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
carl05115 terryw
Posted
My apologies to you, Kombi, if I misunderstood the source of your comment to me. I wish you the best with whatever choices you make with regard to your health.
Carl
Whiteplume terryw
Posted
Good luck I wish you well.
G6 T2c 5.8 Nov 14 - Feb RO 0.07 They can do it I put all my trust in the one person that had the expertise to bring about a good outcome and had he not it would NOT have been for the lack of effort of him & his TEAM.
Ik
andrew86541 terryw
Posted
I am to have a MRI scan in a weeks time followed by a biopsy 4 days later. I regard this as too sooner gap between the two procedures and will enquire first whether the clinicians should discover the results of the MRI scan before whether commencing with the biopsy. My count was 8.74ng/mL, although high (perameters- 0 - 4.5) doesn't necessary apply cancer is present. I am by no means an authority on the subject and we are all amateur quacks in these instances and rely greatly on others experiences...well!!, I'll have to do some more enquiring. Regards andrew86541
bruce74450 andrew86541
Posted
terryw
Posted
I've just booked the first of the two PSA tests I mentioned in my original post, and I'll see how the figures look. But unless my psa is suddenly shooting up I will not be booking myself in for a biopsy.
I've already found that the experts say that none of the indicators prior to biopsy actually apply. Psa only slightly raised? Doesn't make any difference. No symptoms? Doesn't make any difference. Psa hasn't doubled in five years? Doesn't make any difference.
Really??
I think the professionals work on the ''better safe than sorry' principle. Slightly raised Psa? 'Better safe than sorry' - have a biopsy. You have a cancerous tumour which may not need treatment? .Well, better safe than sorry - have the treatment. You're now impotent and incontinent? Yes, but you're alive!! Well, that's a matter of opinion!
Sorry if that sounds cynical. I don't mean it to. I really do believe that doctors and nurses, who have vastly more knowledge in this field than I ever will, have nothing but my best interests at heart. The problem is that their definition of my best interests and mine may be very different. A 45 year old consultant may feel it doesn't matter very much if a 71 year old man is impotent - but try asking a few 71 year olds (including me) if they mind!! For that matter, try asking a few consultants when they get to 71.
I don't yet know what the figures will be from my next two psa tests, but since there are no indications that I have an aggressive tumour (I may well have one but it appears to be slow growing) I have no intention of having treatment, so I don't see the point of having a biopsy to determine whether or not I am going to have treatment that I don't intend to have anyway.
But as I've said in the past, this is very much a personal decision, based on my circumstances, and my age. If I was 20 or 30 years younger I would no doubt take a totally different view. And that would no doubt also be true if I had symptoms, if my psa had doubled in five years or less, or if there was any history of prostate cancer in my family.
I keep hearing that massive numbers of men die from prostate cancer, yet we know from research studies that of every 100 men who have biopsies - which is not likely to include me - 3 will have aggressive tumours, 22 will have tumours not requiring treatment and the rest won't have cancer - but will inevitably be booked in for more biopsies, with all the risks of infection.
I don't know id that's helpful or not, but i really hope things work out well with you.
All the best Terry
carl05115 terryw
Posted
I will be 70 years of age in October. I submitted to three different biopsies before finding cancer of 3 + 4 Gleason. My PSA was 20 at that time and it was 2005. Doubling time has been a consistent 5 years. I have no symptoms and would not be on this treadmill were it not for PSA testing. The urologist wanted to do a radical prostatectomy. 480,000 of them were done in early 1980(when it peaked) in the United States and the death rate from prostate cancer is down about 3,000 per year. Either it doesn't work very well or they are doing them on the wrong people. By the way, I have read that the likelihood that a male has prostate cancer on full autopsy is roughly your age as a percentage, hence a 25 year old has a 25% chance and a 70 year old has a 70% chance. Also, impotence from surgery is higher than you've been led to believe. My Best To You with Your Choice, Carl
terryw
Posted
Thanks that's really useful. I want to see some absolutely clear indications before I decide to get on the treadmill. If I decide not to go that way then I figure the odds are in my favour. And if I'm wrong, and I find out too late to do anything, well we've all got to go sometime. The first thing I read when I started researching pc was a conference speech by a leading US urologist who said (I paraphrase) that it's the one cancer where the cure is worse than the disease. I didn't have a clue what he meant then, and now that I do I am certainly leaning towards taking my chances with the disease.
All the best Terry
carl05115 terryw
Posted
In the United States the cure is frequently worse than the disease, so much so that the Preventive Services Task Force report on Prostate Cancer suggested no screening and no treatment unless there are obvious symptoms and even then not sometimes. They also said that we shouldn't call it "cancer" because then people get treatment because they are scared, not because they need it. The report is online. I suggest you read it. I am at least 20 years out with prostate cancer, 10 years confirmed by biopsy, and have yet to have any symptoms.
Go online sometime and look up the highest PSAs and you'll find a few references to people with PSA's over 20,000. Even with doubling time I'd be into my 120s. I'm hoping to live to 87 and believe that I'll make it. I view my prostate cancer as an old man's disease (almost always) and a friend, and expect I'll die of something else with the old man disease that I've identified as my companion in tow. I don't wish to harass my cancer in any way because that p*sses it off and makes it more aggressive (read about how androgen deprivation therapy can cause it to morph into a far more aggressive androgen independent cancer.
The one thing I am glad about is that when I was getting biopsies there was not as much post biopsy infection.
A caveat, however. A fellow on this site pointed out that the overtreatment in the US may be balanced by undertreatment in some locations. So do bear that in mind. My Best, Carl
Whiteplume carl05115
Posted
Thousands of men die every day because it went to far! When its out (if its contained) Its gone. And the treatment is not so bad don't let him Scare you with Statistics the fact is that you have CANCER and it needs treatment soon TAKE YOUR DOCTORS ADVICE and if you are not sure get a 2nd opinion from a DOCTOR don't listen to so much on this site. . ITS A CHAT FORUM. remember!! Listen to those who specialise in Urology A UROLOGIST this is all lighthearted CHAT. I wish you well and a truly speedy recovery.
Ik
Dudley71081 Whiteplume
Posted
carl05115 Dudley71081
Posted
carl05115
Posted
Well, your comment from Alan Minter prompted me to look up deaths from biopsy in the U.S. In an article that raised concern for the increased number of biopsies prompted not by symptoms, but rather by PSA screening with a population of 12,300 there were 1.3 deaths per 1,000 where no cancer was found. The conclusion: "This prostatic biopsy mortality would occur earlier than any benefit from a screening program and could reverse any potential gain from screening such as recorded in ERSR study."
Life really is a crap shoot! Hope you get double 7.
Dudley71081 carl05115
Posted
it is good to hear from you Buddy. I'm going along pretty well at the moment. and hope you are too ? I see my Urologist on Wednesday re a stricture and my Onco wants to see me too same day. But I think that's just to see that I'm not falling through the net, as Uro stuffed up a little on my post benign urethral lesion excision follow ups and he stepped in, unbidden.
So all in all, I'm pretty happy at the moment in how I've ended up after 42 IMRT's ( last PSA 1.2/ P: smooth/ some laugh and cough incontinence [ working on my Keigels though ] ). We have a saying here in Australia when things are generally O K and even if they are not, we accept the situation. : ' It's all good '. ( I'll let Kombi fine-tune that one for me ).
Dudley71081
Posted
Anyhoo ... Yes, we are in a Medical no-Mans Land over all this, aren't we ?
i suppose it's the vaccination/ anaesthetics/ lethal medications/ infections/ risky ops dilemma brought into regular and acute focus by the stream of newly diagnosed/suspected Patients who contribute here.
The older I get /the less I'm sure of. It ought to be better, but it ain't. Does the Forum help with decision making ? Maybe, maybe not. It's a case of both trying to avoid whichever Ghost scares you the most and what you really didn't want to know, whichever way you cut it.
Dudley71081
Posted
But before I do, could you please take a look at the Post ' Until Yesterday '. By David 41094. He's doing it tough at the moment.
Thanks Carl.
With best wishes and Kind Regards,
Dudley
Kombi_Cruiser Dudley71081
Posted
I do have the feeling however that I'm not really being told all but perhaps only what they want me to know...that's the part that kinda goes around in my head lots... Example: during a conversation I was told that trying to generally time frame things was difficult as they aren't exactly sure if my Gleeson Score is a 9 or a 10 as apparantely I have rated with both at some stage...
Anyway everything is still 'all good' as we say (even after being thrashed by the New Zealand Kiwis in the ANZAC Rugby League test match)...
Kombi_Cruiser Dudley71081
Posted
carl05115 I hope you enjoy your 70th birthday come October as I know that I will never reach that milestone. Your ambition to reach 87 I admire as I haven't made any plans past my 55th birthday at this stage.
I read your comments to terryw regards the 'cure' being worse that the disease. Hmmm, I wouldn't mind having the opportunity to be cured. If this disease shouldn't be called Cancer then what should it be called???
Personally I don't care how p*ssed off my cancer gets so I'll continue with my hormonal treatments for as long as I stay responsive...suggestions to me so far are that I'll likely move into the hormonal resistance stage with a year or two from when I started (scary when I'm almost 3/4 of the way through year 1...
But nevermind, it's all good...!!!
Dudley71081 Kombi_Cruiser
Posted
You are officially allowed another glass of red ... having sat through that hammering ! ( As an Englishman however, I can't be too sympathetic because you very regularly, hammer us ! )
Anyway, more importantly, you are obviously soldiering on admirably and our thoughts and prayers are with you. You are bearing up manfully and I hope to have as much courage as you are showing, when I also get to run onto the pitch for extra-time.
In the meantime too much introspection is I reckon to be avoided if possible, I might even say 'at all costs '. Because, I have not had one single session of assessing my personal situation, which I kind of approach sideways anyway, that reached any comforting conclusion other than ' it could be worse '. Then I simply go back to living in the moment and trying to remain up-beat. The alternative is too grim.
Anyway Mate I think you've got more to look forward to than me. Because the upcoming Ashes Test series should cheer you up no end and provide you with plenty of opportunity ... to flog my pride !
If only the rest of the world knew how hard it is to be an England Supporter.
By comparison, Prostate Cancer is ... ' nothing ' !
with Best Wishes and Kind Regards,
Dudley
Dudley71081 Kombi_Cruiser
Posted
Respect,
Dudley
Kombi_Cruiser Dudley71081
Posted
Kombi_Cruiser Dudley71081
Posted
Being a realist I deal with the things I can change and I have always stated that if ever you want to know something always ask someone who is qualified to know...
carl05115 Kombi_Cruiser
Posted
Complex issues that you raise in your comments. Certainly, if you have Gleason 9 or 10 cancer that should be called Cancer. And I am assuming multiple markers pointed to a very aggressive Cancer. My heart goes out to you. Were I in your position, I too would probably lock into a fight to the death. I wish it were different for you.
My cancer is a borderline malignancy, Gleason 3 + 4, doubling time just over five years, diploid manifestation so my decision not to treat fell close to the line. I believe, as does the us preventive services task force on prostate cancer indicate in their recommendations that anything less than what I have should not be called cancer because the word frightens people and they not only seek, but they demand treatment for a condition that is not likely to be lethal. Unfortunately, in the us if a physician doesn't treat they can be sued and loose their license to practice medicine so they provide treatment even when they don't think it is in the best interests of the patient.
Were I in your situation, I probably wouldn't care how angry the cancer might become, because yours is aggressive and if you could knock it back awhile, that only makes sense. In my situation, treating my cancer would likely cause it to mutate into a more aggressive version. Stephen Strum, M.D. a medical oncologist wrote "APrimer on Prostate Cancer." I consulted with him and learned that starving my cancer via hormonal deprivation could cause it to mutate into androgen independent prostate cancer, a much more lethal version.
But again, my situation is different than yours.
And to clarify, I am a realist and not looking the other way. I am just in a different situation.
I wish you the best and, although I am from the us, "it's all good."
Kombi_Cruiser carl05115
Posted
Moving forward I trust that you understand where I am coming from when I make my statements regarding this disease that plagues us mere males regardless of where we live...
I may be just that little bit different from most if not all with regards my personal views and challenges but hey that's me...
You are lucky (I hope for you) that you are not exposed to the severities of what Prostate Cancer can put us through...
My experiences reach a little deeper than just prostate cancer as I am now in my 6th year of being treated with a 'High Grade' bladder cancer which thankfully has been a superficial cancer and not an invasive one...
Six years ago they removed a tumor the size of a clenched fist from my bladder (it returned twice) and now I seem to be in the clear in that regard...
Experience, yes, I have way too much than I have ever wanted with regards all these medical procedures...
I wish we could all organise ourselves and gather together over many red wines and have a good old chat about everything rather than having to communicate on here...
To all I wish you the very best of luck with what you are faced with...
Never give this disease an inch (or another moment) if you can avoid it
as I can guarantee you that it will eventually dominate...
Anyway I'm off to enjoy a nice Barossa Shiraz now so take care and good luck...
carl05115 Kombi_Cruiser
Posted
The Shiraz does sound very nice and comforting. Your health sounds like it has been a thoroughly traumatizing roller coaster. Again, my heart goes out to you.
Your story of bladder cancer described originally as "high grade" that turned out to be superficial is informative. While your prostate cancer appears to be aggressive with a Gleason 9 or 10, I trust there were other markers that also suggested aggressiveness. Aggressive cancer really does leave us with no options other than to simply submit and die or fight for everything it is worth. My wish is that you'll dominate.
Yes, sueing in America is the native pastime. It is truly sick. I am a professional in an allied health discipline and I see the negative impact of a sue mentality daily and the overtreatment it prompts (defensive medicine) and damage caused to patients. It is truly tragic.
As for cancer, some is simply slow growing, benign, and not likely to ever cause a problem. The US Task Force Preventative Services Task Force recommended no screening of anyone with PSA testing ever. The inventor of the test supports this and is appalled at the level of overtreatment in this country and the souls whose lives are damaged needlessly as a result of PSA screening. They recommend for Gleason 6 that it not be called cancer. Gleason, remember, is merely the fact that the prostate cell is "less well differentiated," a condition that can result from many different things.
So, is it true that you are an Aussie too. Blessed country Australia. I traveled there in 1980-81 and wandered from Sydney to Hobart with my then wife and 5 year old son. I have a truly priceless picture of him (all 3 1/2 feet of him) standing feeding breakfast serial to a wallabee that hopped out of the forest. The grin on my son barely fit on his face. Magical country you live in.
Have a sip of Shiraz for me and here is to your health. It is all good. Carl