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Posted 8/25/2016 12:13 AM (GMT 0)
I was diagnosed with PC in May. PSA 9.9, Gleason 3+3

I chose Active Surveillance. Three months later my PSA is 14.0.

Is it time to abandon AS and seek treatment? Would appreciate opinions from the learned members of this forum.
Posted 8/25/2016 1:01 AM (GMT 0)
Sorry for your news and welcome to the club Can you give a few more details about you? What is your age and have you had a biopsy?
Posted 8/25/2016 2:53 AM (GMT 0)
PSA rising that rapidly in just 3 months is almost certainly a sign of prostatitis, especially with only GS 3+3. Your PSA was very high (9.9) to begin with, suggesting that there may be another prostate problem beyond the GS 3+3. Here are some steps you can take:

(1) Get your biopsy slides confirmed by Dr Epstein's lab at Johns Hopkins

(2) Read your biopsy report closely. Is there mention of chronic or acute inflammation? Benign prostatic hyperplasia?

(3) How big is your prostate as measured by ultrasound when you had the biopsy? Was there any sign of urinary retention or blockage?

(4) Do you have a history of prostatitis? Did you have any fever or tenderness after the biopsy?

(5) ask your urologist to do a DRE to see if it feels swollen and tender.

(6) discuss with him whether it makes sense to try a course of antibiotics, or just wait and re-test.

AS always involves a follow-up biopsy within a year of the first one. If you can, try to make sure it is mpMRI-targeted at a place with a very experienced radiologist. Or, you can ask for a transperineal template-mapping biopsy (or both!) which is very thorough.
Posted 8/25/2016 4:49 AM (GMT 0)
I vote for a retest.

Plus do everything TA says.

No it's not time to abandon AS, it's time to get more tests and info. Depending the results, you may or may not need treatment.

Andrew
Posted 8/25/2016 12:40 PM (GMT 0)
PSA kinetics (that is, the movement up or down of PSA) for a man who has not had his prostate surgically removed or radiated, typically has very little to do with prostate cancer. PSA is definitely NOT the key case metric to watch for someone on AS. It's incredibly common for men to be walking around with a prostate infection AND small amounts of benign prostate cancer at the same time. The infection makes PSA jump around; the prostate cancer doesn't cause those fluctuations.

Your second, confirmatory biopsy within 12-18 months of your original diagnosis will dictate next steps for you...not much else really matters. Your urologist should suggest infection treatment.
Posted 8/25/2016 2:02 PM (GMT 0)
Too bad urologists haven't caught on to the fact that there is more than one reason for an elevated PSA (at least the ones I have encountered).
Read, ask, research and don't trust.
Posted 8/25/2016 2:12 PM (GMT 0)

Robertmp said...
Too bad urologists haven't caught on to the fact that there is more than one reason for an elevated PSA (at least the ones I have encountered).
Read, ask, research and don't trust.



Robertmp, your underlying key point in your first sentence is spot-on in the big picture. Just two days ago, in another thread, I wrote to someone else about the prostate biopsy that they should "be aware that urologists like to pull this lucrative trigger early and often."

But in our new friend bdbbauden's case, he's already on AS, and apparently already found some small amount of PC to monitor. His urologist has probably already informed him of his second, confirmatory biopsy...but it's likely being planned-for (appropriately) around next May.

Regarding your second sentence "Read, ask, research and don't trust," my guidance would not to "don't trust" your doctors. Rather, I would encourage men to become empowered patients by following the first part of your advice...read, ask, research. An empowered patient will better understand the perspective that each doctor is coming from, and that they ALSO have their own business considerations to factor into their patient recommendations.

Best wishes
Posted 8/25/2016 8:19 PM (GMT 0)
Thanks to everyone for their replies.

I am 66 years old. In 2014 my PSA began to rise and my primary care physician recommended I see a urologist. PSA rose from 4.9 to 6.3 in three months. I had an MRI and a needle biopsy, both came back negative.

By 1/16 my PSA had risen to 9.9. Another MRI showed a lesion. A guided biopsy was performed on 5/16 with the following results:

"Adenocarcinoma, Gleason grade 3+3 = score of 6, in one of five cores, measuring 1.3 mm in length, and involving <5% of needle core tissue. Acute prostatitis."

As stated earlier, I learned yesterday that my PSA is now 14.0. This afternoon I got a call from my urologist's office. He is prescribing antibiotics to be taken for two weeks and then do a repeat of the PSA test.

In light of the thoughtful responses I received here in the forum, this sounds like an excellent course of action.

Thanks again.

Bruce
Posted 8/25/2016 9:45 PM (GMT 0)
Yup. Antibiotics and retest sounds like a prudent step.

Keep us updated on your progress,
Andrew
Posted 9/15/2016 7:36 PM (GMT 0)
Bad news. After two weeks on antibiotics and a retest, my PSA has jumped from 14.0 to 19.9 in three weeks.

My doctor is prescribing a different antibiotic and another retest.
Posted 9/16/2016 12:24 AM (GMT 0)
Am I missing something? Isn't a lesion something to worry about? Were only six core samples taken both times? If so why so few? Do you have symptoms of prostatitis ? Like burning and frequent urination?
Bob
Posted 9/16/2016 12:56 AM (GMT 0)
Bdb,

Unfortunately you're following at least parts of my trail. Hopefully with a different outcome. When I was at your point of growth in PSA and after a discovery of a small G6, I decided to get a scan with different technology using Color Doppler Ultrasound. My thinking was to get an alternative view every six months or so -- going back and forth between mpMRI and CDUS. In my case the new scan and doctor couldn't even replicate the small original G6 found by mpMRI, so I got to enjoy some happy confirmation bias for awhile, thinking there's virtually no cancer. The doctor thought prostatitis, and I went through three rounds of cipro and levaquin, which temporarily reduced my PSA. At that point I decided to enter the UCLA Active Surveillance Program. It required a fresh UCLA-produced mpMRI to start. I knew what it would show -- a small tumor already biopsied as G6 in the transition zone. The scan report triggered another biopsy as a baseline for the Program. This time it was a fusion biopsy to sample all the prostate zones and evaluate the tumor, including taking five cores surrounding the original tumor. Now the tumor was reported to have enlarged, and was read and confirmed by a second opinion as a G4+3. Time for me to act.

I sincerely hope yours is a case of prostatitis. In my situation of a rising PSA (eventually hitting 24.7) and a G6 identified earlier, I was glad that I obtained three biopsies over the span of ten months. The rising PSA indicated growing prostate cancer, and frequent biopsies finally found it.

Best wishes,
Jim
Posted 9/16/2016 1:57 AM (GMT 0)
Your PSA velocity in that short period of time concerns me, as it did in my case along with my urologist. When my PSA hit 4.0, the old standard, had my first biopsy. No cancer, lots of PIN and evidence of PNI. Waited a year, PSA went to 12.3, second biopsy, no cancer, lots of HGPIN, PNI, and a couple of shadows. Six weeks later, at my doctor's begged insistence, had 3rd biopsy. PSA rose 4 points in 6 weeks, and I had zero infection, no enlarged prostate, no urinary issues. 3rd one was limited to 7 cores, all came back positive Gleason 7, most cores were 90% pure or higher. Doctor went into the shadows where he believed the cancer was located. He was correct.

Due to my PSA velocity issues, my cancer has always been difficult to treat and control. There are doctors that believe that velocity can be a predictor of worse outcomes.
Posted 9/16/2016 8:54 PM (GMT 0)
Break60--- In Dec. 2014 I had a needle biopsy in my urologist's office. Twelve cores were taken, all negative. But 36 hours later I was in the emergency room with septicemia. I spent 5 days in the hospital (3 of them in intensive care). In order to minimize the risk of infection during the guided biopsy in May, I was given additional antibiotics and the doctor took only 5 cores.

I do not have any severe symptoms of prostatitus, but the last biopsy indicated i had it.
Posted 9/16/2016 11:41 PM (GMT 0)

bdbbauden said...
I do not have any severe symptoms of prostatitis, but the last biopsy indicated i had it.

Well, that finally answers my Question #2 from last month with a "yes." That explains a lot - thanks for answering that. It makes sense, given the septicemia you had.

You should understand that only about 5% of prostatitis responds to antibiotics. Many urologists won't even try antibiotics for it. It relapses and remits, so there is some evidence that any declines in PSA following antibiotics were just coincidental - it would have gone down without them anyway. Also, it is not unusual for prostatitis to be asymptomatic. It is hard to diagnose and hard to treat.

Now that you know the cause of the elevated PSA, it should give you some comfort in staying on active surveillance. However, it raises a problem for you - how can you tell when your PSA is increasing due to prostatitis vs prostate cancer?

One solution is to use PHI instead of just PSA to track while on AS. PHI includes PSA, but is not as affected by prostatitis. It's still affected, but not as much. Call the link below to find out where you can get it in your city - your urologist probably won't have it, but you can check. It's inexpensive and covered by insurance.

www.myinnovativelab.com/prostate-cancer/

For your future biopsies, you are less likely to get infections if they are transperineal rather than transrectal.
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