Time for anther biopsy - Maybe??

As seen in my signature, my PSA is on the rise (again), although it's "only" a 4.0. The last time it was a 4.0, I had 2 biopsies and Gleason 6 was diagnosed in 1 core in each. In the first biopsy, 3 different pathologists had 3 different diagnoses - Gleason 7 (3+4), inconclusive and Gleason 6. I decided it was Gleason 6 because it was the "average" of the 3 pathology reports and the second biopsy was also a Gleason 6 (adjacent "quandrant" to the Gleason 6 from the first biopsy). There wasn't enough tissue to do any genetic tests and because of my defibrillator, I can't have an MRI.

My second biopsy was done in July 2016. In Oct. 2016, my PSA dropped to 2.5. Between Oct. 2016 and Oct. 2018, my PSA increased to 4.0, although between Oct. 2017 and May 2018, it was stable at around 3.5.

When I decided on AS, my urologist told me that biopsies should be repeated every 2-3 years, however, PSA results could change that time period.

So, I guess it's time for another biopsy, however, in 6 months, if my PSA again drops to 2.5, I may want to reconsider that. If my PSA would have remained stable at 3.5, I would have questioned having the biopsy - even though it's been 27 months since my last biopsy. For people on AS, I don't think there is published data to support the frequency of repeat biopsies. I believe the Canadian urological guidelines say every 3-5 years, although I don't know how they came to that recommendation.

I expect many of you will say that I should have the biopsy - irrespective of what my next PSA is. I spend the winters in Florida and I'm heading south in about 3 weeks. I plan to have another PSA when I come home in April and will probably schedule the biopsy at that time. Maybe....

With 3 different pathology opinions on my first biopsy, I question everything.

I suppose that if I were in your position, I'd want to be cautious and get the biopsy. And send it to Epstein.

ddyss said...
I would get a mpMRI - biopsy are hit and miss - since you know you have some cancer , why not get a scan done for the whole prostrate to see a complete picture

He stated that he can’t have an MRI. Due to having a defibrillator.

Pratoman said...

ddyss said...
I would get a mpMRI - biopsy are hit and miss - since you know you have some cancer , why not get a scan done for the whole prostrate to see a complete picture

He stated that he can’t have an MRI. Due to having a defibrillator.

Thanks Prato. Missed that one !

When Dr. Epstein said "inconclusive," did that mean he was not sure it was cancer at all?

I saw my urologist today and he wants to do another PSA and a free PSA free test in 6 months. This is the first time he ordered a PSA free test. He commented on my PSA velocity - specifically that my PSA was about 2 in 2009 and it's now 4. It therefore doubled in 9 years. He also said that PSA generally increases with age, irrespective of having prostate cancer.

As far as the guidelines for repeat biopsy's every 2 - 3 years, in his opinion, there isn't published data confirming that this time period is optimum for confirming/detecting the cancer. When (and if) I have another biopsy, he would definitely take more cores. I trust him and was happy with his recommendation especially because I'm going to Florida in 2 weeks. If he wanted to do a biopsy, I probably would have come back for it.

I know he has many patients on AS and his AS "program" is not as rigid as large institutions like Hopkins or MSKCC. I think that one of the reasons for structured programs is to enable institutions to collect data and publish papers. Additionally it "forces" men to follow their rules.

For the time being, I will stay with this doctor as I like him and more importantly I trust him.

Jim, thanks for the input. Two years ago, I had a consultation with Dr. Ehdaie of MSKCC. At that time, he strongly agreed with my AS decision. He suggested that the next biopsy should be done in 2-3 years and there should be 2 additional anterior directed cores taken. Since I will be sedated for the next biopsy, my doctor said he will take additional cores.

I thought about having Dr. Ehdaie as my urologist and may still decide to change doctors. At a minimum, I will continue to consult with him. I can't have an MRI because I have a defibrillator. I will edit my signature to include that. Both Dr. Ehdaie and my urologist would have liked me to have it done.