How is PC diagnosed? Must there be a biopsy?

I've searched all over the internet and all forums are for after diagnosis. Hubby had an enlarged prostate and bladder about 10 years ago and now has ongoing abdominal pain. He's had an ultrasound and a series of tests and sees a urologist next week for PSA results so the Dr must suspect it's prostate related. I'd like to have as much knowledge as possible prior to the appointment. I know it could be anything, but wonder if his PSA is elevated whether a biopsy will be done or if an MRI might be less invasive, especially as he's on low dose aspirin. We're in Australia so we have different protocols and insurance rules.
Having been through breast cancer myself including chemotherapy and radiation I am familiar with some things but most of the PC terms are new to me so I copied the abbreviations in this forum. I also read about the gleason score. Anyway, no point in getting too far ahead of ourselves.

Ok, thanks Halbert. I realise the PSA can mean anything but didn't know if a biopsy was normal as I've read some negative things about it. I wonder how they know where to put the needle or if they could miss it? Mine was nearly missed as nothing showed on a mammogram and everyone thought it wasn't cancer and the needle barely touched it.

I'll do some more searching for biopsy information.

The most common biopsy technique is the TRUS (trans-rectal ultrasound) biopsy, where an ultrasound probe in placed in the rectum, to guide the biopsy. Usually 12 samples are taken in a specific pattern...4 rows of three samples, top to bottom, left to right. It's unpleasant, but done fully awake or mildly sedated. For me, the worst part was the antibiotic injection in the butt.

A newer, less random method involves going through the perineum with an MRI coil in the rectum and collecting a great number of samples, up to 50 or more. This type is done under anesthesia and takes a while.

Hello Rainbird!

I only joined this forum a few days ago because frankly I was standing on the edge, but these guys talked me down and saved my sanity, something for which I will forever be in their debt. I'm very early in my story, may even yet dodge the bullet, but I too am staring the prospect of biopsy in the face. In the tradition of giving back, I'll share what little I know; which may help inform your questions to the URO etc.

I'm under the care of Johns Hopkins Hospital in the USA, a not inconsiderable stroke of luck. My PSA is swinging all over the place and my rectal exam (DRE) concluded 'enlarged' (but evidently still squishy, which is a good thing). Their automatic next step at this point is a 3Tesla MRI. From what I understand a 1.5Tesla MRI machine is not really up to the job of mapping the prostate (resolution-wise) and so the 3T is the 'ginormous magnet of choice'. These (newer) machines cannot be found everywhere yet, so you may need to dig into where in Aus' you can find one.

The 3T MRI looks for lesions (as far as I can make out this is a less scary way of saying tumor, a somewhat semantic difference). The outcome of this can be "yes we see a lesion (or more)" or "we see nothing". If the answer is yes then you are likely looking at Prostate Cancer, if the answer is no, then you 'may' be looking at prostate cancer as even the 3T MRI cannot spot the smallest of small.

NOTE: Prostate cancer comes in different flavors and levels of progression... not all of them are the scary monster by a long chalk.

Given this, a biopsy is pretty much automatic if they see something and may well be advised even if they don't, but PSA is up. As has been said, the most accurate (but still fallible) test is the biopsy. What the MRI does is help tell them where to stand the most chance of hitting the suspicious cells vs. (literally) stabbing in the dark. I liken it to the old schoolboy game of 'Battleships'. If you call a grid reference and get a hit, then you know where to keep firing!

BTW, Hopkins no longer uses a rectal coil (automatically), saying that with 3T, their folks are good enough to see what's going on without the anal intruder. Personally, I don't really care, if I'm going to go through this, I want the most expensive, high-tech stuff shoved up my ass that I can get!!!

The thing I can add here is the 'Fusion Biopsy'. In the Fusion Biopsy, a clever piece of software (by Varian I think), takes the MRI data/image and overlays the location of any suspicious lesions onto the 'real-time' Trans Rectal UltraSound (TRUS) imaging used during the collection of the biopsy samples themselves. Essentially it overlays a map for them of where the battleship(s) are likely hiding so that they can target more accurately. They do also put some shots around the general prostate volume to get an idea of what the MRI 'may' have missed.

Your mission, should you choose to accept it is (IMHO) to try and find a 3T magnet and ideally a Fusion Biopsy in sunny Aus' ; if the URO sucks his teeth over your man's PSA and other data points when you meet. Fusion isn't the only way this can be done... but if you can find it, it helps.

If I have any of that tech' wrong the folks here will point you right for sure...

Hat's off to you Rainbird... you came here. If you can encourage hubby to join you here, it will help, these guys are strong and have broad shoulders, they will help to carry him (and you); sometimes even we 'men' have to wise-up and let that happen.

PS: There are a couple of newer, more specific PSA 'type' blood tests you could seek out. I was given one called the Prostate Health Index (PHI). This is really one entry point into Active Surveillance, if you score less than 27, you win and get AS, if not, you proceed to Biopsy, via MRI if possible. I scored a solid 47.5, lucky me!

PPS: I did a quick search, looks like 'Men's Health Melbourne' have Fusion capability (at least).

Paul

That's excellent information Paul. Thanks for taking the time to explain it. Unfortunately Australia has too few MRI machines to go around. I insisted on having one for my unusual form of breast cancer 6 years ago and had to pay for it myself, but at least the surgeon knew where the tumour was before he applied the scalpel. Anyway I'll do a search to see what comes up in Aus. I doubt hubby will want to join any forum as he isn't the type, but at least I will be able to follow the appointment better now so we can discuss it afterwards.
I hope you're able to have successful treatment and remission. I have hope that the new antibody treatments will be a game changer for all cancers and not too far in the future before they are used.
Well, off to bed as it's early hours here in eastern Australia.

Rainbird,

The only way that is proven is via a biopsy, but that doesn't mean that one should rush into a biopsy, unless the PSA is really high (even then, prostatitis or urinary retention are more common causes) and/or lumps are felt. In fact, I think it's a good idea to eliminate other, more likely sources of high PSA before getting a biopsy.

In most places in the world, standard protocol is a TRUS-guided biopsy for the first biopsy. If it is negative, and about 2/3 are, then they look for signs of something progressing, like rising PSA. If PC is still suspected in spite of the first negative biopsy, they can bring out the big guns and use mpMRI targeting or a transperineal template biopsy. But that is seldom done on a first biopsy.

PHI, Prostate Health Index, is a simple blood test that is cheap and more accurate than PSA. It's been used in Europe for years, and more recently became available in the US. I don't know if it's available in OZ. It is less sensitive to distortion from prostatitis or BPH (enlarged prostate). In the US, a urine test called PCA3 is approved only after a first negative biopsy when suspicion remains. There are other biochemical (e.g., 4KScore, TMPRSS2:ERG fusion) and genetic tests (e.g., Prolaris and Oncotype Dx) that are very expensive.

Since your husband has an enlarged prostate (BPH), one option to consider is taking a medication like Proscar or Avodart that shrinks the prostate over time and lowers the PSA output from the BPH. This has a secondary advantage of rendering PSA a better indicator of PC. If the PSA does not go down, or continues to rise while on it, PC is suspected. Also, it is the only drug proven to prevent PC.

Mine started with a psa score of 5.3 during a wellness exam. They told me to contact my Dr. He sent me to a oncologist who did a prostate exam and could feel something. From there we did a ultrasound biopsy. Which came back positive for prostate cancer. The good thing is we caught it early before it spread. After doing a lot of research I opted to do image guided radiation therapy. Which I finished my treatments at the end of june. So now I'm waiting for my psa test to see how things went.

What concerns us is the abdominal pain which he's had for about 6 to 8 weeks. This isn't listed as a symptom of benign or cancerous enlargement. As it was his presenting symptom and his local Dr is sending him to an Urologist after different tests, he must think the two are related. If it's not referred pain then it sounds more like mets or something unrelated. His bladder barely emptied at all during the ultrasound so he is retaining a lot of urine, yet he sleeps through the night and doesn't have the usual incontinence or frequency. I'm wondering if the pain is from the bladder pressing on something. Maybe he has scarring or adhesions from his complicated appendix surgery from 10 years ago as the pain is in that area, though why it should suddenly happen now I can't imagine.
He is retired so gets lots of rest though he does plenty around our small property but spreads it out over the week. Thanks to all for your concern and help.

Hi Greg. We're south of Sydney. We don't have private insurance so have to take what we're offered. He seems to have excellent credentials including robotic surgery so we'll see how it goes.

Good news. His PSA was very low so they want him to try medication for 6 weeks, then if there's no improvement in the bladder retention he'll need a re-bore as his Dr calls it. Then we will see if the abdominal pain goes. So no reason for biopsies.
Greg, we had our first baby using private insurance then found the public patients paid nothing while we got a large bill. So we dropped the insurance. They seem to shoot themselves in the foot when they charge high premiums then charge us an arm and a leg in hospital fees. Thanks for all your advice which we will keep in mind if needed.
Reading about PC has given me a new understanding of what you guys go through and I do hope some new treatment or cure is around the corner.