Should I have a prostate biopsy?

Cancer
1

Introduction

I’m 70 and have a PSA which was at 4.6 when I was 66, and while it has been regularly monitored over the past 18 months or so has been moving up and down between 6 and 7.  My doctor thought that I should be referred and I have had two hpital appointments, but I have so far decided against having a prostate biopsy, though it is obvious that my local hospital’s oncology department would like me to have one.  The health worker I saw at my first hospital appointment was happy to discuss the issue with me, but I suspect the consultant I just saw probably thought I should stop wasting his time and get booked in for a biopsy without further delay. 

I have received information from those two appointments, but I have obtained much more information from online research.  Based on studying a number of online medical reports over the period 2008 – 2014, it is evident that there is increasing prejudice, at least in the US and Australia, against the use of prostate biopsies.  The primary reasons for this seem to be an increasing risk of serious infections from the most common type of biopsy, a growing recognition (though this may be controversial) that psa screening and biopsies are ineffective in reducing the incidence of terminal prostate cancer, and that screening and biopsies contribute to massive ‘over treatment’ of prostate cancers

 

Summary of Statistics (some of which may be controversial but all of which are based on (my interpretation of) studies published in urological journals, research reviews and conference speeches by leading urologists).

Of every 100 men who have a prostate biopsy:

·         97 didn’t need it (that is, they don’t have a prostate cancer requiring treatment)

·         6 will get a serious infection as a result (a figure which has doubled in recent years), which will cause them to be hospitalised, and from which a very occasional man will die, while others (we don’t know how many) will have persistent painful side effects

·         between 17 and 22 will be offered treatment that they don’t need, as a result of which about 25% of men in their 70s will become incontinent or impotent.

 

The Perceived Indicators for Biopsy

Primarily a raised psa; a psa which has increased rapidly over a fairly short period, typically a year; smoking; family history of prostate cancer; age (considered with the other factors).  I have a raised psa, but it’s not dramatically high – it’s been between 6 and 7 over the past 1 ½ years, and it has not increased dramatically – it was 4.6 five years ago.  I do smoke, and I am 70, but I am generally in good health, and there is no history of prostate cancer in my family that I know of.

 

Statistics Based on Recent Urological Papers

Of every 100 men who have a biopsy, between 75 and 80 have no cancerous cells and didn’t need the procedure; 20 to 25 will have cancerous cells found on biopsy BUT a large percentage of these men will have a tumour which develops very slowly, will not be terminal and doesn’t really need any treatment.  Only a small percentage will have an aggressive tumour requiring immediate intervention; the Harvard School of Public Health, in a 2014 paper, put this percentage at 10 – 15%, or 3 men out of the 100. 

This means only 3 out of every 100 men who have a biopsy really needed it.  And there are two other real concerns.

1.       The one certainty with prostate biopsies is that 100% of the men who have them will have ‘side effects’.  Some will be shortlived and not really a problem, but some will be painful and longer lasting, and some men, currently about 6 out of the 100, will be hospitalised with serious infections, and the very occasional one will die.  There are no statistics for the number of men receiving treatment for post-biopsy infections at doctors’ surgeries.  I don’t necessarily see this as a reason not to have a biopsy, because obviously if you really need a biopsy to diagnose a terminal cancer then it’s worth putting up with the side effects.  But do you really need it?

2.       Most worryingly, doctors apparently can’t tell from the biopsy result whether cancerous cells denote an aggressive tumour which requires immediate treatment, or a slow developing tumour which probably does not need any treatment.  As a result, as I understand it, all patients with cancerous cells may generally be assumed to need immediate treatment, such as hormone replacement, radiotherapy, chemotherapy, even though 85-90% of them don’t need any treatment.  Research papers suggest that in men in their 70s, 25% who have this treatment will become incontinent or impotent as a result.  Many of these men will suffer these consequences despite the fact that they didn’t ever need the treatment they were subjected to.

 

It’s also worrying that at two hospital appointments the issue of what happens after the biopsy has not been raised, even though it was clear that both the people I saw thought I should have a biopsy.  Maybe they would say that it would have been raised if and when I agreed to a biopsy, but given concerns about receiving unnecessary treatment, I feel it should have been raised at the time the issue of having a biopsy was raised.  Would they have explained to me that if cancerous cells were found, they might not be able to tell whether I needed treatment or not?  Would they have told me that there was a risk (if not a certainty?) that I would be ‘offered’ treatment that I might not need?  Since they did not have that conversation with me I cannot answer those questions.

Conclusions

My psa is raised but not highly raised and it didn’t move up fast, so I feel it is not at present a firm indicator of the need for a prostate biopsy – it’s inconclusive.  The only additional risk factor I have is that I smoke, and I suspect that is often overplayed by the NHS.  According to NHS statistics, I should be suffering the ill effects of smoking by the age of 70, in the form of early signs of lung cancer, but when I had a chest scan a year ago it was clear.  In addition I have an enlarged prostate – which was determined at my first hospital visit not to feel cancerous – which means I would have a heightened psa anyway.

I have been offered another appointment by the hospital in six months, and I am going to take that up, but unless things change I think that has to be the last for the moment.  It’s pointless me trooping up to the hospital every six months when I don’t want a biopsy – which is all they can do by way of diagnosis – and there could be people with aggressive tumours urgently needing those appointments.  So I need to decide over the next six months finally, whether I am going to have a biopsy or not. 

The hospital has asked me to have another psa blood test before I go for the 6 month appointment, but I have asked my GP for three-monthly psa tests, so that I can get more of a feel for movement on the results before I go for the hospital appointment.  If my psa is suddenly moving up rapidly over the next six months, then, depending how fast and how far it is moving, I may agree to a biopsy.  Otherwise it is unlikely that I will, in which case there is not much point in the hospital continuing to see me – though I will ask my local surgery to continue monitoring me with 4 or 6-monthly psa tests.

 

At the age of 70 I still work full-time (for myself), and having unnecessary treatment for prostate cancer would certainly have far more of an impact on my life than having a slow developing prostate cancer which would not affect my health or life expectancy, and might even have more of an impact in the short term than having an aggressive prostate tumour.  So it’s a numbers game.  None of us is going to live forever, and at my age quality of life is more important than lifespan.  Younger doctors especially often don’t take account of this, and assume that keeping you breathing, no matter what state you are in, is some sort of medical triumph.  Not surprisingly, there are lots of older people who don’t see it that way!

 

2

Hi terryw,

Without sounding harsh all the stats around the web are fine but the bottom line is you may! Have cancer and the sooner you find out the better it can be dealt with, hopefully successfuly. My psa was 5.2 after biopsy gleason 3,3 (6) after removal T2c RO NO MARGINS This all took place within 2 months diagnosis to removal. Agree not all like to move so quickly but if it is confirmed pads are better than departure from this life. Don't be afraid of thr biopsy the risks are a lot less than the alternatives should you go on undiagnosed and then find iys to late! ! I am 64 for me there was no stepping back Forward get it dealt with. A life in the Army may have helped.

All I can say is I had all this done in Grrmany so if I trusted a Germam Urologist I would think your task is easy TRUST your doctor or find another. By yhe way mine was fantastic and its true 4 door techneak really does work! Good these Germans.

Well I wish you lots of luck and my advice is go and get it sorted NOW

Best of luck

Ian

3

G'day TerryW and welcome to the world of indecisiveness...

By the sounds of things you have done a pretty good job of convincing yourself NOT to have a biopsy...

From a personal viewpoint I have been one of those that has had a biopsy done...it was a quick painless and simple procedure after which I drove myself home and had absolutely NO effects from it whatsoever... :-)

Unfortunately I am also one of the so-called 3% that has an aggressive tumor...

I truly hope that this is not the situation with you or anyone as I know what's ahead for me...:-(

I am a big believer in everyone's right to choices however Prostate Cancer is not something I would ever take lightly...

Good luck with you decision making but just remember one thing - I'm now and always a couple of steps behind my cancer and will never catch it...time is an extremely important factor...

4

Hi Terri, this is such a difficult call. Without the Gleason score you cannot assess the competing risks. Without a biopsy you cannot get the Gleason score.

I don't think you have had an MRI scan. I am firmly in favour of an MRI scan as part of the information feeding into the decision about a biopsy.

5

Yes, well ... take a look at David 41094 's posts.  From their optimistic beginnings,   to the ongoing reality check !

Also if you think you are tough enough take a stroll through your local Hospital's Rad/Oncology suite, have a look at the pallor and resigned despair of the Patients,  the tubes etc.,  and then speak to one or two people about dying from terminal Prostate Cancer.

Yes,  your Consultant does think you are wasting his time because he lives with the disease,  trying to preserve both life and it's quality.   Yours in fact.   And you are a 'Johnny come lately '  trying to intellectualise your way through a maze of statistics,  thinking that you will dodge a bullet.   Well,  you may ...but even so in that event,  no-one else can benefit from your good fortune and so you can't really contribute very much to a site like this where many participants are fighting for their lives.

Incidentally I assume that at the moment,  you are pain-free ?

In the meantime,  please do us all a favour on this site and don't persist with your hypothetical.

Thanks and Regards,

Dudley 

 

6

I like the way you put it and you are absolutely correct, well said.

Tommy

I have to say my only thought was fear! When I walked out after my biopsy, but you have to fight with all you have and get the support of those around you. So come on terry get down to your urologist and sort it!

All the negative talk is not good for those looking for a LIGHT at the end of the tunnel.

Good luck ALL

Tommy

7

I entirely agree with your approach. Biopsies are invasive and generally painful. 6 percent of people will require hospitalisation as a result of sepsis and one in a thousand people will die as a direct result of the biopsy. I would recommend a scan which will provide at least as much useful information. Only then would I consider a TARGETED biopsy. The prostate is the only part of the body which is routinely biopsies without prior imaging - madness in my opinion, especially given that it is  typically trans-rectal. I would read 'Prostate cancer breakthroughs' by Jay Cohen MD which gives a step-by-step approach to diagnosis and treatment. I wish you well.

8

I entirely agree with David.

9

It seems likely that posts on PCa and an acceptance of and concurrence with Professional Medical Advice ;  as opposed to individual interpretations of statistics and deferrment of treatment,  will continue on this Site and so it may be helpful to try and clear away some of the fog of generalization :

It is acknowledged and accepted within the Medical Profession that unilaterally there are no empirical studies on PSA/Biopsy/ infection rates/ treatment/mortality et al.  And this lack of uniformity produces unclear Clinical Data.

Currently for example,  statistics on infection do not necessarily show the age bracket,  ethnic origins,   or underlying health status of the Patient,  nor what the biopsy's resultant Gleason score was for that Patient.  

Just as an example,  in my case I was given to understand that as my underlying general health status is pretty good then even though I'm in my early seventies, I would not be at contra- indicatory procedural risk.  And so it was.  But hypothetically if I were say in my late seventies/early eighties and had diabetes and a cardiac condition and therefore had an impaired immune system,  then I might easily have sustained an infection/death.  And that's not to say that even with that underlying scenario I didn't need the urgent Prostate assessment, seeing as how I'd been ignoring impaired flow for a long time and now presented with no-flow urinary symptoms,  suspected to be caused by a Prostate tumor.

What seems to me as being most relevant in choosing a way forward,   is the Provisional Diagnosis,  Opinion and Recommendation of your Consultant.  He/She will have assessed you,  your current general health status,  your medical and Family history,  your test results and your symptoms if any.

Based on years of Training, Continuous Study,  Practical Experience and Peer Review Consultations,   the most expedient and beneficial course of treatment will be recommended for you. Those initial consultations when they are focusing intensely on you Terry,  are vital.  And if they thought you were at increased risk of infection,  they would definitely appraise you of that.

Having been through the process and during that from what I was given to understand generally,  your particular type of PSA velocity creep is pretty much indicative that you have a PCa issue to address or at the very least,  illiminate.  

What you don't want,   is for slow-growing PCa to turn aggressive on you.  And it can and does.  And you DEFINITELY don't want to die of an un-treated PCa. that you could have completely knocked off inside 6-12 months,   were it not for the confusing muddle of inconclusive statistics you are wading through.

To conclude,  I quote you :  ' ... and at my age quality of life is more important than lifespan '.  

Well,  I'm sorry to tell you that if what may well have been a slow-growing PCa is turning aggressive on you,  you will not have a quality of life,r a life-span.

 

10

Terry

I read with great interest your posting and the very first thing that struck me and that George and another has pointed out is the issue of an MRI Scan. Another key fact that you mention is that you have an Enlarged Prostate. 

A major problem in the NHS at many of their hospitals is this insistence that they Biopsy before they do an MRI Scan. If you attend any of the major specialist centres or if you speak with leading Urologists around the UK you will find that they all recommend an MRI before biopsy. In addition to the MRI many places also offer the PCA3 Urine test. A combination of both of these non invasive tests can put your mind at ease on the risk of you having Prostate Cancer and subsequently requiring a biopsy to confirm a diagnosis. 

A major problem with biopsies taken before MRI's is that even if a positive result is found you will still need that MRI scan to determine the extent of the cancer. The trauma of the biopsy often means you have to wait several months for the prostate to settle down to enable a more clear scan to be taken, often leading to more anxiety.

For you peace of mind, I would recommend seeing if you can get an "Enhanced MRI" and a PCA3 test. 

Neither of these tests were available to me in 2012 when I had my surgery. I just had the standard MRI after my biopsy. My surgeon/urologist told me that he would have preferred me to have had the scan before the biopsy. Due to the trauma of the biopsy my scan only showed cancer on the right of my prostate. When it was removed there was considerably more cancer on the left and the apex - this wasnt seen on the scan due to the biopsy.

So get a Scan first and then sit with your consultant and decide upon next steps after that. 

Also, try not to worry. You say you ahev an enlarged prostate. I am assuming you are on medication to reduce that? You wouldnt do anything until your prostate has reduced in size anyway. Are they giving you an MRI for your Enlarged Prostate or are you just relying on an ultrasound?

I would highly recommend that if you are worried you give the help line at Prostate Cancer UK a call. The clinical nurses who man that service are excellant and can answer any worries you might have.

Best regards

Eddie

11

Entirely agree, Eddie. The NHS typically get this the wrong way round with the result that many people suffer unnecessary and blind biopsies. I would insist on an MRI first and see what this reveals. It is a painless procedure and most NHS facilities use the latest 3T DCE machines (try to insist on this as the old 1.5T machines can miss smaller nodules). My MRI found a nodule in the left apex. I did further research and found our that the apex is often missed in routine biopsies due to the anatomy of the rectum/prostate and nearly all false negatives are due to PCa in the apex. There is a good chance that my nodule would have been missed by a blind biopsy. You need to weigh up a number of factors (PSA, PSADT, freePSA, family history, prostate size etc etc) but if I were in your position I would not even consider a biopsy for exactly the reasons you have given. Others will disagree, but I think you are the perfect candidate for Watchful waiting.

12

Its simple the costs are lower for the NHS to give biopsy without MRI. What about ivp scan no one mentions it its quite common in Europe to give biopsy followed by IVP SCAN.

I would like to believe that the Urologist would have a good idea of what he may find with an increasing PSA. It sounds like the biopsy procedure in the NHS should be looked ay of so many men are doubtful of the risk, which are very low and the benefits out way the small risk, when you find it and DEAL with it!

You could carry on as you are but it may become to late to give you a successful outcome! Think about it carefully and stop all the confusing facts you keep displaying to those who look for a simple answer.

13

The simple fact is that this disease has been massively overdiagnosed and massively overtreated in the past. Most people are put on a conveyor belt of high PSA, biopsy, RP. The largest study of its kind (July 2012 New England Journal of Medicine) showed that surgery produced 3% fewer deaths than watchful waiting. But at what cost? I think it is madness for a man of 70, with PSA ranging between 6 and 7 to even consider invasive treatment and I am sure most Urologists would agree with me. 70% of 70 year olds have PC and the vast majority will never know anything about it. I would urge Terry to read any of the books available on the subject (Walsh, Cohen, Horam etc) and to make an informed decision. Google PIVOT (Prostate Intervention versus Observation trial) to get the full picture.  

14

I was just looking at the Professional Reference section on this website (look up and you will see it) and followed the link to Prostate Cancer. What follows is a copy and paste from that webpage.

Prostate cancer screening with the PSA blood test therefore results in at most a small reduction in prostate cancer mortality and leads to considerable diagnostic and treatment related harms. Most men with prostate cancer detected by PSA testing have tumours that will not cause health problems (overdiagnosed), but almost all undergo early treatment (over-treated).[4]  At age 70 I think you can safely forget about PC and get on with living. As I have said before, the majority of your contemporaries also have PC (about 70%) so you are in good company.

All the best.

15

Many thanks to everyone who has posted on this thread so far with helpful comments.  Just to pick up on some points made, I am not on any medication for an enlarged prostate, which is something I suspect a lot of guys of my age have, and I don’t have any symptoms.  The whole thing resulted from a psa test that my doctor suggested I had because of my age, and it has gone from there with further psa tests, and my doctor’s suggestion that I be referred to the local hospital.  Even the doctors at the practice don’t seem to agree on the approach.  I was sent a note on one of my test results, obviously written by a different doctor, saying my psa was slightly raised but nothing to worry about.  Considering that my psa must have been raised for two years or more and I still don’t have any symptoms, they could well be right.  I’m well aware that whichever way I decide to go I could be making a really bad decision – there are no easy options here – but we’ve all got to go sometime, and if it turns out fairly soon to be my turn, well at least I know I made what I considered after looking at all the information, was the best decision for me at the time.  Which is all any of us can do.

What has mainly concerned me is the lack of information from the hospital.  I’m sure they are doing the best job they can for me, as they see it, but I really think they should be telling me much more.  Most of the information they have given me has come from me asking questions based on my research.  They haven’t mentioned an MRI scan, nor any tests other than the standard psa.  My key question now, as I think I said above, is whether they would be able tell from a biopsy result whether – assuming I have a tumour - I have an aggressive tumour or one not requiring treatment – and the only reason I hadn’t asked before was that I wasn’t aware of that possibility until I did further research after my second hospital appointment.  I really think that was a conversation they should have been having with me when a biopsy was first mentioned.  After all, it is a fairly unique situation.  Usually, being found to have cancer means you’re on your way out soon.  Prostate cancer must be unique in that that isn’t the case for most men with tumours.

I will post on this thread what I decide to do next, and if this thread is still up in years to come I will post in the future on whether I made a bad decision and I’m on the way out, or whether I’m still going strong.

 

16

I am strongly in favour of MRI scan first. It is non invasive, moderate to slight radiation and informative. Then one can weigh up whether a biopsy, invasive and risky, is a good option so that the potential danger of a tumour can be assessed by pathology.

17

Hi Terry,

I appreciate all your research and applaud you for your work.  Urologists like to do surgery and are awarded handsomely depending on their country for doing so.  They are also obligated in the USA to follow "standard of care" as opposed to "evidence based practice" or risk a malpractice suit, hence the almost universal recommendation for surgery. 

I have had prostate cancer identified by color doppler guided biopsy in 2005 when my PSA was 20.  My doubling PSA time is just over five years.  I am now one year younger than you.  Knowing what I now know about biopsy I would never have one with your stats.  Your cancer appears to be very slow growing (like mine).  Urologists like to use PSA velocity to determine aggressiveness, it is a conceptually flawed marker.  PSA doubling time records whether the cancer is changing from slow growing to fast growing (a conceptually better measure of blooming aggressiveness).  My PSA is now 86 and I have no symptoms and would have zero concerns were it not for a trigger happy GP who recommended PSA testing when I turned 50.  The US Task Force suggested against PSA testing and biopsies.

A thing I would encourage you to look up if you are considering a biopsy is a thing called "needle tracking."  Urologists will tell you there is no such thing.  I would like you to imagine sticking a fine guage needle into a lemon, withdrawing it and then licking the needle.  It would taste like lemon.  Your cancer is very likely encapsulated within the prostate.  With eight or twelve biopsy sticks you will have broken the capsule and risk "lemon" throughout your body (hopefully none of the prostate cells would take up residence as metastasis, but at this point with what I know I personally wouldn't take the chance).

I would suggest that you live your live, make friends with your cancer and enjoy the integrity of your life......oh, and give up smoking it can kill you.  

You might want to look up my post as it gives greater details of my situation.  I wish you the best. 

18

By the way, Terry, if you do have a biopsy, in addition to your Gleason score, you should find out whether the cancer is haploid or diploid.

19

Sorry I couldn't find your post...???

20

Thank you Carl for that  idea new for me. I have looked that up and find that it is a further indication of how agressive the cancer is. I wonder if it is too late to find out with the biopsy now 6 months old? Probably not as scientific people seem to squirrel things away just in case. While I got one of the most agressive treatments available it could make a difference on the closeness of follow up. My reasoning being that the earlier the treatment on recurrence the better the outcome is likely to be. A question to be added for my list for my oncologist.

The follow up attitude seems to be the longer the PSA Remains tiny or at the nadir the more relaxed one can be. The statistical analysis suggests to me that close attention is needed to measure the nadir or discover the treatment has failed. Then with a load nadir there is a period of low risk of reoccurrence followed by a period of increasing risk followed by a low risk. Theses periods are determined by the PSA history and Gleason score. I have not seen haploid and diploid deferentiated anywhere.

No harm done of course in discovering the haploid/diploid fact if there is no recurrance. Just continuing aggressive attitude to prostate cancer - no quarter given or accepted.  (In am sticking with the bellicose metaphors PC incorrect or no. PCa is an implacable enemy.) If the Oncologist doesn't know and is unwilling to find out I shall press for follow up on the basis that it is haploid (23 chromosomes ) and so the more agressive (that is treat the Gleason score a little more pessimistically). 

Thank you Carl. That is a very helpful suggestion.