Hi Mitch-
Congratulations on your diagnosis and for being such an empowered patient. You should feel really good about
taking charge of your own health and not blindly following your urologist.
There are about
even chances that the atypia they found will turn out to be prostate cancer. NCCN recommends a repeat biopsy within 6 months (
see this link, page MS-25), but it is certainly acceptable to do some other tests first to see if that is warranted.Epstein told you a very good protocol to follow:
"Follow up is warranted with serum or urine tests, imaging and, in some cases, repeat biopsy with relative increased sampling of the atypical site may be recommended."
Let's break that down:
Serum or urine tests: Next time (I would do it within 3 months), instead of having just a simple PSA test, have a Prostate Health Index (PHI), which is a serum test, and a PCA3, which is a urine test after a prostate massage. PHI, which is FDA approved, includes PSA, and a lot more. PCA3 is FDA-approved for after a first negative biopsy. So insurance should cover both (get pre-authorization). There are lots of other tests (e.g., 4K Score) but they are expensive, not any better than those, and not usually covered.
Imaging: A multiparametric MRI read by an experienced radiologist can provide suspicious areas to target on a second biopsy. In your case, because of the defibrillator, there is another kind of imaging called color doppler ultrasound. But I would only recommend Duke Bahn in Ventura, CA for that. I think he charges $700 and does not take insurance.
Repeat biopsy: If your serum/urine tests indicate cause for concern, you can opt for another biopsy. The imaging will target areas to take extra cores from, and extra cores from the area of the atypia.
Some other comments on your post:
A rubbery prostate may be more an indicator of prostatitis than prostate cancer. Did the biopsy report note anything like "chronic inflammation?" If that is a cause, sometimes a course of Cipro can bring the PSA down. At your age, the most common cause for rising PSA is BPH. How big is your prostate (they measured it when they did the ultrasound-guided biopsy).
AS is certainly acceptable if you later turn out to have low-risk prostate cancer. NCCN is even including it as an acceptable option for men with GS 3+4 and few cores that are cancerous.
If you ever do have a diagnosis of prostate cancer, there are some things you should know:
It is not correct that your only options are surgery or 40 IMRT treatments. In fact, did your cardiologist clear you for surgery? There is a kind of external beam radiation called SBRT (or sometimes CyberKnife - see links in my signature) that is completed in only 4-5 treatments. You are also probably a candidate for brachytherapy. There are two kinds - low dose rate (or seeds) and high dose rate (temporary implants). They are all good choices. Of course, if your diagnosis turns out to be low risk PC, active surveillance is a superlative choice.
While it is true that salvage surgery after radiation carries a high risk of side effects, so does salvage radiation after surgery. After radiation failure, lower side-effect salvage options include focal brachytherapy, focal cryotherapy, and whole gland SBRT. For a low risk patient, the odds of failure are only about
5% irrespective of which of those therapies is chosen.
You should also be aware that your odds of dying of prostate cancer are quite low even if you have no treatment. Assuming atrial fibrillation, chest pains, and no other comorbidities, you have only a 4% chance of dying of untreated PC in the next 15 years (2% in 10 years). Your odds of dying from something else is 58% in 15 years (36% in 10 years).
MSKCC Male life expectancy if untreated