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PSA rising/Free PSA falling....advice for newcomer.

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Posted 2/4/2015 1:16 PM (GMT 0)
My history:
47 years old

PSA 2.6 in November 2012
12 core Biopsy negative January 2013

PSA 4.26 June 2014
Free PSA 10% June 2014
20 core biopsy negative August 2014 (though there was evidence of HGPIN in one area)

PSA 4.57 February 2015
Free PSA 7% February 2015

Just got these latest results online this morning. I meet with my doctor on Monday to review. I was pretty secure after my 20 core biopsy that there was no cancer but the rising and falling numbers has me concerned. Should I be asking for another biopsy so soon? As a smart patient, what should I be bringing to the appointment with me on Monday? I respect your advice as I know you have all been through these tests so many times before. I want to do what's in my best interest.

Thank you!

Post Edited (ToddW) : 2/4/2015 6:24:42 AM (GMT-7)

Posted 2/4/2015 1:44 PM (GMT 0)
Welcome Todd! I have read where you don't want to see your Free PSA to be <10% however, a Prostate infection can raise PSA and lower Free PSA. You could be looking at an infection which you should rule out with antibiotics. Other folks will chime in soon with more recommendations! Hang in there!

Cheers, Doug
Posted 2/4/2015 2:01 PM (GMT 0)
Thank you, Doug.....

I should have mentioned that my doc was attempting to treat this as an infection. As recently as a week before this biopsy I was on a four week course of Levaquin.
Posted 2/4/2015 2:10 PM (GMT 0)
Todd I think it's best to discuss with your Doctor on Monday, I certainly wouldn't worry (too much) at this stage especially with that biopsy report. Might just need another antibiotic.

Cheers, Doug
Posted 2/4/2015 2:10 PM (GMT 0)
Also quite possible the biopsies missed the cancer.
Posted 2/4/2015 2:54 PM (GMT 0)
I was so anxious before the last biopsy because of the low free PSA but felt fairly confident with the number of cores taken that any cancer would have been found. Before this 20 core biopsy my doc had mentioned the possibility of an MRI guided biopsy if the PSA continued to rise. I really appreciate all of your input. Thank you!!
Posted 2/4/2015 4:28 PM (GMT 0)
Todd, I'm no expert, but maybe when you meet with your Dr, ask about a 3Tesla Multi Parametric MRI. It may pick up something missed by the biopsy? Also next time he takes Psa ask about a PCA3 which is a urine test.
Posted 2/4/2015 4:42 PM (GMT 0)
Thank you for the information and suggestion. I am currently seeing a urologist at The Cleveland Clinic who I am very happy with him. He had mentioned that if my numbers continued to rise he would consider an MRI guided biopsy so maybe that's next. It does help to have all of your information before my visit. I do appreciate it all so much..
Posted 2/4/2015 5:46 PM (GMT 0)
Welcome to HW, sorry you need to be here.

I think you really need to look into the MRI guided biopsy. The standard 12 core biopsy is a bit random.

Hang in there and keep us updated on your progress,
Andrew
Posted 2/4/2015 7:04 PM (GMT 0)
Thanks, Andrew. I'm very fortunate that my Doc is just amazing. After a 20 core biopsy in August I had no problems, no pain during the procedure and I was informed of everything he was doing to me as it happened. Very different from my first biopsy. So I'm glad that if I have to go through this again I am in good hands. I'll be honest....the 7% free psa scares me but I guess I'll know more on Monday.
Posted 2/4/2015 7:51 PM (GMT 0)
% free PSA is affected by a lot of things - many false positives. Ask your Uro to try PHI:
www.myinnovativelab.com/prostate-cancer/
Posted 2/9/2015 8:12 PM (GMT 0)
Just wanted to update everyone on this. My urologist scheduled me for an MRI guided biopsy. I go for the MRI on Wednesday and the biopsy procedure on March 4th. Hopefully this will give me a definitive answer. Thanks again to everyone for their advice and help!! I'll keep you updated!!
Posted 2/9/2015 9:40 PM (GMT 0)

Todd,

The biopsy after the mp-mri should be contingent on the mri finding suspicious tumors. In my case,  I 've had 3 mp-MRIs taken. The biopsies that were scheduled in conjunction with  the MRIs were cancelled when the MRIs showed negative results.

Posted 2/9/2015 10:58 PM (GMT 0)
Thank you, yes. I was informed that if there were no suspicious areas they would not do the biopsy.
Posted 2/10/2015 12:22 AM (GMT 0)
Allen,

Doesn't Walsh more or less say that <15% free PSA is almost certainly cancer and probably aggressive..not that he is the last word...but. I wonder of the specificity of PHI at 65% is really that much better than free PSA at 55%..or something like that. Does that small increase mean a lot?
Posted 2/10/2015 12:43 AM (GMT 0)
oops..make that 18 and 26 percent, I was thinking PPV.
Posted 2/10/2015 4:30 AM (GMT 0)
Too many biopsies in succession could possibly cause psa rises. {irritation, inflammation}. no infection, just the other 2. I would take an 8 mos break, get your mind off this, than revisit, the results will be more definitive, is my take. Or you could ride the medical system all the way to a diagnosis of of an indolent cancer that is just budding now. pick your poison. I always go back to an old flames grandmothers advice. "If you look hard enough to find something you don't want, you will find it" Lifes a beach
Posted 2/10/2015 5:45 AM (GMT 0)
sheepguy,

You have to look at both sensitivity and specificity to gauge how good a test is, and both sensitivity and specificity are given relative to a cut-off. So, for example, at a PSA of, say, 2.5, the sensitivity is 41% (it will miss 59% of the men who have cancer), and the specificity is 81% (19% of men who don't have cancer will undergo an unnecessary biopsy). If you set the cut-off lower, it will detect more of the men who have cancer, but it will send more men to unnecessary biopsies. There's no cut-off that does a good job at both. It's a really lousy test.

For % free PSA, let's say you set the cut-off at 10%, with PSA between 4-10. Then it has a sensitivity of 45% (55% of men with PC will be undetected), and the specificity is 95% (only 5% will get unnecessary biopsies). Again, there's no cut-off that does a reasonably good job at both.

For PHI with a cut-off of 35, it has sensitivity of 65% and specificity of 65% - a reasonably good job at both - but not a great job. So it's better than PSA or % free PSA (it includes both), and it's cheap ($60) and guaranteed covered by insurance. Why wouldn't one get it instead of PSA or % free PSA?

- Allen
Posted 2/10/2015 12:37 PM (GMT 0)
I understand what you're saying, Logo but I also think my doc is trying to remove the necessity of serial biopsies by being as comprehensive as possible. (the first 12 core biopsy was performed by my first Uro who I left shortly after that biopsy because of how terribly the procedure went and how little I trusted him) I doubt my .31 rise in PSA since June could be attributed to a biopsy I had last August but maybe I'm wrong. God knows it seems like all of this is a learning process for doctors and patients alike. I think both my doctor and I want to understand why my bloodwork is behaving like the bloodwork of someone who has Prostate Cancer. If the MR scan shows no suspicious areas there will be no biopsy. If this MR Fusion biopsy detects cancer then I guess we then try to make the most informed decision possible on how and whether to treat it. And if it doesn't then I get added to the numbers of people who are cautionary tales of over treatment. Either way I am thankful to have a doctor I trust who includes me in on the decision making process.

Post Edited (ToddW) : 2/10/2015 5:48:29 AM (GMT-7)

Posted 2/10/2015 12:42 PM (GMT 0)
Allen,

Thank you for the most easily understood description of sensitivity and specificity I have ever read. One questions as regards to the specificity of free % psa: Is that 95% an accurate number or one you used for illustrative purposes. Understand I'm not fishing for bad news.....I'm more than willing to be the 5% but I want to know what I'm dealing with so I know what to hope for. Thanks for your time!

Todd
Posted 2/10/2015 1:47 PM (GMT 0)
Allen,
Yup,I do realize there is a sensitivity/specificity relationship. It does indeed sound like PHI is a reasonable test with a fair number of both false negatives and false positives but fewer than anything else. Wouldn't it be nice if we could find a test that gives us more than a 60% chance of accuracy? A rhetorical question.:)
Posted 2/10/2015 1:51 PM (GMT 0)
However, with an already very low freePSA how much diagnostic value will be added by PHI?
Posted 2/12/2015 12:47 PM (GMT 0)
I had my prostate MRI last night at The Cleveland Clinic. From check in until I got my clothes back on it was about two hours. The scan itself lasted about 45 minutes (a little longer than normal since the MRI Specialist wanted to re-do two of the pictures). It was not an unpleasant experience but I wouldn't want to make a habit of it either. I asked about results and they said my doctor should have the radiology report today. My biopsy is scheduled for March 4th. My understanding is that if there is nothing to investigate the biopsy will be cancelled. More waiting.....but I can see how this might become the biopsy protocol of the future. The idea of getting the most accurate results the first time (even though it's a more drawn out process) makes sense to me. And I can't imagine that one MRI guided biopsy costs too terribly much more than traditional biopsies that have to be repeated several times. I'll keep you all posted on the process. Thanks again for your kind words and advice.
Posted 2/28/2015 2:57 PM (GMT 0)
Just a quick update for those of you who were kind enough to respond to this thread:

It's been over two weeks since the MRI and have not gotten results from my doctor but the office has also not cancelled the biopsy scheduled for this coming Wednesday, March 4th so I'm assuming they saw something they want to investigate the the biopsy. I'm hoping he goes over the MRI report before the biopsy so I can understand what they are looking at and the likelihood that it is something serious. I'll keep you all posted when I get home on Wednesday. Thanks again!
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