Should I have a prostate biopsy?
Posted , 74 users are following.
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!
15 likes, 312 replies
ferdinand21223 terryw
Posted
I find myself in a similar position to what you experienced two years ago. Given that time has passed, are you able at this stage to provide me with any further knowledge or insight to what has happened since!
Kind regards, Ferdinand.
ferdinand21223 terryw
Posted
Hi Terry,
I find myself in a similar dilemma to that you encountered two years ago. Since time has passed, I'd appreciate if you could provide me with any further understanding or insights of your experience!
Kind regards, Ferdinand.
terryw ferdinand21223
Posted
Hi Ferdinand
Sorry about the delay in getting back to you. I did an update on the thread about a year ago, but it's not easy to find so I've pasted it below. Hope its useful.
All the best Terry
Hi and thanks to everyone who has posted on this thread. I had no idea when I started it that I would get such a wide range of opinions, and knowledgeable opinions at that. And I'm very well aware that I rudely have not been responding to posts on the thread. I lost my sign in because of tech problems on my system, and kept meaning to re-do it, but there never seem to be enough hours in the day and I just didn't get around to it. Not good I know.
Well, with your help I have answered my own question, 'Should I have a Prostate Biopsy?', and very much along the lines that many people have suggested. I have cancelled my next consultant's appointment and taken myself off the pc rollercoaster.
Since I put up the post I had a psa test about 6 months ago, which came out 6.5, the same as 6 months or so earlier. Its gone there from 4.6 6 years ago, and the last 2 or 3 years its been between 6 and 7. The doctor I was seeing recommended I be referred to a consultant, but I know other GPs in the same practice would not have thought any action necessary. And I think they are right - I know I have had BPH for some years, which is pretty common and is probably why my psa is up. Bigger prostate = higher psa. In any event, if my psa of 4.6 from 6 years ago had been an indicator of an aggressive tumour - which a consultant suggested it could be - I would probably be dead by now.
I have no symptoms - no getting up in the night, no blood in my wee - I have no family history of prostate or breast cancer, and I have no interest in running up to 6% risk of Sepsis from a biopsy, or the possibility of receiving treatment I may not need, which is nevertheless likely to leave me impotent and incontinent. At 72 I want to carry on being as I am as long as possible, and I think my best chance of achieving that is to steer clear of treatment I don't want and probably don't need.
I've been intrigued by some of the stuff that is available in the US, and maybe in the UK in private medicine, but not from the NHS. PSA may be unreliable, but it's cheap so the NHS will keep using it, and the same is true of the random biopsy through the rectum. The NHS is fantastic, but it's never going to offer all the latest testing, because there must always be hard choices about how the money is spent, for example, should it be spent on better prostate testing for old guys, or specialist services for sick babies? Not really any contest is there?
I'm not necessarily assuming that I don't have a tumour. I may well have. But if I have, it seems likely to be slow growing, and if it's not going to kill me or cause me any problems I don't give a damn about it. It can carry on doing what its doing and I'll do the same.
I wouldn't say there's no risk. I have read patient postings elsewhere saying they had no symptoms and by the time they were tested it had spread into their bones and nothing could be done. Obviously they were urging everyone to get a psa and a biopsy as soon as possible. And I'm not doing that, so I could be putting myself at serious risk. But that risk is at most 2 - 3%, which is half of my risk of becoming seriously ill from a biopsy!
I really don't believe that most NHS staff would deliberately put me at risk, or give me treatment that they knew I didn't need, but inevitably they have a different viewpoint from me. In most cases I suspect they think 'better safe than sorry' . That's probably what the GP thought who referred me to a consultant, that's no doubt what the consultant thought when he wanted to give me a biopsy, and would probably be his attitude to treatment also, after which it's very likely that I would be impotent and incontinent. 'But,' my consultant would be likely to say then, 'you're alive!' To which I would be likely to reply 'That's a matter of opinion!' I hate to disagree with the medical professionals, but that's not my idea of being alive. Of course, if I really faced a choice between biopsy and treatment, with all the side effects, and death, I would be foolish to make the decision I have, but my assessment is that I'm not in that position, and since it's my life I'm going to back my assessment.
I'm still thinking about whether to keep monitoring with a 6 month or annual PSA, but it's a major problem trying to persuade the doctor's receptionist to give me the result. One told me she couldn't do it because she hadn't been trained! What sort of training course do you need to read 6.5 off a screen? The only way I could get the result, and even then with difficulty, was by getting the doctor who referred me to a consultant to put a note on my file telling the front desk to print me a copy of the test result. But she has now left the practice, so I would have to go and see some other doctor and start all over again, and I really don't think it's worth bothering with.
Anyway, that's the decision I've made, and my reasons for it. It's not the right decision for everyone, and I would never try to persuade anyone to do what I'm doing. We all have to weigh up our own personal circumstances and make our own decisions.
Good luck to all of us.
romneyj terryw
Posted
I have PMd you.
Romney
bob31328 terryw
Posted
Hi,
This is a very active discussion with a lot of very good and useful information so I am hoping people might be able to point me to some more information to answer some questions I have.
I have read anecdotal information that claims some patients have had permanent degradation in the quality of their orgasms and/or erections from merely having a prostate biopsy performed.
This makes some sense since I can envision that the biopsy needle could easily hit some of the nerves which go through the prostate that have to do, I believe, with orgasms and erections.
if anyone here can please point me to any existing research on this that has been published in peer-reviewed, well known, respected medical journals, I would be very appreciative. If not, than anything that's been published or any other information you think is useful would be appreciated.
It also appears to make a lot of sense to get a multi parametric MRI before getting a biopsy because from what I have read they are more accurate in detecting cancers that are likely to be aggressive than are biopsies and further, a guided biopsy can be performed which merges the results of the MRI and the ultrasound so that it can more accurately target areas likely to contain aggressive cancer.
As with the risks of biopsy, I've also read anecdotal information claiming that there is a risk from being exposed to the Gadolinium contrast agent used in contrast mpMRI. Supposedly the risks can include developing multiple sclerosis, severe joint pain, clumping of skin, and cognitive problems, all on a permanent basis.
Although I have read that some claim these problems only occur in people with kidney problems, I read recent work claiming that even people without kidney problems can have these problems.
Again, if anyone here can please point me to any existing research on this that has been published in peer-reviewed, well known, respected medical journals, I would be very appreciative. If not, than anything that's been published or any other information you think is useful would be appreciated.
NeilMiller bob31328
Posted
I had an 18 core biopsy 2 years ago at age 60. I can't quite tell which had more effect for decreasing often stopping semen flow.. . biopsy or the 2 medications for enlarged prostate.. Flomax and Proscar. Definitely it is all understated by all the specialists I've seen over the past 10 years. In the end (not really a good expression for us aging guys) our procedures are an unknown trade off between benefits and side effects. When it comes to many health issues, science can only do so much.
I thought Prostate issues were complex until the last few years with an Intestinal twist.. and IBS-C or bacteria in gut. OMG! Dr's have more contradictory theories of cures/maintenance than I've seen with Prostate issues. My conclusion? The person who first said "getting old is not for wimps" was far wiser than I ever thought! Lol
davidcarlton bob31328
Posted
My urologist wanted to do prostate biopsy. I asked for an MRI first and then use those results for a targeted biopsy (much more efficient). He said most insurance companies will not pay for a MRI initially. I can't get excited about the shotgun approach needle approach to prostate biopsy with only a 30% accuracy rate.
craig84609 davidcarlton
Posted
I don't blame you at all. What the Doc said may be true, but he or she may also be looking out for their bottom line as they don't make any money if you get an MRI, but if you get a biopsy done they get a good payday, plus they know you will probably get another one done after the first one shows nothing and your PSA is still going up. In my case I have the symptoms of PC or BPH, but I have a super low PSA. My PSA is at .32 and I still almost needed to be cathed in the ER. Go figure. The pain has gotten worse and my doctor will not do a biopsy, because of my low PSA, nor can I have an MRI, because again my PSA is super low. She still thinks that my problem is my Prostate, so I may have to have an ultrasound to see how big it is. My situation is the opposite of most. I have active Crohn's Collitis in my Rectum and wonder if that is causing my issues.
bob31328 davidcarlton
Posted
I'm still searching for information about how safe or unsafe a multi-parametric prostate MRI with contrast agent is. I'm tempted to have myself screened for prostate cancer with a mpMRI if the chances of having permanent serious problems from the mpMRI is low enough. Some anecdotal info I've seen claims the Gadolinium contrast agent has been found to accumulate in the brains of even people who have no kidney problems and this has been associated with Multiple Sclerosis although nobody seems to know if it is a cause of MS or not. Plus I've seen other anecdotal info about it causing permanent cognitive problems, joint pain, and clumped up skin.
I had a psa test last march whose result was total 2.8, free % 17.
I had another psa test about a week ago whose result was total 2.5, free % 16.
I'm inclined to not have an MRI or biopsy (have seen anecdotal info that biopsy has caused permanent ed, loss of ability to orgasm and have seen studies saying it sometimes causes death/infections/etc).
Anyone here have any thoughts about the risks associated with my recent psa total and free % results??
davidcarlton terryw
Posted
Thank you VERY MUCH for your posting.......at 66 years old my psa has been under 4 for several years. I recently had a NEW psa blood test known as the "4K". My 4K blood results show that I have a 90% chance of NOT having aggressive prostate cancer, OR, as the urologist stated to me, " you have a 10% chance of having aggressive prostate cancer.....and he wanted to schedule me for biopsy. I too have been reading/researching many of the statistics and I am very reluctant to proceed with biopsy for exactly the reasons you cited. I plan on going back later this year and for the time being continue "active monitoring" of my psa results. I inquired of my urologist about having a prostate MRI and then a 'targeted biopsy' utilizing the MRI results. Was told that most insurance companys due to cost will not initially conduct a MRI. Keep posting.....many of us are following...
Thanks again
Vermont007 terryw
Posted
I've commented here before, and just wanted to mention another option that hasn't been referenced here (that I can tell).
My own asymtomatic situation stems from a fluctuating PSA, from 1.52 in 2013 jumping to an alarming 8.91 in 2016, down to 7.33 (immediately following a DRE!) and receding back down to 4.93 in January of 2017.
I had resisted getting the suggested 12 Core TRUS Biopsy and instead opted for a PSAFT this year . . . . this is another type of PSA Blood Test which goes a bit further to identify how much of the antigen present is "Free" and what percentage is "complexed" or possibly associated with a cancer protein or marker.
The measure of concern on the PSAFT is currently set at 25% . . . . when the percentage of the "FREE" Prostate Specific Antigen drops below the 25% threshold, or when the "complexed" antigen exceeds 75%, indicating that the prostate is not suffering from mere BPH or some indolent malignancy; but needs to be considered aggressive, and a biopsy is then in order.
So the PSAFT allows for the diagnosis of prostate cancer also provides important information about its aggressiveness.
I'll report back after I have my first PSAFT (without a preliminary DRE); but meanwhile, I was wondering if any of the other contributors here have taken advantage of this newer PSAFT Free and Total Serum Blood Test ?
sallie84 terryw
Posted
Just wondering if you are still doing OK.
terryw sallie84
Posted
Hi Sallie
I don't always post much, because there are so many other people posting here with greater knowledge than myself, buI'm doing fine thanks.
As I've mentioned before here, I had a psa of 4.6 at 66, which a specialist told me could be an indication of an aggressive tumour. If he had been right - which I didn't believe he was - I'm sure I would have known about it before now, and 7 years on I would probably be dead. But at 73 I still have no symptoms, no problems, and no reason to regret my decision not to have a biopsy.
As I have also said before, I made a decision for myself in my individual circumstances, and other people may take a quite different view, but I'm very happy with the decision I've made.
All the best Terry Wardle
gregs70711 terryw
Posted
I'm 57. I had a prostate biopsy because my urologist recommended it. My PSA was elevated. Eleven of the needles went in without too much trouble but a 12th went through me like a lightening bolt. It was extremely painful, and the pain remained long after the procedure. I felt like I had a urinary tract infection and there was plenty of blood coming out of both ends for several days. The worst part is that I swear, my testicles dropped very rapidly over the next few weeks. My urologist said that was simply not possible but they did, and it is uncomfortable and permanent. Also, the test showed that I was showing some problems (clusters) and that I would need a a second biopsy. The stress of waiting a couple months to do the followup was tremendous. With the second test, I was given two different antibiodics, somewhat sedated and there was little pain this time. The tests came back that I was fine. And the cruelest of all, my PSA level was just fine too. Had I waited and had a second PSA test first, i would not have needed to go through the two biopsies. Also, although Insurance paid for much of the procedure, the most expensive part is the labwork, which can run several thousand dollars. So the nightmare procedures ran me around $800 with insurance. Urologist paint these as a routine procedure, but for me, it was very distructive. Incidentally, I visited a plastic surgeon to see if the testicles can be raised back up. They can, but the cost is staggering. The plastic surgeon told me others that had come to see him came after having prostate biopsies.
hank1953 gregs70711
Posted
Thanks for sharing. I am now glad I did not agree to the biopsy my uro suggested after my DRE last July. He said that he felt a small nodule on my prostate. I waited for the next PSA test which was done in April showing it was almost unchanged at around 3. I am not going to have a biopsy unless my PSA elevated significantly. Hank
craig84609 gregs70711
Posted
I am sorry you had to go through that, what an ordeal. These doctors need to have a biopsy done on them, that way they can be a little more careful when it comes to their patients. I would have a tough time going in for one myself and they are not routine or safe. There are very serious risks that come with these tests and for someone like me that has Crohn's disease it could be fatal. The reason for this test in the first place is to save ones life, not make it worse or kill them in the process. I am a firm believer in the 3T MRI's ability to accurately asses ones risk of PC. I think in the near future random biopies will no longer be needed or done. I have never heard of a biopsy causing ones testicles to droop, but if a biopsy can cause it, you will be hard pressed to get any doctor to admit that it does, or tell their patients that it could happen. I hope you are feeling better now and can get past that experience.
romneyj gregs70711
Posted
I do wish you well in your final recovery from all this.
Vermont007 gregs70711
Posted
Your plight suggests that somehow one of those 12 Core Samples (outer diameter ?", inner diameter 1/16" ) disrupted (or severed) the vas deferens or the seminal vesicle. Besides for all of the nerve tissue in the prostate gland, it is an amazing network of plumbing connections, carrying four different fluids: semen, sperm, urine and blood; like a very complicated highway interchange.
I'm surprised that more damage isn't reported from the TRUS Biopsies, when you consider the anatomy of the prostate and that a TRUS Biopsy creates at least 24 random wounds: 12 through the rectal wall and 12 through the prostate case PLUS whatever seperate internal vessals and nervous tissue bundles (connectors) that might be within the line of fire.