Active Surveillance PSA Creeping Up

Hey all...
Just got back from my 3 month checkup on my AS program and as you'll see in my stats, the PSA is beginning to creep up, although it is still fairly low (1.24).

My uro says if we see another rise next month he will recommend a bone scan and a CT scan. I asked him about another biopsy and he said it was necessary, because he already knows I have prostate cancer.

I am looking for a bit of advise at this juncture.

• Why not another biopsy? They found just a small amount of G6 in only one core. Wouldn't it be wise to get another biopsy, maybe MRI guided or whatever?
  
• With only a G6 and such a low PSA even still, would it even be necessary to do a bone scan and/or a CT scan? Seems to me that there would be almost no chance of finding something.
  
• What else, if anything, should I do now?
  

That's all for now. Any advise from some of the more experienced and knowledgeable members would be greatly appreciated.

Hey, let me just add one more thing to my earlier post.

I'm really confused as to why your physician would order bone/CT scan. This is against the "best practice" recommendations of the American Urological Association because it is a completely wasteful test for someone with your very low case characteristics.

Here's the link: PSA TESTING FOR THE PRETREATMENT STAGING AND POSTTREATMENT MANAGEMENT OF PROSTATE CANCER: 2013 REVISION OF 2009 BEST PRACTICE STATEMENT

And here's (copy/paste) what it says specifically about bone/CT scans:

2. Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL.
An analysis of 23 studies examining the utility of bone scan found metastases in 2.3% of men with PSA levels <10.0 ng/mL, 5.3% in men with PSA levels from 10.1 to 19.9 ng/mL, and 16.2% in men with PSA levels >20.0 ng/mL.9 The authors concluded that low-risk patients are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally not necessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 ng/mL unless the history or clinical examination suggests bony involvement. As metastatic disease is significantly more common in advanced local disease or in high-grade disease, and as some high-grade prostate cancers have lower PSA values, it is reasonable to consider bone scans at the time of diagnosis when the patient has Gleason 8 or greater disease, or stage =T3 prostate cancer, even if the PSA is <10.0 ng/mL.9, 10

3. Computed tomography or magnetic resonance imaging scans may be considered for the staging of men with high-risk clinically localized prostate cancer when the PSA is greater than 20.0 ng/mL or when locally advanced or when the Gleason score is greater than or equal to 8.
Although this guideline is commonly used by the experts in the field, supporting data are lacking. CT scan is not a useful staging procedure for the vast majority of patients with newly diagnosed prostate cancer for whom the estimated incidence of positive lymph nodes is approximately 5%.11-13 CT is rarely positive when the PSA is <20.0 ng/mL and is generally reserved for men whose risk of lymph node metastasis is =20% by Partin table estimation.14

Additionally, several studies have found a correlation between Gleason score and lymphadenopathy detected on imaging; 1.2% of patients with Gleason score =7 have detectable lymph node enlargement on CT scan, compared to 12.5% in men with Gleason score =8 .9 However, it should be noted that many men with Gleason scores of 8-10 on biopsy, may be downgraded based on examination of radical prostatectomy specimens.15 CT scan identification of pelvic adenopathy depends upon lymph node enlargement, and the correlation between nodal size and metastatic involvement is poor.16 Although the histologic incidence of positive pelvic lymph nodes is substantial when PSA levels exceed 25.0 ng/mL, the sensitivity of CT scanning for detecting positive nodes is only about 30% to 35%, even at these levels.12

For similar reasons, MRI scanning using a body coil is also not a useful staging procedure in the vast majority of patients with newly diagnosed prostate cancer, because sensitivity is again determined by lymph node size.17 Its sensitivity for detecting nodal metastases, as determined from the analysis of seven studies using MRI, was only 36%.13 Endorectal coil MRI together with magnetic resonance spectroscopy (MRS) for characterization of cancer stage and volume is still considered an investigational procedure, but has shown promise in preliminary studies.18, 19

MRS allows MRI technology to identify functional and metabolic abnormality.20 However, imaging modalities of various types are being refined and will likely play a greater role in the routine diagnosis, staging, treatment and post-treatment evaluation of prostate cancer in the future.21, 22

Share this with your doc, too.

(Are you sure you didn't mis-hear "bone/CT scan" for "mpMRI?" That would make much more sense.)

"Why not another biopsy? They found just a small amount of G6 in only one core. Wouldn't it be wise to get another biopsy, maybe MRI guided or whatever?"

Yes, definitely. The first confirmatory biopsy is always given within a year of the first one. It can be mpMRI-targeted, or you can have a transperineal template mapping biopsy, which is more thorough. I should also note that your PSA is still very low. It naturally goes up as we age.

"With only a G6 and such a low PSA even still, would it even be necessary to do a bone scan and/or a CT scan? Seems to me that there would be almost no chance of finding something."

Right again! A bone scan is for unfavorable risk guys with PSAs over 10 at least. A complete waste of time and money, and in conflict with AUA guidelines.

"What else, if anything, should I do now?"

AS should be done as part of a rigorous program. I recommend you explore any nearby tertiary care hospitals to find such a program. If it doesn't include periodic re-biopsies, run!

JackH said...
Hey, let me just add one more thing to my earlier post.

I'm really confused as to why your physician would order bone/CT scan. This is against the "best practice" recommendations of the American Urological Association because it is a completely wasteful test for someone with your very low case characteristics.

(Are you sure you didn't mis-hear "bone/CT scan" for "mpMRI?" That would make much more sense.)

I'm confused too, thus my questions. He for sure said bone and CT scans.

We'll see where my PSA is in 3 months and go from there.

Tall Allen said...
"Why not another biopsy? They found just a small amount of G6 in only one core. Wouldn't it be wise to get another biopsy, maybe MRI guided or whatever?"

Yes, definitely. The first confirmatory biopsy is always given within a year of the first one. It can be mpMRI-targeted, or you can have a transperineal template mapping biopsy, which is more thorough. I should also note that your PSA is still very low. It naturally goes up as we age.

"With only a G6 and such a low PSA even still, would it even be necessary to do a bone scan and/or a CT scan? Seems to me that there would be almost no chance of finding something."

Right again! A bone scan is for unfavorable risk guys with PSAs over 10 at least. A complete waste of time and money, and in conflict with AUA guidelines.

"What else, if anything, should I do now?"

AS should be done as part of a rigorous program. I recommend you explore any nearby tertiary care hospitals to find such a program. If it doesn't include periodic re-biopsies, run!

Thanks TA. I really, really hated the biopsy so I don't want another one. But it does seem to me that should be the logical next step. Would it be your advise that I proceed with that, even before my next PSA test? I have only had the one biopsy back in 2014. Does anyone have a recommendation for a real AS program in Minneapolis, MN? I love my Doc but he doesn't seem to be to attuned to AS programs.

GeetarMan said...
I'm confused too, thus my questions. He for sure said bone and CT scans.

We'll see where my PSA is in 3 months and go from there.

Good plan! At "1-point-something," your PSA seems quite good.



If I can just offer some personal opinion here...here's what I would probably do. I would darned-near memorize the Klotz document, and also that AUA document section on bone/CT scans, and then bring a printout of each (as backup) to your next appointment. Then, with a firm grasp on the information gleaned from Klotz's paper, I would seek to have a 2-way conversation with the doctor about creating a more clear protocol for your case which is based on some of the AS best practices.

Element #1 of the protocol needs to focus on the confirmatory follow-up biopsy...which it sounds clearly like you have not had. That's a red flag to me. Klotz, the world's AS expert, and just about anyone else I've see discussing follow up protocols, always, always talks about the importance of a second, confirmatory follow up biopsy usually around a year after the first. This, I believe, is really fundamental. I hear that you didn't like the biopsy...nobody does. It's important; get some numbing meds.

Element #2 is to see where your doctor is at with the mpMRIs. What's emerging as being common now is to alternate biopsy/mpMRI, with one every couple years (following the 2nd, confirmatory biopsy), if things otherwise continue to look good. The mpMRI is more tolerable than the biopsy, but also establishes some mapping baseline for future comparisons. So discuss this with the doc.

Element #3, what the heck is he recommending bone/CT scans for when hit goes against the recommendations of his professional medical society? Discuss.


I think on AS, the importance of having conversations—rather than being talked at—are even more important than ever. In another thread, I talked about a book I recently read called Being Mortal, where the author spoke of 3 different types of relationships doctors have with patients: i) Paternalistic (I tell you what to do), ii) Informative (I tell you what I know, then you decide), and iii) Interpretive (a hybrid of the two where the doctor has genuine back-and-forth dialogue with the patient, sharing both information and recommendations, and why). I would want an Interpretive relationship with my doctor if I was on AS, and if I did my reasonable part to have that relationship but it just didn't seem like it was going to be achievable, I'd consider taking time to look elsewhere.

Post Edited (JackH) : 1/18/2017 1:54:19 PM (GMT-7)

Geetar, you have obviously already received some great advice. I would get a MP/MRI and the follow up targeted biopsy. The bone and cat scan are a waste. I cannot advise on AS programs near you but can emphasize the need for you to get into a more formal one as it looks like your doc is winging it a bit.

Jim

Finding a good AS doc will take some legwork on your part...making some calls, and maybe those calls don't yield anything, but maybe they result in an even better lead than the first one...


I entered these four keywords into a Google search: prostate active surveillance minneapolis

One of the first hits led to THIS summary of a clinical trial at UMinn titled, "Active Surveillance for Men With Low Volume, Early Stage, Screen Detected Prostate Cancer"

Information I got from that link was that the study is being run out of Fairview Maple Grove and Masonic (near you?). The principal investigator is Christopher Warlick.

I then Googled: Christopher Warlick, MD. Guess what? One of his listed areas of expertise (from his UMinn webpage) is "Expectant management for prostate cancer." Guess what else I saw there? He was co-author of an AS program with some big names (it looks like he used to be at JHU):

Carter HB, KettermannA, Warlick C, Metter EJ, Landis P, Walsh PC, Epstein Jl. Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J Urology. 178:2359-2364, 2007.

Make an appointment with Dr Warlick (612-625-7486, from his web site)...your possible participation in the study is a secondary thing; but he sees patients just like every other doc. If he can't see you, ask whomever answer the phone if they'd make a recommendation on another doc who specializes in AS.


It takes some digging...

One or two more clicks after posting my previous response and I ran across this 2014 article he wrote in American Cancer Society's CANCER Journal, titled "Multiparametric MRI for prostate cancer: Seeing is believing"


He's the guy you want...

Personally, I wouldn't wait for your next PSA test. Make a parallel appointment...my suggestion.

Thanks Jack! I did just send a request for an appointment with Dr. Warlick. I will get in to see him ASAP. Your information has been great. I love this forum. If it weren't for this place, I would have probably gotten an RP back in 2014! Thank God I didn't do that.

JackH said...
Excellent. I'll be keeping my eye out here for an update about your visit with Dr Warlick!


If you don't say it up-front, I've found that most doctors on your first visit will ask, "So, why are you here today?"

I think it is absolutely reasonable to respond (and even better to say it up-front) that you have started on a so-called "program" of AS with another "community" doctor, but felt uncomfortable with him being fully up-to-speed on the best-practices, and so you wanted to case a wider net looking for a higher level of care.

And then as you spell out your case history, I'd express concern/awareness that you have NOT had a second, confirmatory biopsy (yet).

best wishes...!

That is EXACTLY the information I filled out online as to why I was requesting the appointment.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840176/

sheepguy said...
With a PSAD of 0.04, a PSADT of about 3 yrs. and a single core of G6 <5% why would you expect the mp3TMRI to find high grade cancer..which it is the most accurate for?

Well, my PSA has gone from .68 (11/15) until the current 1.24 so that's a little concerning. Although I guess it would have be about 1.7 now to have actually doubled in a year because my my reading exactly 1 year ago was .85.

And as far as the mp3TMRI, people are saying it is Best Practice for folks on AS, but I see reading the article you linked to that it might not necessarily be needed by someone with my stats.

Anyway, I've requested an appointment with one of the the leaders in the AS field hear in Minnesota (Dr. Warlick). I'll be interested to see what he says.