Should I have a prostate biopsy?

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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!

 

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  • Posted

    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.

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  • Posted

    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.

     

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    • Posted

      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.
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    • Posted

      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.

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  • Posted

    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. 

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  • Posted

    Hi Terry - about 4 years ago, then aged 77, I complained to my GP about a 'weak flow' and suspected it was simply an enlarged prostate. Blood tests showed my PSA as normal but after his rubber glove examination he told me the prostate felt unusual and recommended a biopsy. I baulked at this, knowing the risk of infection, the uncomfortable nature of the biopsy and having normal PSA. However, he insisted, saying 'if you were my Dad I'd make sure you had it'. So I did and was diagnosed with prostate cancer and underwent the prescribed 56 sessions of radiotherapy and 2 years of Zoladex implants. The side effects of the Zoladex have been total impotence, shrinkage of penis and testicles, absolutely no sexual desire, continuing hot flushes 18 months since my last Zoladex implant and a period of depression which I eventually overcame.

    All very uncomfortable, but the fact remains I am still alive and PSA levels have remained constant at 0.05 over the past year.

     I go with 'Whiteplume' and say that at your age - 70 - the sooner you find out for sure whether or not you have it the better.

     

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    • Posted

      Ye I think all the talk of risks of biopsy are scary and over the top, of course there are risks but under good management and don't forget the antibiotics its a lot less risky than the outcome if its not found and goes on spreading!! I wonder why some people decide against having it removed if ofcourse it is contained. With a good surgical procedure it gone you don't have to think about it so, ok you still have the psa tests but hopefully you are signed off after 2 years to the normal yearly psa test at the annual medical. Well that's what happens here in Germany.

      I know people will scream inconvenience but you overcome it, it takes a while and it takes a little willpower but do the kegel exercises and eventually you will get past this. I am 3 months post op doing well feeling good and with thr guidance of my Urologist I hope to be back on my bike by the summer! ! And if knot there are many other things to do.

      You have to be positive strong and determined and get your close friends around you for those moments like when you get those dreaded words " you've got cancer"

      Yes don't hide away we all shed a tear until we picked ourselves UP.

      ITS THE ONLY WAY FIGHT!!!!

      Tommy

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    • Posted

      Yes I agree, fight this dangerous and unpredictable disease. In considering biopsy risk remember to take into account your own state of health. Consider it in two ways. 

      1. How it will affect your risk of side effects

      2. How it will effect the progression of untreated agressive PCa in you should you have such.

      Without a biopsy you cannot tell if an identified tumour is agressive or not. PSA doubling time is not reliable for this purpose. It was not in my case. Only examination in the Pathology lab can give a Gleason score.

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  • Posted

    Hi Terry,

    Unfortunately there is a tremendous amount of superstitious myth attached to what people have done to treat or not treat prostate cancer.  Whiteplume and Harry argue for assessment and treatment......their arguement resting on the fact that they are still alive, albeit wounded from the treatments they endured.  I was formally diagnosed in 2005 with a PSA of 20.  Because my PSA doubling time is approximately 5 years, working backwards my PSA was 10 in 2000 and 5 in 1995.  This means that I very likely had a slow growing cancer that could have been diagnosed as far back as 1995 had I been evaluated with color doppler guided biopsy or MRI guided biopsy.  I chose to do nothing......and I am still alive......and I have a robust sex life and no symptoms other than getting up to pee at night (usually once and sometimes twice) and, at times, a weak flow.  Am I alive because I did nothing?  Well, it is true that I didn't suffer infections, or the occasional bleed out and death after prostatectomy, etc.  So, yes, I didn't die as a result of getting treatment.  Are Whiteplume and Harry alive because they did treatment?  It is absolutely the case that we don't know whether they would have died without treatment and there is no way to know that.  So, you see, there exists many superstitious myths about what to do.

    The US Preventative Services Task Force Weighed in on Prostate Screening after reviewing all available research on the topic.  I would suggest that anyone considering testing or treatment read it in its entirety.  It is very informative, was produced by epidemiologists, medically trained, people with no financial interest in the outcome, and is easily read.  You can find the article here http://www.aafp.org/afp/2013/0215/od1.html ; I wish you the best with your choice.

    It is nice to be alive and still intact.  I cannot say that what I have chosen to do would be the right choice for you.  You will likely have to address your anxiety over having and living with cancer.  There are many men who simply don't know they have it and life goes on as normal.  Other men, myself included, who know that they have cancer must effectively deal with anxiety.  But when my surgeon/urologist recommended surgery back in 2005 and when pinned down to "what is it about my cancer that causes you to recommend cancer?" kept saying "well most men get anxious/scared and just want it out."  My response to him was "So you would surgically remove my anxiety/fear.......I didn't know that was a recommended treatment for those feelings......shouldn'e you recommend me to a therapist instead?" 

    Realistically a man of 70 has a 70% chance of having prostate cancer.  At 80 that chance goes up to 80%.  Given those stats, it is amazing to me how many people don't die of prostate cancer and rather die of something else.  I do, sometimes wonder what will take me.  But so far I am alive having done nothing.......and, my life remains a pleasure. 

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  • Posted

    Terry,

    You are right. You won't live a day longer if you go down the intervention route,you'll just have stress and worrying side effects. Look at the website What Doctors Don't Tell You and also find a chap on the web called Ben Ong who has written a book about prostate cancer which talks sense and tells you how to change your lifestyle,what to avoid,what to eat and drink,why biopsies,radiotherapy and surgery are a bad idea when you have low grade prostate cancer. I decided to follow the non intervention route despite being heavily leaned on. I changed my lifestyle and followed the right recommendations and my PSA has fallen from 9.5 to 5.6 in 20 months. It wasn't a leap in the dark - I've spent over 30 years in healthcare at a high level,including setting up monitoring clinical studies. You are on the right track Terry.

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    • Posted

      thanks Mike. How did you determine it was low grade cancer? I agree with you once that grade is determined. If it is high risk / agressive cancer then treat agressively and change your life style.

      Change of life style may not be enough for agressive cancer. Radical therapy may not be enough for agressive cancer. So always change your lifestyle. After all, your old lifestyle let the cancer develop.

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    • Posted

      Hi  George,'I had the biopsies (before I knew any better) with 2 of the 12 biopsies showing abnormalities and scored 3 each. This was followed (rather than preceded - as it ought to be) by a scan and other tests to determine spread (none) and a closer look at the prostate. Everything was ok and I felt good. So I determined to improve what I could about my lifestyle - mostly diet,exercise and good supplements. I've virtually cut out dairy (strong links to breast and prostate cancer),very little red meat (grass fed or organic),very few carbs,purified water(not in plastic bottles due to plasticisers being leeched into the water) and so on.i just try and do things automatically rather than be fixated. I use almond milk rather than soya,which has become a bit industrialised in itself,I have 100% pomegranate juice at breakfast (really miss the orange stuff) and mix up walnuts with my cereal. All of these things either have studies saying they're good for the prostate or are better than the pesticide laden stuff we've been fed for years which I think have contributed to the rise in cancers generally. I'm happy,I don't stress or worry,I enjoy each day and feel I'll be around a long long time. Positivity is important. :-)
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    • Posted

      Hi Mike, we seem to think in much the same way. My urologist did things in a better order with the MRI scan PRECEEDING the biopsy. Indeed the indications were that the cancer had broken through the capsul. It wasn't until the more extensive scanning during RT it was established that the cancer had not broken through the capsul. A veyr close run thing it seems.

      Our diets are similar. Mine a bit narrower. I use fresh pomegranate juice when I can find the fruits. Soya like you is out. Boxed fruit juice is out. Fresh orange first thing at breakfast. Cod liver oil and hemp oil. Olive oil and coconut oil for cooking. I still eat porridge. I eat home made bread -  spelt 50% white flour 25% rolled oat 25% all three organic plus yeast and honey.. Five walnuts from the shell. Green tea - no black tea or coffee. Like you no dairy. Basically vegan plus chicken and fish two or three times a week. I have developed a strong liking for pulse stews. Various forms of cooked organic tomatoes. 

      I have been anorexic since my biopsy so I have to be careful not to over eat any healthy food I don't like much as dislike can turn to loathing very quickly. So that is an added difficulty which I am glad you do not have. I used to eat happily nearly everything set before me. Barley and Marmite being exceptions. It looks as if anorexia will be permanent. Still set against agressive PCa I am doing well. Generally I feel very fit and like you I am happy.

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    • Posted

      . . . And we have started to make and eat black garlic daily. We were unwilling to eat raw garlic because of the odour. However black garlic is fairly pleasant to eat and is reputed to be twice as efficacious. We also eat an apricot seed daily, working up to two soon. Instead of bottled water we filter water so that it is mildly alkaline and use that for drinking, cooking and washing vegetables.
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