month PSA tests and at least one more biopsy for me.

But let me stress that if PCa is found, you probably have a great chance of it being totally treatable like mine. It seems like you (just as I did) are trying to use math / probability to predict your outcome. And that can drive you crazy. Try to relax if you can and let the time pass until your biopsy. But I know that this is a tough time and I worried greatly during this period. The day I found out that I had PCa was very bad to say the least. But the next day I met with my surgeon and a plan was laid out for treatment. I became super calm and counted the days until surgery. I remember my surgeon calling and asking if I wanted to move the date up by 3 weeks since there was an earlier opening in the O.R. For sure! I really looked forward the day of surgery to be cancer free. Again, I wish you good luck, and remember that you and your doctor are right on top of things and you are doing all you can do.

Bill K. from NJ
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