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Posted 9/28/2022 3:09 PM (GMT 0)
Friend , age 73, has been on Active Surveillance since 2016. You can see his PSA and biopsy history below. He’s a bit concerned about this last jump, as well as what seems to be a slow trend developing the last 4 PSA tests.

His biopsies all showed G6, one core, small % of core. Epstein confirmed all three biopsies as G6.
Unfortunately due to a device implanted in his chest, he cannot have MRI’s

So two questions…
1. Any of you on AS who can’t do MRI’s? Is there an alternative? CT Scan?
2. How would you proceed in a situation like this, would this latest rise to 5.2 lead you to another biopsy? consider treatment? Retest in 3 months instead of 6?

Any thoughts appreciated

June 2, 2009 – 2.26
Aug. 13, 2010 – 2.10
July 23, 2011 – 2.3
June 8, 2012 – 1.7
Sept. 12, 2013 – 2.5
May 30, 2014 – 2.1
Oct. 6, 2015 – 3.4
April 13, 2016 – 4.0
First Biopsy – May 27, 2016
Second Biopsy – July 29, 2016
Oct. 4, 2016 – 2.5
April 29, 2017 – 2.9
Oct. 20, 2017 – 3.4
May 15, 2018 – 3.5
Oct. 30, 2018 – 4.0
April 13, 2019 – 3.3
Sept. 23, 2019 – 3.05
June 5, 2020 – 5.7
Third Biopsy – June 26, 2020
Nov. 18, 2020 – 3.7
Nov. 18, 2020 – 3.9
May 6, 2021 – 4.7
June 2, 2021 – 4.1
Nov. 21, 2021 – 4.7
April 8, 2022 – 4.8
Sept 27, 2022 - 5.2
Posted 9/28/2022 3:45 PM (GMT 0)
My layman's thinking is that the rate of rise since the third biopsy warrants another biopsy at this 2-year mark, rather than waiting. Even if all lesions are again G6, there may be too many lesions, too much total tumor burden, or it may be too widely distributed within the prostate for your friend to remain a good AS candidate. Put another way, you don't want to wait another year or two only to then find grade progression and have to second guess yourself about waiting.

Another though is to hold up on a biopsy and have a Decipher test done to see if he is one of the approx. 10% of G6 men who are high risk for developing higher-grade lesions and mets. A low risk result could buy time, but another biopsy appears unavoidable relatively soon given the continued rise.

What is his current PSA density? Is there a history of BPH? What is his uro saying? Was he told "we can biopsy now or we can wait -- it's up to you"? If I were on AS, I'd prefer to have 2-year biopsies with a steadily rising PSA rather than push the interval toward 4 or 5 years. I had biopsies roughly every 2-3 years just for a slowly rising PSA with (confounding) BPH and no cancer diagnosis! It was basically AS without cancer--and it paid off!

Djin
Posted 9/28/2022 6:25 PM (GMT 0)
Just curious if he has BPH. If so, maybe a TURP would give the docs a better look and larger sample size for a second opinion.
Posted 9/28/2022 7:32 PM (GMT 0)

Jack64 said...
Just curious if he has BPH. If so, maybe a TURP would give the docs a better look and larger sample size for a second opinion.

Having had both a TURP and, a few years later, a RP, I would not want to have a TURP knowing I had PCa unless I was categorically ruling out RP as a treatment choice (should treatment be needed). I would have paid a pretty penny to have a crystal ball to know before my TURP that PCa was in my future, so I could treat both conditions with one treatment, the RP.

The thought of going through both major procedures in a short time span would be devastating to me. Also, the majority of PCa lesions form in the outer portion of the prostate (the cortex), whereas most of the tissue removed during a TURP is deeper, around the urethra. I had hours of bladder spasms after my (very successful) TURP. The continuous, excruciating pain was essentially impervious to even the strong opioid combo I was given in the hospital. If I were leaning toward surgery as a treatment for (diagnosed) PCa, I would never have a TURP first.

Djin

Post Edited (DjinTonic) : 9/28/2022 1:32:26 PM (GMT-7)

Posted 9/28/2022 9:26 PM (GMT 0)
Djin Tonic, I am Pratoman's friend and wasn't near a computer when I spoke to him this morning. No history of BPH. Never had a Decipher test and I don't remember if I had a ever had a PSA Density test. In my last biopsy (2 years ago), my urologist took more samples and again only 1 came out positive (Gleason 6).

I just received the PSA result this morning and I expect a call from my doctor or his assistant within the next few days. My guess is he will recommend having another PSA in 6 months. I will ask him about a decipher and density test. I saw him a few months ago and he told me that PSA increases with age. I don't know how much PSA is expected to increase as we age.

I've had several consultations with Dr. Ehdaie of Sloan Kettering and I can also speak to him.

I thought about repeating the PSA test now, but I think it makes more sense to wait.
Posted 9/28/2022 11:02 PM (GMT 0)
Thanks for the responses guys. mitchden will take it from here.

Funny story, mitchden and I met here on HW, about 5 -6 years ago.
Postings led to emails which led to a phone call. We found out that we both spend winters in Florida. So when we got to Florida, we met for breakfast. Found out we went to high school together, graduated same year lol.

3 months later, he bought a place in my Florida community, right across the lake from me.
The rest is history.
Posted 9/29/2022 2:21 AM (GMT 0)
Hi mitchden4. Your doc will have at hand your PSA density. Rather than a test, it's just your last total PSA (in ng/ml) divided by prostate volume (in mL), i.e. your PSA per mL of prostate tissue. It takes into account that larger (normal) prostates will produce more PSA. Volume is calculated automatically by software formulas built into the ultrasound equipment whenever you have a biopsies, an US scan, or other imaging. The higher the density, the more suspicious.

If BPH (increased benign growth) isn't contributing to your PSA increase, I would think that any increase is more concerning. But remember--we are not doctors!

Best of luck to you. Please keep us informed--we learn all the time, too.

Djin

Post Edited (DjinTonic) : 9/28/2022 7:27:40 PM (GMT-7)

Posted 9/29/2022 2:53 AM (GMT 0)
Mitchden4, Possibly you can have a perineal biopsy instead of transrectal. They have almost zero risk of infection and better access to the entire prostate. Best wishes…Terry
Posted 9/29/2022 3:15 AM (GMT 0)
You normally get your prostate volume from an MRI, but I believe they can measure it via ultrasound too. Do you know your prostate volume?
Posted 9/29/2022 3:52 AM (GMT 0)
mitchden - If I read your PSA history correctly, your PSA was higher almost 2 year ago which was followed by a biopsy. Your PSA seems to be creeping up slowly overall so that warrants keeping an eye on it but does not seem be all that unusual with your long history. Might be worth considering the transperineal biopsy which samples differently and might provide some new information as well as being much less infection risk. Active surveillance is a mental challenge and not everyone can live with it forever.
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