Asking for a friend….really

A friend asked me to put this out for a response. He has been on AS since 2016. But doesn’t look like a rigid AS Program to me. Partly because no MRIs. That is because he can’t have an MRI Due to an ICD Defib implant.

I’ve pasted below all of his PSAs and dates of biopsies.
Important to note:
First biopsy report came back from local pathologist, as G7. Slides sent to Epstein at JH , Epstein said, the pathology was “inconclusive and it couldn’t be determined if it was actually cancer”. Later on, pathology at MSKCC called it G6.
Second and third biopsies, both came back one core G6. Epstein concurred on both.

.All PSA tests done with same assay. He believes it was all the same lab, except the two results from Nov 2020.

So with that information, and the series of PSA results pasted below
1. At what point would you treat?
2. Time for another biopsy? (That should probably be the first question, and I would guess yes)
3. Should he have a perennial (Sp?) biopsy?
4. Antibiotic then retest first?
5. CT Scan instead of MRI?

He meets with Dr in two weeks and just wants to get his ducks in a row.

PSA Tests and Biopsies
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 (Ultrasenstive)
June 5, 2020 – 5.7
Third Biopsy - June 26, 2020
Nov. 18, 2020 – 3.7 (Lowell)
Nov. 18, 2020 – 3.9 (Zimmerman)
May 6, 2021 – 4.7
June 2, 2021 – 4.1
Nov. 22, 2021 – 4.7
May 12, 2023 – 5.4

Good point Mumbo, he is 73.

I didn’t think the PET Scan would show anything but actually that’s a good idea.
And I agree I couldn’t let it sit forever. He seems to have no problem doing that if it’s safe. Everyone is different.

In light of the MRI situation, I suggest that the next biopsy be a saturation one, with 20+ cores. Even at his age, you want to rule out any progression to more serious disease. Otherwise his PCa can putter along.

Djin

Maybe he should consider a Decipher test on next biopsy sample to get additional data from different vantage point.
Saturation biopsy possibly but transperineal either way to sample differently (and reduce infection risk, pushing odds as it is).

I requested a transperineal biopsy guided by a the ExactVu microultrasound in real time. This was at Johns Hopkins. I have heard that I am the only patient who had this done. The head of Urology had even written a booklet on interpreting the microultrasound images into a PIRADS-like risk assessment.

He found a lot of lesions he thought had significant cancer. Really scared me.

The biopsy pathology found no evidence of cancer. JH has since concluded that the micro-ultrasound gives false positives.

Based on my experience, micro/ultrasound is not ready for prime time.

I still think he should consider a PSMA-PET/CT scan since the MRI is out. An estimate of prostate size would be helpful. If he is up for it, a saturation transperineal biopsy of some sort would be a good idea as others have suggested. He has got time on his hands to arrange such things.

Does your friend "behave" and prepare for his PSA test a couple of days ahead of time? Seems larger prostates and prostate influenced activities cause all sorts of variances.

Prato, first of all the drop in PSA might or might now mean anything. Mine actually went into the 5's pre-treatment then dropped back into the 4's just before I had brachytherapy. The fact is that he has had a steady increase over the years which might be age related/prostate size related or due to increased cancer activity. Depending on his insurance he might have trouble getting a PSMA scan approved given his stats though it certainly can't hurt to ask. As important is your point suggesting his active surveillance become more "active". I think Djin had the right idea, i.e. it's time for a biopsy with 16 - 20 cores.

Jim