PSA Spike on Finasteride

Hello Everyone,
I was here back in 2013-14 seeking help and information for my DH who's First PSA was high and spiked from 3 to 6 back to 3 after antibiotic and right back up. of course I am the biggest nervous Nelly and you all gave me the advise needed at that time to take a breath. He had a TRUS biopsy 2013 with 12 core samples that was negative but did show inflammation. Dx'd with BPH and started with Rapaflow wich helped some but later ended up on finasteride 5mg and Cialis 5mg a day and has been on since.

This brings us to present time. So I was aware of how Finasteride will effect PSA and asked his Urologist about this and at the time ( 2013) he let us know that if his PSA goes up more than .5 on finasteride he will want to do another biopsy. His total PSA has stayed between 1.54 to 1.9 tested every 6 months with a PHI test in most appointments. His last 6 month test jumped to 3.76 ( some reason did not order a PHI, just total) URO had him come in for another blood test to make sure lab correct. Told me lab had not changed. Second test about 4 days later came back at 3.35 but did order PHI test this time. We both assumed he would be wanting to do another biopsy but instead were shocked when his nurse called to inform that he wants to wait and see? All of his records are online so I went back in to research and the only comment that I see is under his PHI score was "In published studies to date, patients with PHI values between 0 and 24.9 have an 11.0% probability of being found to have prostate cancer on biopsy." His last Free PSA 21.2 and PH-HYB calculated 15.9( between the 0-24.9). His symptoms have not changed and not needed to urinate more or any burning etc. DRE had not changed. Looking through history below
04-18-18 PHI-HYB 18.0, Free PSA % 24.2, Total PSA 1.9
10-18-18 PHI-HYB 29.6(spiked), Free PSA 18 %, PSA total 1.72
04-19-19 PHI-HYB 22.1, Free PSA 19.6, PSA total 1.89
10-19-19 PHI-HYB 15.9, Free PSA 19.6%, PSA total 3.75 and 3.35 4 days later
There is more info on the PHI (PSA free ng)( P2psa)?. I know this is all a guessing game and nobody wants to go through a biopsy unless sure, but my husband is not the best advocate for himself so I made an appointment with his URO to sit down and 1. ask why he wants to wait and see when it spiked so high wile on Finasteride ( I know the answer he gave above but....) I know the best case is it spiked because of some sort of inflammation response but walking around for another 5 months not knowing it might be the worst case scenario seems wrong. I know imaging is not always the most accurate but what about at least doing that to rule out the worst? Should he get a second opinion on getting biopsy ( kind of biopsy) or imaging if waiting seems wrong, realizing most second or third opinions are for after Diagnosis?

I would love to know, one, what questions do I need to ask with this consult? The other question are for all you educated people out there to inform me as I keep trying to empower myself with information
1. Finasteride changes total PSA and I know it is normally doubled but does it effect all the other PHI numbers as well?
2. What type of imaging is for what and when is it warranted? MT MRI? For guided biopsy only?. Bio metric MRI? Is this used more to help in the decision of doing a biopsy?
3. There are several types of biopsy's still out there, is one better then another and when to know to ask for certain kind? I know some of the newer ones take an experienced doctor and mostly TRUS is still used, just curious. We are in the Chicago land area and might have access to this?
I am so sorry for the book but I am super nervous and stressed about this ( more then DH) so any advise for this consult is appreciated. I also apologize as I do not have a signature for him yet but will add this ASAP. Thanks again

Noseywife

My experience was that none of the imaging showed much danger. I was a Gleason 6 with less than 5% involvement in two cores. Still, since I was taking finasteride for 20 years I viewed it as a wildcard and opted for more aggressive treatment (surgery). Upon post-op pathology I did have more serious case and had to go right to Salvage Radiation.

Hi everyone,
Sorry for the delayed response back
Thanks for the advice. If we can convince him of MP- MRI I think that might be some info to see if waiting might not be such a good idea?

AZ Guy: Your experience and others like you is why I am stressing out about his waiting. This whole thing is a wildcard and in this day in age it seems so wrong to have to guess and going by the numbers is still just a guess. Did you decide after the imaging ( which kind of imaging) to do a Biopsy and if so which kind of biopsy was done? In all the time you were on the finasteride did you ever have it double but come back down or once it doubled did your doctor recommend biopsy as soon as that happened?

George: I am still trying to figure out the whole PSA value and PHI info. What is confusing is on his 10-18-18 PHI his Calculation doubled ( PHI-HYB, no idea what this is) to 29.6 yet his PSA total was 1.72 and free was 18%?

Jmadrid: Thanks, some peace of mind would be great. It is all about catching this thing early if you have it and the biggest fear is guessing wrong and then finding out that because he waited something more aggressive was missed.

Why does the percentage of post op pathology always seem to be worse then the original? Scary statistics. His doctor probably wont feel that 3T MP- MRI is warranted and not sure how DH would convince him differently if it
comes to it. Thanks again and any questions above are for anyone. Our consult with his Uro is tomorrow so we will ask about the numbers ( which is why Uro probably wants to wait) and about Imaging? Anything else we should ask about, please let me know. Thanks again

nosywife

Thanks for all the info.

So the consult was interesting. His Uro was open minded and I agreed with most he said but not all. He has seen a lot of patients on finasteride that have had spikes and it was nothing. He explained there have been patients that also have had low PSA and have had aggressive cancer diagnosis( as wee all know). Saying it is not an exact science and the PHI coming along( in the last 5 years) and those values is why he wasn't panicking to do biopsy right away. Also that Total PSA will change as age. He felt that if in three months he retested again we would be having the same conversation? Would we? what if the total PSA goes all the way back down in that time frame and his values are still the same? Not sure why he felt a Pca3 test was not any better then PHI test when mentioned? I disagree in the sense that you can look for infection and or cancer cells ( maybe it is not used as much as a screening tool)?

The good news is even though he seemed very confident about his DRE and PHI Values and thought he should wait and see, he was open minded in the sense that he understood if my DH needs some peace of mind and more info before any possible biopsy that an MRI was fine and gave him a prescription that just says" MRI of the prostate". Since my DH works in Downtown Chicago area I let him know that we would probably get MRI there ( University of Chicago), he didn't care where we wanted to get it done as the test would just be sent back to him. When I mentioned specifically a 3T MP- MRI it wasn't that he didn't know what it was, just kind of assumed it would be a MP-MRI or whatever kind they do depending where we go. He didn't talk to us about different kinds of MRI, contrast/no contrast, coil or not ( not on script)? Oh yea and he has a colleague that would perform a guided biopsy if needed.

So he is sitting on a script for an MRI that we are not even sure is covered by his group insurance? DH is grappling with waiting to see what total PSA does but not in 6 months ( more like three) or getting this MRI done? If the PSA would even go all the way back down and PHI values staying the same, would you then just assume it was a spike do to inflammation and keep checking as he has been? I am thinking he is leaning toward getting the MRI done. Did inform him that the MRI could also not be completely accurate as well ( but at least it is another non evasive bio marker).

Sorry but I am confused about all the different types of Imaging out there and which to look for. I understand that some MRI's will move to live guided biopsy's using MRI or something that overlaps for ultrasound if needed? He gave another script for a CT scan but I think that is more because my DH worried about family history of Kidney issues. I think he should wait on that one not only avoiding unnecessary radiation but get a good GP opinion ( looking) and see if warranted first. Only came up since online results showsing Bun/ Creaetan ratios as high but he checked individual numbers which were all normal range and the ratio was only like .3 over normal. Plus not sure good idea to do both a CT and MRI?

If he decides to get the MRI do I just call UC Hospital to make this appointment for the MRI? Is this prescription even written correctly to get the correct kind of MRI? I have read on this forum and heard from reviews online that University of Chicago is a good place for 3T MP-MRI but not sure what the difference is between a 1.5 and a 3 Tesla???? I thought that UC might only use 1.5? Is this good or bad for best results? I know I like the doctors there, especially if at some point soon we switch URO's or need another opinion.

I do not dislike my DH URO at all and I know he is a very good one in our area(burbs), just felt he could have been a little more informative. The fact that we were talking in an open exam room and not his office with people in the waiting room close by was a little weird. I was the one explaining to him on the ride home about the possible endorectal coil part of the MRI test Not sure when you know it's time for a change to another URO? Thanks for the help to get to the bottom of what is going on.

Nosywife