82 yr old dad "needs a biopsy"

So my dad has had a slowly rising PSA. It is a bit awkward to get details from him. He said it is about 5ish. He didn't say anything about any lumps. The PCP sent him to a Uro for a consult. The recommendation is for him to get a biopsy and they scheduled one for him on the spot. He is having second thoughts based on no family history and basically being a chicken. He is going to talk to his PCP again about maybe just keeping an eye on it. I told him that they would need to biopsy to see what the Gleason score is. Obviously if it is G6 or G7 then AS would be fine. Is it at all prudent to just roll the dice at his age and not get one? He is in decent not great health. Bad knees, overweight, occasional polyps which require regular colonoscopies, espoghus issues, minor blood pressure issues. His dad lived to 84 and his mother 94.The weird thing is he has been getting testosterone shots for awhile. I don't think the PCP is prescribing them. I told him he should lay off of those but he didn't like that suggestion. Any advise would be helpful. Thanks.

If it were me, I think I’d know how I would play this. I think....I’d follow his lead. I’d support him no matter what...and I’d keep my opinions to myself. He’s a big boy. He deserves to be treated like one.

I would never bring it up....first. Just act and behave as if I knew nothing about it. (‘Cause I wouldn’t. I’d know nothing about being in his shoes).

I think I know myself well enough to be able to say that.

Good luck

Part of me says, he has enough health issue without adding one more.

Part of me says, he should get the biopsy and then decide what to do or not do.

and then there is that he is an adult and should make his own decisions. But without knowing more about the DRE and PSA progression, we can only guess whether or not a biopsy is truly warranted. I'd also be wondering why an 82 year old without family history is getting a PSA test.

I'd be reluctant to say do the biopsy.

Just to let you know my dad had a biopsy radiation treatment and hormone treatment for six months at age 78. He is now 94. He was overweight, had a bad knee and hip (hip replaced at 90) and told me yesterday, on his birthday, "I feel pretty good and I certainly have felt worse." Your dad has continued to have colonoscopies which are more dangerous than a prostate biopsy. Patrick Walsh at John Hopkins would be a good person for your dad to talk to. Here is a quote regarding the recommendation to not do PSA testing for men over 70. “There is increasing evidence that this age-based approach is significantly flawed,” said Patrick Walsh, an internationally renowned professor of urology at Johns Hopkins School of Medicine, who co-authored a recent study on high-risk prostate cancer in older men. According to the John Hopkins investigators, men age 75 and older account for 48 percent of metastatic cancers and 53 percent of the deaths from prostate cancer. Without PSA testing and a biopsy if needed, cancer can go undetected, limiting treatment options and longevity.

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69 yrs., marathon runner, 39 of 44 3D-CRT/IMRT Radiation delivered via 3D-CRT in 1.8 Gy minimum dose fractions to a total of 79.2 Gy., 10.5.18. PSA .012, 8.12.18, 1.42 June 18, 2018 (Lupron 5.21.18 & 8.15.18), 12.7 May 2018, 13.7 Jan. 2018, 2.1 May 2012. SpaceOar 9.6.18, testosterone <.7, 8.15.18, Tot Mayo 19 ng .17 testosterone Free 6.18.18, Gleason 3+4=7 involving 15% of the right apex and 15% of the right mid, 3+3=6 prostate cancer involving 5% of the left base. Pathology interpretations by John Hopkins, UNM Cancer, and SF Path 3+4=7 or 4+3=7 MD Anderson Proton Center w/o %. T3 MRI w/ contrast 1.8 lesion left side 5P, Neg. Bone Scan. Prolaris test 3.5 consistent with intermediate and a PTEN test negative. Father PC age 78 RT & ADT now 93 yrs. Neurogenic bladder due to lumbar disk disease and recurrent bladder neck contracture with urinary retention man. 20 years doing catheterizations. TURP & scaring 2003, Finasteride 5 milligrams daily since 2002

Post Edited (SantaZia) : 11/19/2018 5:27:25 AM (GMT-7)

I would rethink the need for a biopsy. At least get a second opinion.
Prostate cancer is SLOW. I was diagnosed in 2006 at age 56 4+3=7 Gleason. I did not get treatment for 7 years.
Now 12 years after diagnosis I am still here.

I personally believe that treating an 82 year old is borderline malpractice. Even if he does have cancer, it will not be likely to affect his longevity. The treatments carry a huge potential to be worse than the disease.

Again, a second opinion is warranted.
Good luck.

I am that 85 yr. old poster. I had the biopsy and diagnosed localized g9, t2b. Had 3 mos. of firmagon ht, then a six-mos. shot of lupron while undergoing radiation therapy. I have 7 more sessions to go after today. I'll be on ht for 18 mos. II would characterize my se as tolerable, mostly annoying. My qol is excellent, do all my former chores, and I have a very positive outlook. My urologist says he'll keep me going another 15 yrs. Of course I believe him!

GoBucks said...
I agree with JNF. I disagree with the notion that an 82 year old should never have a biopsy or ever be treated. There was a poster here within the last few months who had a biopsy and treatment at age 85. It is an individual decision to be made after careful research. Keep researching for Dad, find a good Doc, get a 2nd opinion and support his decision.

I'm quoting this and the reference to JNF's post - I agree with both here.

I did "head in the sand" as to testing, my first PSA was my decision point. I'm still here!

Re. Up4thefight's dad (and everyone, but he's the topic of this thread), I 100% agree that head-in-the-sand is NOT the right thing...and nothing I've ever said in my 266 posts or anywhere else has ever supported such a notion. (I’ve seen people here at HW/PC label Watchful Waiting as head-in-the-sand, but that seems like an example of naivety and not understanding PC.)

I'm also 100% confident that "a biopsy scheduled on the spot" is NOT the right thing for him.

I'm also 95% confident that an 82 YO with a known track record of low PSA (completely within age-adjusted normal range) should never have a biopsy (that is, they would never benefit from having a biopsy). This known track record is an important case characteristic that everyone else seems to be overlooking...that track record is probably much more important than the actual number...even if it was 10, not 5, I'd say exactly the same thing.

[That 95% confidence is based ONLY on the provided data, which I highlighted in the quoted post...more non-invasive data can help to drive that confidence up, or down.]

An immediate biopsy is completely inappropriate, and medically unethical. Treat the patient, not the number.

Post Edited (Blackjack) : 11/23/2018 7:41:06 AM (GMT-7)

U4F - You've gotten some really good advice here already about the biopsy/potential treatment issues.

Let me also address the testosterone question. DO NOT jump to any conclusion about whether he should stop his shots or not. Newer research has shown that for certain prostate cancer patients, TRT is fully appropriate as long as it is monitored and managed correctly.

Those certain patients are any low or favorable intermediate risk prostate cancer patients. These are patients for whom the standard of care does not include ADT. The thinking is that if we do not need to withhold T from a patient for medical reasons, then why should we penalize a patient whose own testes do not produce sufficient T? After all, his body cannot tell the difference between the T that it manufactures internally and that which he purchase down at the pharmacy. (For clinical data, search the web for "Saturation Theory"+"Morgentaler") Dr. Morgentaler, one of the prominent authors on the topic, has spent most of his past 20 years researching the intersect of testosterone, TRT, and prostate cancer.

By "effectively managed" I mean only that the patient's T level is periodically monitored, and is within the standard "normal" range. My uro and I try to keep my T level somewhere just below the midpoint of the normal range.

Testosterone does not "cause" prostate cancer. For low and intermediate risk men, it does not even add any risk to the equation. Only for those patients whose treatment would include ADT should we withhold TRT. (That is my non-professional summary of a conversation I had with Dr. Morgentaler.) I won't bore you with all of my opinions about the original 1940-something research that drove the "testosterone is like gas on a fire" analogy. Suffice it to say that said study started out with only 3 participants, and only 1 completed the study. We now call that sort of statement an anecdote. Draw your own conclusions.

Anecdotal Evidence--My father's urologist kept up PSA testing until he was in his early 80s. As expected with age,the PSA kept going up and was around 5. The risk of complications from a biopsy would have far outweighed any benefit. And what would be the actionable result of a biopsy at that age? As it turns out, he developed other health issues, a debilitating stroke at 86 and idiopathic lung fibrosis at 89. I don't see the point of PSA testing if there is a life expectancy of less than 10 years. There are always exceptions to any rule, but the general rule holds firm: 'First, do no harm'

Writeblock, good to hear from you I was wondering how your doing. Keep up the good work!

Larry