Prostate biopsy for hi PSA level

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Greetings all

I seem to be having chronic problems with a raised PSA level. I have a urologist but have turned down just about everything he wants to do to me, just because cic seems to be solving my problem. I'm not having any symptoms of prostate cancer - actually I don't think there are any symptoms - but my yearly blood tests for medicare and some other ones I've had lately keep showing a high PSA. It's been 5.7 and now my doc says its 6.4. About a year ago we tried antibiotics to bring down this level. He said normal for me would be between 0 and 4. So he has made another referral to my urologist and I suspect they are going to recommend a biopsy.

I am doing cic on average about 4 times a day depending on how much water I drink. I understand from reading these forums that this can raise PSA levels. My doctor (GP) concurs but apparently doesn't think that can account for that much of a raise??? I know he doesn't really like me doing cic and thinks I should have gone with my urologist's plan for Green Light laser so he is not real helpful with the cic thing. He wanted to give me another round of a/b to see if that brings it down as it did before. I was surprised it brought it down because I did not have a UTI; at least not like the prostatitis I had when all this started. He says I have chronic prostatitis but I corrected him on that; so, anyway, I take this doctor's advice with a grain of salt.

So my question is: should I do a biopsy based on a fluctuating PSA blood level? It mostly has been spiking up. I am using a hydrophilic coude catheter and don't have a problem getting into the bladder with it but I suppose it is nudging the prostate on the way in.

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  • Posted

    Do you know what your PSA density is ( PSA divided by the size of the prostate)? Larger prostates will result in an increased PSA. Although most urologists use a PSA level of 4 as a reading where a biopsy should be considered, some urologists are willing to look at PSA density. PSA density in my mind is a better measure.

    Here is the title of a technical article on the subject:

    Re-examining Prostate-specific Antigen (PSA) Density: Defining the Optimal PSA Range and Patients for Using PSA Density to Predict Prostate Cancer Using Extended Template Biopsy

    Here's the closing paragraph from the authors:

    " Although screening for prostate cancer with serum PSA can result in an alarming number of men to undergo unnecessary testing, the use of PSA density helps avoid biopsies in men whose PSA may be elevated, but appropriate for the size of the prostate."

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    • Posted

      Rdemyan, thanks for your message. It reminded me that I wanted to tell Keith to ask for a 'free PSA' test. When my PSA number went to around 6, I declined a biopsy, so the urologist that I was going to at the time prescribed the 'free PSA' test. This test is much more definitive as to whether there is actually any cancer. And it's completely non-invasive. My test results came back: "no cancer".

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    • Posted

      I had the Free PSA test in 1995 when it was new. In the UK hospitals knew it was better but did not do it as it was much more expensive. The Uro I was seeing said that they had been given funding for a trial they had been successful but the accountants did not let them continue.

      I seldom ever hear it mentioned on this or other forums.

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    • Posted

      Yes, but I'm not stating what I think the cutoff should be because I'm not a health professional. Read the technical article for some guidance if you are interested.

      But I would definitely have the DRE, free PSA and PCA-3 tests. I've had those and just underwent the 3T MRI last month. All tests indicate no prostate cancer, even though my prostate is 100 grams in size (as measured by the 3T MRI) and my PSA adjusted for taking dutasteride is 4.0. So, in my case, I see no reason to have a prostate biopsy.

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  • Posted

    Your urologist is using the old recommendations. It is well known that PSA levels increase as we get older, and the 'magic' 4.0 number is probably appropriate for younger guys, but not for anyone over 60. As you noted, other things can affect the PSA numbers, including CIC. But there are also other causes such as bicycle riding, certain exercises, digital rectal exams, etc. But you are doing the right thing to watch and wait.

    Your urologist is recommending the Greenlight laser most likely because that is what he is most familiar with. It has been around for years, but now there are other, less invasive procedures that will give you good results without the side effects of the laser 'reaming'. One thing that they don't tell you is that procedures such as the laser, TURPs, etc. actually are removing sections of the urethra itself.

    Personally, I went for the Rezum procedure because it only treats the prostate tissue itself, and leaves the rest of the body intact. And it doesn't preclude you from getting an additional treatment years down the road if you decide to.

    I strongly suggest that you avoid the blind biopsy. If you actually did have cancer, the needles may or may not find the actual tumor. And because it's invasive, you may end up with problems created by the biopsy, such as an infection or prostatitis.

    If it were me, I would find another urologist who is more up to date on the various procedures.

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    • Posted

      This is from a much longer article I posted earlier this year:

      TURP and PVP are performed with surgical instruments that allow for continuous irrigation of the prostatic urethra and bladder. When tissue is vaporized with a greenlight laser, or cut with a TURP resectoscope, there are many tissue particles that float in this irrigation fluid and are taken out of the patient through the scope. They just do not condensate. TURP and PVP destroy the urethral lining (the correct word should be endothelial - rather than epithelial, endo means inside, and epi outside, so the epithelium applies to the skin, and the endothelium to all "internal skins", it is used for any lining of internal organs), but this epithelium grows again and when you look inside after some time, you see it has regenerated completely. In some areas there is some scar tissue, specially after TURP, but as it happens with wounds in the skin, the regenerative process manages to cover the wound surface completely.

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    • Posted

      Derek, yes I have heard this explanation before, and I'm sure that the urethral lining does regenerate/regrow in time. Still, I think that there's just something very logical about ablating the tissue inside of the prostate itself and minimizing the effects on the rest of the body. Except for the need to temporarily catheterize (I strongly recommend self-cathing for a couple of weeks or so after Rezum), the recovery for most patients is relatively easy.

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    • Posted

      It really seems like "normalizing" the PSA by dividing by the prostate size is the way to go. My guess is that they don't want to encourage this because then it means that patients will need to have a "test" to determine the size of the prostate. Said test is probably quite a bit more expensive than a PSA test. Still, if a guy already knows his prostate size, normalizing the PSA reading to PSA density is the way to go, imo. Almost every other technical field uses normalization to remove variables - in this case, the knowledge that large prostates just naturally produce more PSA - in order to provide more meaningful comparisons. For example, I work in the energy conservation field. We routinely divide a building's energy use by the square footage of the building. Otherwise, it wouldn't make sense to directly compare the energy consumption of one building that is 50,000 square feet with another that is 500,0000 square feet. Larger buildings of the same type (office, warehouse, lab) just naturally consume more energy mostly because they contain more people. By normalizing we can directly compare the MBTU/square foot used by the small building with the big building. I see no reason why something similar can't be done for prostate PSA measurements.

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  • Posted

    I have also had a rising psa. I had a biopsi and then a mri - both negative. An enlarged prostate does not increase your risk of prostate cancer and psa is not a great indicator. I am very relieved that I had the biopsi and mri.

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  • Posted

    I have also had a rising psa. I had a biopsi and then a mri - both negative. An enlarged prostate does not increase your risk of prostate cancer and psa is not a great indicator. I am very relieved that I had the biopsi and mri.

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  • Posted

    Rising PSA over many years - up and down and 4 biopsies all negative. started cic 2 years ago after 2nd PAE didnt work. MRI looked ok 2 years ago with high PSA but in October my 4score test came back 92% likelihood of Pca. And 3t-MRI guided biopsy results Gleason 10. i think I have had a slow growing tumour for years. would recommend the 4score and if you have a biopsy make sure its at minimum MRI Fusion.

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  • Posted

    you should have mp 3T MRI of your prostate to see what going on, before any biopsy, and if biopsy is needed, based on PIRADS scoring from MRI, consider only MRI guided biopsy, in bore or fusion, preferable by well experienced radiologist

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    • Posted

      I didn't know what a fusion biopsy is. This article explains it very well:

      Moderator comment: I have removed the link(s) directing to site(s) unsuitable for inclusion in the forums. If users want this information please use the Private Message service to request the details.

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    • Posted

      Absolutely. My PSA steadily increased over many years from 3.0 to above 10. 3T MRI showed suspicious lesion, PIRADS 4/5, so I had a targeted biposy. No PCa. High PSA most likely caused by large prostate (90 cc).

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    • Posted

      that's my case, PSA gradually increasing to 10.3 over the previous 5-6 years, 3 years ago had MRI, PIRADS 4, followed with Bx, Gl 6, one core with 10%, on AS, over a year ago in Feb/19, MRI guided in bore biopsy with Dr.Busch, took 3 cores from suspect points, pathology found nothing, despite PIRADS 4 by Dr.Busch and few points with ADC in 700 range selected for Bx, his explanation: likely fibrosis, still on AS as of now, prostate volume increased by ~50% over 2 years ago to ~60cc, partially explaining why PSA is increasing

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    • Posted

      Alright. If you google on "fusion biopsy" the first hit in my results was an article by the Cleveland Clinic entitled "Fusion Guided Biopsy: A Smarter Way to Look for Prostate Cancer"

      It's a good article IMO.

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