On AS with Perplexing Results

I'm 54 and currently on Active Surveillance. No family history of PC, all DREs normal and otherwise in very good health.

My first PSA test ever was done at age 50 (3/12) which was 3.7. One year later (3/13) it jumped to 5.8 which led to first biopsy (5/13) done at Mass General in Boston by an extremely well regarded urologist/surgeon there. 14 cores taken with only 1 positive showing <1% of Gleason 6 cancer. As an additional gate to AS, that was followed by a Prostate MRI on 3T, again at Mass General, so presumably good readers, which showed no evidence of any cancer, marks, lesions, etc. completely clean. My doctor's advice was to go on AS, saying if it were him with my results, that would be his choice.

Over the next year, I had the following PSA results:

10/13 - 5.1 (down from 5.8 prior to biopsy and MRI)
4/14 - 6.0
5/14 - 5.5

In July 2014, I had a 2nd follow up biopsy as part of my AS program. In that one, 19 cores were taken, with again only 1 positive at 5% Gleason 6. Based on this, the recommendation was to stay on AS.

My PSA results after that were:

12/14 - 6.6
3/15 - 6.7
6/15 - 7.1

In September 2015, I had another MRI (again on 3T) which was completely clean showing no marks, lesions nor any evidence of any cancer. My doctor felt this result was very positive.

As part of my annual physical, I just had another PSA test done, less than one month from most recent MRI, and my PSA moved up to 7.9.

So on the one hand, I've had two biopsies, 33 cores total, which have shown only 1 core in each with a small amount of Gleason 6 AND two MRI's which have shown no evidence of anything. On the other hand, since my 2nd biopsy my PSA has shown a steady rise.

Everything I've read about MRI's on 3T indicate that they are very accurate (like 95%) in identifying significant cancers, so with two done that have been totally clean, that would suggest I have no significant cancer. And yet, I am concerned about the rise in PSA.

I would appreciate any ideas, theories or recommendations as I'm otherwise perplexed by my results.

Does anyone think that the biopsy itself, with 19 cores, may have trigger enough inflammation to have elevated my PSA for this long thereafter?

Thanks in advance.

RickTrin, first of all, welcome to HW/PC!


PSA is a very weak indicator for prostate cancer.

Biopsy and especially mpMRI are powerful indicators for PC, (or in the case of mpMRI, for aggressive PC).



You noted that your PSA has gone up and down, so clearly there are multiple contributors to the total PSA value besides your tiny amount of low-grade PC. Chronic prostate infection (not inflamation) is a common cause, but it is impossible to tell how much this might be contributing.

Your doctors seem to be appropriately focused on the important indicators. That's what I would also do if I were in your shoes.

RickTrin,

The size of the PSA number is not always an indication of the amount of cancer present or how aggressive the cancer may be. A case in point is my experience. My PSA number started climbing in 1998 when I was 51. After 3 negative biopsies, my PSA grew to 9.6 by 2011. The following Spring, I underwent a TURP procedure which finally found the cancer that was generating the PSA. 7 out of the 245 chips resected were cancerous with a Gleason score of 6. Dr. Jonathan Epstein who evaluated the biopsy told me that the cancer was small core. Consequently, the total amount of cancer found was only between 1% and 3% of the 25 gm removed. Once this cancer was removed, my PSA returned to around 1, the amount expected to be generated by the prostate tissue of 18 gm left over after the TURP. This occurred almost four years ago. I have been on AS ever since, following it with a semi-annual PSA test and an annual 3T mp-mri. So far, so good.

I can see how you'd be concerned about the rising PSA, but compared to the MRI and biopsies, it's the least significant of all of the tests you're having done. As has been pointed out, there's all sorts of things that can make PSA rise. I'm also not sure if the last PSA test was done by a different lab since it was part of a physical...if so, that's another variable.

As long as your doctor in your AS program isn't concerned, I think you can hang in there and see what happens. Hopefully you can avoid treatment forever, but even if you can't the longer you can safely delay the better. (And the stats do indicated that AS is a very safe protocol.)

A retest is a good idea. We've heard of cases were lab errors affect the result. Best to have the number confirmed.

Let us know what the results when they're in.

Andrew

PSA fluctuates, that's what it does. Some have reported that bike riding can put enough pressure on the gland to push PSA up.

It sounds like you're doing all the right things. PSA is only one indicator, and it's not a good one for cancer. Someone or other called PSA your "check engine light".

Thanks Jim.

Another biopsy may be the next step although one thing I wonder about is why not just keep doing MRIs until something significant is seen? Maybe this is too simplistic, but if these 3T MRIs see any significant cancer, like a Gleason 7 or worse, why not keep doing just MRIs until some meaningful is seen, then do a biopsy? Does this make sense?

According to a different study in 2015 of 1044 men, mpMRI's missed 1 in 6 of the G7's or higher. They're not infallible, but a great scanning tool in the toolkit. And of course they help guide biopsies to suspicious areas.

The question for your doctor is whether a small G6 is the cause of a rising PSA. If you meet with your doctor and he/she is confident in the thoroughness of your past biopsies, then you may have the same issue as me. Multiple docs have advised me that they think I have chronic prostatitis, which also behaves enigmatically. It's difficult to resolve, but at this point I feel very thankful to have minimal cancer and urinary side effects.

My advice is very simple. Call or visit your doc and have a thorough discussion about your fears and any suggested next steps.

Hang in there!
Jim

I'm not overly anxious on the PSA. I put a lot of stock in the two biopsies and especially, the two clean MRIs. If there was something significant, its highly likely would have been identified by these tests. For this reason, I'm pretty comfortable staying on AS.

I'm really more curious to know what else could be driving up PSA.

RickTrin said...
I'm really more curious to know what else could be driving up PSA.

RickTrin, it's a fairly short list.

Big picture (across large populations), there are four major component contributors to one's Total PSA value...one of which is PC, and the other three are benign. All four may be contributing at the same time. Besides PC, there is BPH and prostate infection (which most men never know they have), plus the short term bump-ups caused by ejaculation, bike riding or other activities which massage the prostate.

You could ask your doctor to help isolate each possible contributor. For example, since you've had some up and down, you probably have some contribution from infection...you could ask him to help isolate and reduce that component.

My opinion is that if you ask him for that, he'd simply tell you your current Total PSA is not high enough to worry about it...

According to my last MRI report, my prostate is 33cc, so it doesn't seem like BPH, although in the preceding MRI, about 2 years earlier, it was 27cc implying its grown 22% in 2 years vs. a about 35% growth in PSA in the same timeframe. I'm not sure that's even the right way to look at it.

Jack, per your post, it would seem more likely this is some sort of infection, again given <1% G6 in one core of 14 and then out of 19 in the two biopsies along with two clear MRIs.

RCS, based on your comment, its unlikely i have BPH as my PSA is at 7+ and I don't need to go often during the nite.

That said, over the past couple of years, as my PSA has risen (and I've had a couple of biopsies) at times when I drink more fluids, water, coffee, and I do have to go, the urgency around that has grown much more intense and is much more noticeable . If you were guessing, is that more likely to be tied to prostatitis or PCa?

Will prostatisis usually, if not always, be seen in a biopsy?