Waiting for Biopsy result, need help on doctor information

A couple of weeks ago I did my annual checkup, and found out that my PSA value has increased from 2.5 (12/2015) to 5.6 (08/2016). I started to panic and found healingwell.com led by a google search. In the past few days, I have been looking through posts in this forum and have learned so much here, thank you all very much for maintaining such a wonderful place.

Back to 2008, my doctor found a lump in my prostate, and ordered a biopsy, all negative, back then, my PSA value was 0.5. My doctor said that the lump was benign and could have been there for a long time. From 2008-2014, my PSA value stayed <1.5, and started to fluctuate between 1.5 to 2.5 from 2014 to end of 2015. Then it was the sudden jump from 2.5 to 5.6 from 12/2015 to 08/2016.

A biopsy was done yesterday, and I am waiting for the result. From reading all the posts, I feel that my chance of having cancer is pretty high, and just hope my result is not bad, and it is curable.

I live in San Francisco bay area, does any of you know if there is any good urologist in my area? I learned here that I should seek for 2nd and even 3rd opinion before a treatment plan would be made.

Thank you for all your help!

Welcome to the group. I am sorry that you are here, but there are a lot of very knowledgable people here.

It is scary when the say the word "cancer", but take a deep breath. There is a very good chance the the rise in your PSA has nothing to do with cancer. Even if it is cancer, it may be in the early stages where active surveillance would be the best treatment.

Yes it is hard to wait. Please know the odds are in your favor.

A PSA more than doubling in eight months is not typical of cancer, which tends to be slow growing. Also, as you probably have read, only about a third of biopsies prompted by suspcious PSA find any prostate cancer.

As the others have advised, sit back and don't jump to conclusions. Good luck.

Thank you for your encouragement and good wishes.

I have a couple of questions that I don't understand:

1) will cancer cell grade change if it not treated? what I meant to ask is if a cancer cell has gleason 3, then will it change to 4 if it is not treated? or gleason 4 and 3 cancer cells are totally different type of cancer cells?
2) what cause positive margin? does positive margin mean cancer cells are already out of the prostate? or positive margin is caused by surgeon not cutting at the right place?

I don't know much about PC, sorry if my questions are too basic.

Those are very good questions.

parisamour said...
1) will cancer cell grade change if it not treated? what I meant to ask is if a cancer cell has gleason 3, then will it change to 4 if it is not treated? or gleason 4 and 3 cancer cells are totally different type of cancer cells?

Tumors absolutely do progress to higher grades. How they do that is an open question, but that they do that is certain. However, some tumors never progress (they are called indolent), while other tumors progress quite rapidly. We don't know how to predict which is which, but we do have a method, called "active surveillance" for catching them before they progress too far.

Gleason patterns 3, 4 and 5 represent a spectrum of cell architecture. Less progressed cells - the pattern 3s - look more like normal healthy prostate cells. More progressed cells - the pattern 5s - look more like undifferentiated cancer cells.

parisamour said...
2) what causes positive margins? does positive margin mean cancer cells are already out of the prostate? or positive margin is caused by surgeon not cutting at the right place?

Positive margins means some cancer tissue has been left inside the body. They ink the prostate when they remove it, and anyplace where the ink touches tumor tissue is considered a positive margin. Sometimes they occur because the tumor extends outside of the prostate (called extraprostatic extension) and the surgeon had to gut through it. Sometimes the surgeon cuts through it even though the tumor was within the prostate capsule (stage T2). That can be because the surgeon misguesses how wide he needs to cut to get it all, and sometimes it's especially indistinct at the apex. A good surgeon with a lot of experience will have positive margins with a T2 tumor in only about 10% of his recent cases. It's one of the ways to gauge how experienced a surgeon is.

By the way - a positive margin is a completely different sort of thing from a distant metastasis

Yea, is there evidence that Gleason 6 cells has a propensity to progress to higher-grade cancer cells? Tumor progression during AS is maybe seen at 30% of the patients but I have got the impression that it is often because the higher-grade disease was present from the beginning but missed at the time of initial biopsy. Couldn't it also be that new G4 cells emerge during the AS years after the G3 cells was detected?

Halbert-

I've never heard that quote from Epstein and I am very doubtful that he ever said that. Do you have a source? It's one thing to say that metastases are never associated with purely a GS6 in the prostate, it's quite another to say that a GS 6 never progresses. Of course it can. And no one, except those who misunderstand the data, questions that.

For example, look at Klotz's data on Active Surveillance. Although everyone started off with a G6, confirmed by repeated biopsies over 20 years, eventually, about half of those men reached the GS 4+3 level. Similar data come from Johns Hopkins, which always had annual biopsies as a matter of policy.

The math is convincing. While the odds of missing a higher grade is about 1 in 3 on a single 12-core TRUS-guided biopsy, the odds of missing it on both the original and the repeat biopsy is about (1/3)^2 or 11%, 4% by the third biopsy, !% by the fourth biopsy, 4 in a thousand by a 5th biopsy, about 1 in a million by the 10th biopsy, etc. When they detect a higher Gleason score after multiple biopsies, it isn't because they keep missing it -- the Gleason score does progress much of the time. And this is just for TRUS-guided; if it's mpMRI-targeted or template mapping on repeat biopsies, as it often is in the last few years, the odds of missing a higher grade cancer are even less.

I'm correcting you and Gemlin because I think it's very dangerous to tell others this misinformation.

AS advocate -
Cells don't have a Gleason Grade or Pattern - it is a number attached to tissue architecture, not cells. Parisamour wants to know, if he has a Gleason score of GS 6, if he has a risk of progressing to a higher score. He does. Without question.

Post Edited (Tall Allen) : 9/4/2016 1:20:09 PM (GMT-6)

TA, I may have misspoken. I get the difference between "progression" and "metastisis". Progression, as I understand, could just be the tumor grows and expands, where metastisis means that it escapes and goes elsewhere in the body (bones most commonly).

The statement, oft quoted here and elsewhere, by Epstein, is that true G6 never goes metastatic. Which, by implication, means to us layfolk, that G6 may grow but won't ever threaten the patient. And, as I did say, the idea is that G4/5 pattern cells seem to spring up on their own from base tissue rather than turn into G4/5 from G3 cells. But that isn't proven.

Sheepguy -

I showed the math. If missing it once is 1/3, missing it twice is (1/3)^2, missing it three times is (1/3)^3, etc. It's like the odds of flipping a coin and getting heads X times in a row, which would be (1/2)^x

- Allen

I have searched for studies about the progression question.
Here is one supporting the view that progression is uncommon. Maybe TA can comment if its trustworthy.

Gleason Grade Progression Is Uncommon

Some spread quotes:
...
Pathologists and epidemiologists have long speculated on whether prostate tumors initially arise as well-differentiated tumors and then progress to higher grades over time, or whether grade is an early and largely unchanging feature of the tumor.
...
However, this question cannot readily be addressed through repeated biopsy because of the inherent heterogeneity of tumor nodules within the prostate.
...
Although we cannot rule out the possibility that Gleason grade progresses within an individual, we conclude that it is not a major feature of prostate cancer.
...

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