PSA higher; Free PSA lower

Hi everyone. I’m having some prostate problems and hope some of you will respond. My concerns may be minor compared to others I realize, but are worrisome nevertheless.
Age 68; father had radical prostatectomy at age 75, doing well at 93.
I’ve had my PSA checked since age 50 which was .60. It climbed rather slowly and steadily the first 10 years to 1.47 by age 60. By age 65 it had risen to around 3.5. That year I had my first pca-3 and it was 1.5 so doc did not think biopsy was warranted. The next year PSA was 4.1 and he did another pca-3 which was 1.2. He said my prostate was large and a PSA of 4.0 was probably normal for me. All my DRE’s have been good. Last year at age 67 PSA was 5.13, free PSA 16%. He did another pca-3 which was extremely low (the lowest he said he’s ever seen). He did a 12 core biopsy which was negative. Ultrasound showed the prostate to be 60 grams.
This March (age 68) my PSA was 6.01. DRE was good. He asked me to come back in 30 days for another PSA. I said I wanted a saturation biopsy and he agreed it was probably a good idea. A few days before the retest PSA, I got a stone in my bile duct which caused severe pain, infection, hospitalization, and an ERCP to remove the stone. I was on antibiotics for several days. My liver enzymes were still elevated when I left the hospital and my urologist suggested I see my primary care doc to monitor the liver function. I saw him the day before I was to have my PSA rechecked and he suggested I delay the PSA retest since I had e coli infection which could have spread to urinary tract and prostate. I called urologist office and they agreed. My annual physical was 2 weeks away and I told them I would have PSA included in lab work at that time (they use same lab and are part of Cornerstone Group). What I didn’t know was that my urologist was on vacation in Germany and had left an order with lab to email him my PSA results. When the blood sample for liver function was sent to the lab they did PSA. I got a call from urologist on a Sunday evening that my PSA was 6.77 and Free PSA was 7%. I explained the situation about the possible infection and he said he agreed with my primary that the PSA may not be reliable. Due to the inflection and possible prostatitis he put me on Cipro for 4 weeks. I have another visit with him on May 14 for DRE and pca-3. I am going to suggest PSA be checked 2 weeks after Cipro dose ends in early June. I still plan to have saturation biopsy as soon as possible. He wants to be sure I don’t have prostatitis when he does biopsy.
I was feeling like I had some hope of another negative biopsy until I saw the 7% Free-PSA. How relievable is the Free when one might have prostatitis? Can a large prostate cause this number to be low? Do you think it’s still a good idea to have the saturation biopsy even by some miracle my PSA drops to 4.0, Free goes back up to something in the teens at least, and pca-3 is real low?

Thanks for your responses.

Free PSA is unreliable for psa < 8 or 9. Your psa is consistent with your prostate size. A 60 cc prostate will have a normal psa level of around 6.
If you keep looking long enough you will eventually find something as most men your age have indolent prostate cancer cells.
Low pca3, normal DRE, psa normal for your prostate size, nothing radicle is needed.

Many thanks to all who responded.

John T: I sure like hearing that Free-PSA is not reliable for PSA values <8 or 9. I wish I could see that in some of the reports on the subject that I've read. Apparently, it's not suitable for PSA values under 2.5, but is reported to be very reliable for the grey area of PSA 4-10. I'll cling to every piece of hope I can get right now and assume you're right until my doc tells me otherwise.

Tall Allen: Thanks for the suggestion on the PHI test. I'll ask my doc about that too when I see him on May 14. I guess it wouldn't hurt to have the PHI along with the PSA, Free-PSA, and PCA-3. I'll discuss with him too the Multiparametric MRI if my labs look suspicious. I'm near Wake Forest Medical Center and they offer it there.

John T:

I was told that free-PSA is good if your PSA gets above 4

Mel

Since I posted in early May I had another DRE which was negative. The doc lowered my chances of PC to 20% from 50% based on his exam. Not sure why exactly, but I think his 30 years experience means a lot to him in his differential diagnosis. I had another PCA-3 and the number was 4 which is what I had 18 months ago. That is a good sign. My TPSA is 7.03 which is worrisome, but not as much as the FPSA of 7%. I'm scheduled for another TPSA and FPSA on June 9. My hope is the 4 weeks on Cipro will bring TPSA down and FPSA up. I have saturation biopsy scheduled for June 18 unless PSA numbers improve greatly.

I did not get the PHI. I forgot to mention it to him when I saw him on May 14. I usually take talking points with me, but forgot them and tried to remember everything I wanted to ask but forgot the PHI. I will ask if I can have it done along with my upcoming TPSA, and FPSA on June 9. Thanks for the reminder.

I have to wonder, how is it possible for my PCA-3 to be only 4 and my FPSA 7%? The PCA-3 score suggests my odds of PC are very low; the FPSA suggests PC very likely. Is prostatitis the only explanation?

History:
Previous biopsy in March 2013 was negative. TPSA 5.13, FPSA 16%, PCA-3 <5; prostate 60 grams.
Blood work done at annual physical in April 2014 showed TPSA at 7.08. FPSA at 7%.

Update:
Began 4 weeks of Cipro on April 21, 2014. Urologist did DRE on May 14, 2014 which was negative; no signs of cancer, but boggy prostate suggesting prostatitis. He also did PCA-3 test. I had PSA rechecked June 9.

Lab results:
TPSA 9.40, FPSA 14%, PCA-3 <4.

Saturation biopsy scheduled for June 18, 2014

Not looking too good fellows, but I remain hopeful.

Post Edited (hrpufnstuf) : 6/10/2014 3:21:22 PM (GMT-6)

Urologist called me at home last night. He's been on vacation for 3 weeks and just checked his records and saw that my recent PCA-3 was under 4 and my free PSA had doubled to 14% from 7% after Cipro. These labs plus the normal DRE in May lead to him to believe my chances of negative biopsy next week are very good (80%+). My rapidly rising PSA of 5.13 in March 2013 to 9.4 last week is certainly a concern, but surprisingly does not alarm him and much as it does me. He blames my boggy, fluid-retaining prostate and its large size of 60 grams as potential reasons for rising PSA. I thought free of 14% was weak, but he did not agree, saying 14% is not bad for 68 year old. I didn't think age had anything to do with free. Anyway, next Wednesday he will do saturation biopsy taking 24 cores. I need to decide by then if I want him to call with results (good or bad) or wait until office visit 6 days after biopsy. Last year he called with negative result.

I'll let you guys know the result.

I'm doing great 9 years after treatment and 19 years after my psa started to rise above 4. I had probably close to 100 psa tests and about 25 free psa tests along my journey.
I was told that by Dr Scholz, a noted prostate oncologist and also read it in a Dr. Strum article. Neither of them use free psa.
I haven' seen it anywhere else, this is 9 year old stuff and things may have changed. There are a lot of new tests today that ate much better than free psa. I would call Bostwick Labs to see what new tests are available.