Current diagnostics for raised PSA

Men's health
1

12 months ago PSA raised from 2.5 to 6.4. Had the MRI 3T and biopsy and given the all clear. Just put it down to worsening BPH.

Now my PSA has risen from 4.4 to 8.6 so the consultant goes down the usual route of recommending another MRI and possible biopsy. So frustrating that in 2017 we still don't have good pain free diagnostic testing for prostate cancer. I don't think i have too much choice but to go down the same route again because you always have in the back of your mind prostate cancer. Although, I was reading Dr Scurr's page in the UK Daily Mail today and he was quoting for every 1000 men that have gone down this route just one has had prostate cancer. Anybody on here had similar experiences and decided not to go down the MRI route and biopsy?

ps - is it the scan only that uses the MRI 3T and they then use this to target suspect areas when taking biopsies or is there an option out there to have an MRI biopsy for greater accuracy, like FLA.

2

Andy,

Your story reads like mine.

I had MRI fusion Bx two years ago after the MRI gave me a PIRADS score of 3. 16-core Bx was clean.  But, after the Bx my PSA started to rise even more. 

I had a second 3T MP MRI 6 months ago.  Nothing suspicious was found. I was not given a PIRADS score as there was nothing on the image to score.

Prostate volume prior to Bx was 90 cc.  After Bx my prostate increased to 120-130 cc.

My PSA has jumped to nearly 10 and is presently 8.  Zero evidence of PCa.  But guys who suffer from BPH often wish they were diagnosed w/ cancer. The reason being is that faced with a decision to treat cancer or watchful waiting, it is easier for a man to steel up the courage and opt for prostatectomy to remove the cancerous gland.  Men with very large prostates who are not candidates for TURP (this includes me) or who do not have $20-30,000 in cash to go for FLA or $15-25,000 to go for PAE, must decide to live with the symptoms or to go for something radical.

My uro, for example, is one of the top prostate surgeons in the US.  He employs open prostate surgery, and his patients fare as well as the top surgeons who perform robotic surgery.  My dilemma is whether I, at 59 and in still, praise God, relatively good health, should opt for open surgery to cut out the enlarged section of the prostate or continue to live with BPH.

What was your PIRADS score after your last MRI?

I cannot give advice but I will not undergo another biopsy, not unless my PIRADS were 4 or 5.

My health has only worsened since my Bx.  I bled profusely for 72 hours and still had traces of blood in my urine for 21 days after the procedure.  I was asleep so I don't know what that uro did to me.

I now go to one of the nation's top 10 uro centers and my doctor is world reknown. I wish I had gone to this doctor 5 years ago and been under his care all this time.  He is at the cutting edge of research and has done nearly 8000 operations. He is among the best of the best.  I would not see the guy who did my biopsy for $1 million in cash.  Maybe $10 million, but not $1 million.

Don't rush into another Bx, Andy if your MRI is clean.

3T multi-parametric MRIs are 95% accurate for negative findings. Biopsies are 60% accurate for negative findings.  That means a 3T MRI will only miss 1 actual cancer in 20 negative results wheras needle biopsies will miss 8 actual cancers in 20.  A Bx will miss cancer at a rate 8x higher than that of a 3T MRI.

And with the MRI there are zero risks/complications.

Please keep us posted, Andy.

I wish you health and wisdom in making decisions.  God bless you, Andy.

Michael

3

The gold standard in 2017 is still to offer a prostate biopsy. 3T MRI, while a wonderful adjunct, it still not perfect in detecting possible cancer.

I believe with more data, they will eventually demonstrate that with a PSA <10 and an MRI which is negative, chances of high grade cancer will be extremely low, but I can't put that in stone today.

Depending on age, health, comorbidities, etc..., a prostate biopsy may be warranted (particularly if you haven't had one at all yet.)

Interestingly, some of our local insurers adamantly refuse to pay for an MRI unless a patient has already had a biopsy.

4

In my opinion biopsies should be avoided if possible. The PSA grows higher after a biopsy and it is an invasive procedure. I had one biopsy, 15 years ago, have cancer, am not dying but went through all the pushing me to do something with my cancer. No prostatectomy, no radiation, I am still there . No

Nmetastasis either. Started Lupron on off 4 years ago only, when PSA flared to 75.

5

I started down the BPH trail with just your concerns. My uro was quick to recomend a TRUS 12 needle blind biopsy when PSA went from 2.4 to 4.2. He  Said it was in office procedure and would take about 10 minutes. After a brief discription of the process I bid him goodbye and said I will get back with him later. No way I wanted that if I could find a better solution.

I then found out about FLA for PC treatments and the 3T MRI was the first part of that and used to detirmine and do the diagnostic on the gland. This would tell precisly the size and density of the gland which would tell the doctor what my PSA should acutally  be for the size it was. This is a mathmatical calculation that the Urologist did not even discuss!!  As for me, I had a 125 cc gland with a very low density factor which was great and my PSA was low for the size of my prostate at that time. Also, and most important, the 3TMRI told me  if I had any visable lesions or spots. To be even better comfort wise, I used a pelvic coil rather than rectal coil. It just laid over my lap like a blanket during the MRI. NO entering the rectum with a coil device for 40 minutes. I really appreciated that feature.

I was told that the TRUS biopsy only covers 60% of the gland and it is totally random in the fact that the needles could possible penetrate the gland 12 times but totally miss the lesion. Also, it casued infections about 15% of the time used. This was a fact that my Urologist negeclted to mention. The MRI on the other hand covered 100% of all the gland area. IF a lesion or spot was detected THEN a single needle biopsy would be used to penetrate that specific spot.

OH NO, I had a visible dark spot. Now scared, I sent my MRI to 3 different Interventional Radiologist who each speciallized in reading an MRI for prostate cancer. All from different parts of the country. Each confirmed no cancer but suggested watch and wait on the dark spot.

I was then relieved that I had no cancer, addressed the BPH issues. I am happy to say this was now six months ago and I am sympotmatic cured of my BPH condition and very pleased. And at the same time during the procedure for BPH, they removed my "dark spot" at no extra charge. I got a kind of BOGO deal on that procedure. I will never have a 12 needle blind biopsy, ever. There are better ways to do it and I feel the MRI is it. The MRI with the trained IR in prostate issues was the best for me. Good luck.

6

I realize you are a doctor, a urologist in fact. I therefore cannot debate you - nor would I want to - in your field of expertise.

The OP stated he has already had a Bx and 3T MRI. He did not state if his Bx was an MRI-fusion guided procedure that targeted any areas of suspicion, nor did he share his PIRADS score.

Since he has a previous Bx, hopefully his insurance will not decline a 2nd MRI. From my experience the cost of a 3T MRI and Bx are very close as was my out-of-pocket share.

As I mentioned in my response, my uro is arguably in the top 10 in the US.  His surgical results rival the top DaVinci surgeons in the US.  He has been involved in groundbreaking research for three decades.

My recent PSA was 8.  Given my %fPSA and PSA density, and given my clean 3T MP-MRI from six months ago, he is not rushing into another Bx.

I would take my chances with a 3T MP-MRI over a standard 12-core needle Bx any day of the week.  A "blind" 12-core is simply hit or miss and no urologist can say otherwise.  A fusion-guided Bx is much more accurate, and I will admit to that, particulary if the MRI shows suspicous lesions and high PIRADS (4 or 5).

But a TRUS-guided 12-core Bx is going to miss more cancers than a 3T MP-MRI.

It is simple, given the small-bore needle used to extract sample cores at 12 locations in comparison to the surface area of the gland perpendicular to the direction of sample cores. 

I would hope Andy presses his doc and insurer for a second MRI and that he has a highly competent radiologist read the results. 

If his %fPSA is > 25% and his PSA density under 1.0, and down around 0.4-0.6, which it may well be if his prostate is >120 cc, and if his second MRI is clean, BPH is likely what is driving his PSA up.

Of course, a poor MRI reading with a high PIRADS changes the dynamic.  A 4 or 5 would certainly warrant a 2nd Bx (MRI-guided) to rule out PCa even given the risks associated with needle Bx, which I concur with another poster are widely minimized when uros talk to their patients.

Thank you,

Michael

7

Ah, I missed that he had a biopsy part.

In that case, I would be VERY hesitant to undergo a repeat biopsy.

Biopsies have substantial risk.

OP: How large was your prostate on the MRI? 

A repeat PSA/%Free PSA, possibly repeat MRI in the future may be warranted.

Very unlikely to have a "dangerous" type of cancer with negative MRI and (relatively) low PSA.

There's a reason why many other countries don't even screen with PSA at this point! 

8

I concur with you 100%.

I tell men all the time: do NOT rush into a biopsy, and do NOT settle for a blind 12-core Bx.

If you take your PSA (ng/mL) and divide by your prostate volume (cc) you will get your PSA density.  For example, if your PSA is 5 and your prostate volume is 50 cc your PSA density is 5/50 = 0.10.  If your PSA is 5 and your prostate is very enlarged, say 150 cc, your PSA density is 5/150 = 0.33.  PSA density > 0.1 could indicate PCa.  Lower PSA density likely indicates, but is not 100% certain, BPH.

For PSA between 4 and 10 ng/mL, if % free PSA is 25% or higher, the patient likely presents with BPH not PCa.  If %fPSA is <10% within the above PSA window, the patient likely will be diagnosed with cancer. This is a rule of thumb and guidepost, not a final arbiter of how the paitent-doctor should go forward.

Risk of infection and rising PSA post biopsy should cause every man to seriously consider getting a Bx.

If one's PSA is rising and his gland is small and if his %fPSA is low, then first seek a 3T multi-parametric MRI. After the MRI - and especially if the radiologists sees suspicious areas - then by all means take the risk of undergoing a Bx (MRI-guided, however to ensure cores are taken from the lesion(s) of concern) as it may well save a man's life.

That all said, there are far too many biopsies taking place.  And in particular, the scatter shot 12-core variety.

Hope this all helps someone,

Michael

9

Hi Michael,

Is your math a little off here or is it a typo:

5/150 = 0.033

Does it mean that with the same PSA, it is better to have larger prostate ?

Hank

10

For what it's worth: My PSA is 12+, had an MRI and then a biopsy, benign result. So many reports say that PSA is not a reliable indicator. My Canadian urologist suggested when asked that American doctors in his opinion are overly aggressive. I don't plan another biopsy without really compelling reason.

11

Michael. I agree completely with you therory. 

I do do however have a question, that is this, the person from Jersey has never said they are a doctor or MD or provided and cerditial disclosure of any kind, only that They "represent a large Urology Group" if I am incorrect in that fact, please correct me. 

So, it has never been confirmed nor denied that you are in fact debating a Medical Doctor.

12

Michael, sorry for my typo's but I am using an iPad and with I fat fingers it is  inevitable. 

To to your point, the 12 needle biopsy is in fact a main component of that industry and the current reason is that it is on the same therory as "too big too ... do away with." In 2016 there were a recorded 1,200,000 plus, needle biopsies perform in office in the U.S. at an average fee price of $1,100 each. That is a nice size single SKU product for any industry in fact this is a gross yield of $1,320,000,000 annually for prostate biopsies. This procedure has been very valuable in a lot of cases and damaging in other. But today, with new technology it is best served as a support procedure when indicated it is needed. I have had 3 Tesla MRI' s in two years and two were readily paid for by private insurance and one by Medicare. Without question I agree with you and I was much better off for it. 

 

 

13

Sorry if I didn't explicitly say; I am an MD urologist.

I don't think there was a debate, however?

I am very hesitant to recommend a repeat biopsy for patients who have had a non-suspicious MRI in most cases.

The choice in the end, however, must always be the patient. Certain risk factors (first degree family member who had the disease, etc...) may push a patient to opt for a repeat biopsy.

14

Yes, 0.033

I will try to edit my post.

PSA density should be < 0.1

15

^my typo (and it is a big one)

PSA density calculation

5 mg/mL divided by 150 cc volume = 0.033

This would be a good number and indicator of enlarged prostate driving up serum PSA.

16

I do apologize.

My choice of words was unfortunate.

I've followed many threads here and knew the poster to be a urologist. I meant to preemptively avoid conflict with a medical doctor but may have inadvertently caused it.

I meant no disrespect to someone certainly much more knowledgable than myself.

Michael

17

It seems paradoxical, but yes, for a given PSA, especially when in the "danger zone" of > 4.0, a larger prostate volume tends to point toward benign BPH. It is possible to have an enlarged gland with cancer, however. Seems as though nothing is easy or crystal clear when it comes to the prostate. 😊

18

Yes, having a first degree family member (father, brother, son) diagnosed with PCa may require a more aggressive approach to rule out cancer. Very good point that I and others failed to mention.

Thanks

Michael

19

I fail to see how, unless they, any person, have had a personal experience with PC could be as knowledgeable as you about said subject, let alone More knowledgeable than you.

20

How long agao didn you have the MRI 3T  Ken