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newbie w/ high PSA

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Posted 4/21/2016 7:41 AM (GMT 0)
Hi guys,

I'm 55. Brother had PCa and prostatectomy at 49. I have an enlarged prostate, no urination issues. Haven't had a recent DRE but they have always been negative. I had a standard PSA test last week, my first in ~14 years. Came back 10. I ejaculated the morning of the test and doc ordered a retest 10 days later which came back 7.8.

I have a phone consult w/ a urologist in one week. My GP says the usual next step would be biopsy. Would like to hear any insight or suggestions for how to prep for the consult.

I'm in the bay area, w/ Kaiser.
Posted 4/21/2016 1:07 PM (GMT 0)
ask the doc right away for their procedure for the biopsy - usually an enema and a light breakfast. and antibiotic beforehand.

If you get a negative biopsy - check out a research medical center and get an 3T MRI done, to find the tumor. don't waste time in getting another biopsy in 3 months when the MRI will do a great job.
Posted 4/21/2016 1:46 PM (GMT 0)
If this is an initial consult with a uro, I'd expect another DRE as well as possibly a round of Cipro to rule out infection, then a follow up blood draw. Abstain from prior sex, but you know that already! But yes, it appears a biopsy is likely in your future.

I agree with Teddy regarding the 3T MRI. I'd ask about it as well as a fusion biopsy, but you may have to go to a major research/teaching hospital to get one. I also understand sometimes there are insurance issues regarding coverage if a standard biopsy isn't performed first with negative results. But if possible, I'd highly recommend that route over the standard 'blind' biopsy. As far as the biopsy itself goes, it's not really a big deal. The anticipation is normally the worse part! As Teddy said, light breakfast, Fleet enema, antibiotic before, and I think after. You'll probably have some blood in your urine for a few days, and your semen, will, um, not look too good, but the more you can 'clear out your pipes' the sooner that should resolve itself!

Hopefully your brother has recovered well. I assume if your brother had PCa, then someone else in you guys' direct paternal familial line had it, too, like a father, or grandfather?

Good luck.
Posted 4/21/2016 1:51 PM (GMT 0)
Welcome to HW.

You still might want to wait and get one more retest in a few weeks to confirm a rising pattern. That you have PC in the family is a risk factor. Before you schedule a biopsy, the URO should do an exam including a DRE. An enlarged prostate could push your PSA higher and could account for some or all of your current PSA. Remember that PSA isn't a test for cancer. Enlarge prostate, infection, sex, bike riding and so can also increase your PSA. Before doing a biopsy you want to eliminate all other possibilities.

I use Kaiser as well. I am happy with the result I got and think you'll do fine. The only problem with Kaiser is your choice of doctor is limited to theirs, but they do have some good ones on staff. The other problem is location. They don't do everything at each hospital. I asked about doing LDR Brachy and was told I'd have to go to Sacramento to get that.

The biopsy is annoying and uncomfortable, but not too painful. Not much prep - enema, close your eyes and try not to think of what they're shoving up your backside.

Afterwards you'll have blood in your urine and semen for awhile and will be a bit sore for a few days.

Hang in there and keep us updated on your progress,
Andrew
Posted 4/21/2016 5:14 PM (GMT 0)
Before you rush into a biopsy, there are a few things to rule out.

How enlarged is your prostate? If it is 52 cc or larger, then you are putting out a normal amount of PSA for that size prostate. He might also want to try some antibiotics to see if that brings your PSA down. Remember - no ejaculation or bike riding for 48 hours before a PSA.

There's a blood test called "PHI" that is somewhat more specific to prostate cancer than PSA. Last year, a urologist at Kaiser in Southern California told me that they were considering offering it, but I don't know if they have yet or if they are giving it in Northern California. If not, they certainly can do a % free PSA (which is included in PHI).

If you decide on going ahead with a biopsy, there is seldom a need for any fancy imaging (like MRI) on a first biopsy. The reason is because only about a third of biopsies are positive. Advanced imaging is only useful if suspicion remains after a first negative biopsy.

- Allen
Posted 4/21/2016 5:22 PM (GMT 0)
I also think the uro will want to give you a round of Cipro first before you go to the invasiveness of a biopsy. (Not that they're terrible, but if you don't need one that's clearly preferable.) I hope everything works out well for you and that you don't even need to have one. Good luck to you and keep us posted!
Posted 4/21/2016 8:57 PM (GMT 0)
Thanks everyone for the replies, it means a lot to me. I'm pretty isolated. My brother is my only family and he's 3000 miles away in Boston. I'm disabled and don't have many friends.

My brother was diagnosed in 2000 so I started getting PSA tests a couple years after that in my early 40's. First results were in the 2.3-2.6 range. Then I got a 12. Was retested a week later and got a 4. Uro said the 12 was a "bad day at the lab" and lets retest in 6 months. By that time I had switched insurance. I told the story to my new uro and she said she had similar experience w/ spurious results w/ the PSA. She said, "it's a bad test, I don't order it". She gave a DRE and sent me on my way, and that was my last PSA before now.

A few years later enlarged prostate was diagnosed by DRE. My big question is how much could that elevate my PSA?

As for my brother, I respect his decision to treat aggressively, but I've always felt he was over-treated. No other cancer in my family.
Posted 4/21/2016 9:19 PM (GMT 0)
The average PSA output per g or cc of prostate tissue is 0.15.
Posted 4/21/2016 9:33 PM (GMT 0)
...and you have the mpMRI before the biopsy not after... It should be used to identify any lesions that need specific targeting. However, take all those other steps first!
Posted 4/21/2016 9:49 PM (GMT 0)

Tall Allen said...
The average PSA output per g or cc of prostate tissue is 0.15.


OK I haven't had my prostate measured. How is that done, w/ ultrasound?
Posted 4/21/2016 9:59 PM (GMT 0)
Yes. Urologists often have ultrasounds that they do in their office. Some have done so many DREs that they get pretty good at estimating just from that. You said that you have an enlarged prostate - whoever told you that must have estimated its size.

- Allen
Posted 4/21/2016 10:11 PM (GMT 0)
It was over a decade ago and I don't recall being given a size estimate. I'll ask about it next week when I see the new uro.
Posted 4/21/2016 10:52 PM (GMT 0)
Things could very well change in a decade from your last DRE, but those aren't a great indicator, either. An ultrasound measures your prostate size, as will a MRI.

Allen already mentioned the PHI blood test, which I had intended to include in my comment, along with a PCA3 test. Tests of your 'free PSA' are also considered beneficial. A biopsy is still the only procedure that can actually diagnose PCa, but it's good to have as much 'pre-biopsy' stuff in the arsenal before you go that route.

Speaking of those blood tests. in my particular case, other than my PSA numbers, the PCA3 seems to have been the best indicator.

Best of luck....
Posted 4/21/2016 11:27 PM (GMT 0)
MDNative -
You had the PCA3 after a negative biopsy - which is what it's approved for. Insurance usually won't cover it before a first biopsy, and it (and other tests) can be expensive out-of-pocket.

- Allen
Posted 4/22/2016 12:08 AM (GMT 0)
Good point Allen. My suggestion was merely meant to give the OP some info for questions to ask at some point.

Interesting though, I wasn't offered a PHI test until after my 1st biopsy either and after a facilities change. Not that it mattered.

I have no idea what the costs are out of pocket for a PCA3 test, but I find it odd that, as you say, insurance may not cover it (as I've heard regarding the 3T) prior to initial biopsy, and the point of the test is supposed to indicate the probability of detecting cancer _on a biopsy_. Am I the only one that seems to find this thinking backwards? Wouldn't it make more sense to start off with the test, before getting involved in a more expensive biopsy? Same with the 3T?!
Posted 4/22/2016 1:54 AM (GMT 0)
MDNative-

I agree with your logic. However, the makers of the test, for some reason, only did their initial trials on men who'd had a negative biopsy and in whom there was reason to suspect undetected cancer (this was before mpMRIs, used for the same purpose, were as prevalent as they are now). Because of this, the FDA could only approve it for the designation it was tested for, and Medicare and insurance typically only cover what the FDA approves. To get "first test coverage" the manufacturer would have to provide evidence of its usefulness for that indication to the FDA who could then expand its indication based on the new evidence. Someone on here mentioned that the mfr has lowered its price, which might make it affordable to some without insurance coverage. I would always check with insurance for pre-authorization first.

PHI, on the other hand, is approved for use before a first biopsy based on evidence Beckman-Coulter submitted for that. So it is insurance/Medicare covered and it's more affordable anyway. For some reason it's only available from "registered" urologists, though, so the patient has to call Innovative Diagnostic Laboratory to get the name of a local Uro who offers it. I don't know why they add this complication.

Insurance/Medicare coverage is a mystery to me.

- Allen
Posted 4/22/2016 3:29 AM (GMT 0)
This is an article from Dr. Scholz about biopsy.

http://prostatesnatchers.blogspot.com/2015/08/alternatives-to-immediate-prostate.html
Posted 4/22/2016 4:19 AM (GMT 0)
WithHope--interesting what your link states about the need for less biopsy needles with a targeted biopsy after MRI. I got those targeted needles---PLUS the standard 12 needles.

Not that it was a big deal at that point. I already had a wand up my tush!

Maybe it's facility/doctor dependent?
Posted 4/22/2016 6:06 AM (GMT 0)
This video claims that 3T MRI is a way to avoid unnecessary biopsy and is a newer, better technology for following up multiple high PSA readings. They urge men to look for uros who will go this route. Is this realistic?

Post Edited (Platy) : 4/22/2016 12:11:42 AM (GMT-6)

Posted 4/22/2016 4:55 PM (GMT 0)
Daniel Margolis, one of the radiologists who wrote PIRADS II, disagrees with that. He's published studies where the targeted biopsies missed high grade areas that were only detected with random cores. As always, it's better to go with expert opinion than to go with the advice of a medical oncologist who has no specific expertise in this. Saturation biopsies remain the gold standard.

- Allen
Posted 4/23/2016 1:51 PM (GMT 0)
Good luck Platy. Glad you found us. My path is listed in the signature below. I feel I made the right decision to treat how I did. Still have side effects with sex, but there has been some improvement too.
Posted 4/23/2016 2:16 PM (GMT 0)
MDNative and Tall Allen, there was an article published by Johns Hopkins a couple of years ago about the better results with PHI than with PCA3. My specialist wanted a PHI for me this year. Of course, I will also need an MRI in a few months (hopefully not also a biopsy) after skipping them last year (the rules relax if over age 70).
Posted 4/23/2016 3:31 PM (GMT 0)
Dr. Scholz is a prostate oncologist.
Most new patients have to go through their primary doctors and urologists before seeing a oncologist.
So most likely the urologist decides what to do for new patients.
The 3T-MRI and 4K Score are new tools came up in recent years.
Posted 4/23/2016 6:10 PM (GMT 0)
ASAdvocate-

The two tests seem to be complementary.

- Allen
Posted 4/23/2016 7:25 PM (GMT 0)
Try to do MRI pelvis and biopsy as soon as possible.
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