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
terryw
Posted
I had two rectal examinations when I was 70/71, one with a GP - I'm in the UK - and one with a practice nurse on my first hospital appointment when I agreed to a referral. The consensus was that my prostate was slightly enlarged, which didn't surprise me because I was aware since my 60s that I probably had BPH because I was peeing rather more often. Your psa seems very low. When I was 66 my psa was 4.6 and I was told it should be 5 by the time I was 70. My psa on referral was stable between 6 and 7, probably slightly raised because of my enlarged prostate, and I know other GPs in the practice would not have referred me for that.
Despite that, and that I had no symptoms, no family history, etc, etc, on both my hospital appointments they wanted to do a biopsy. I suspect they think that must be what you are there for. Anyway I declined both times and cancelled a further appointment.
I'm reluctant to suggest that anyone should follow my example, since not everyone's situation is the same, but I certainly think you need to ask a lot more questions before considering any further investigation, especially with such a low psa.
I had done a lot of research before I went for my first hospital appointment, and I found there was a good deal that they were only prepared to discuss with me because they realised that I already knew about it. That isn't the way it should be, but in my experience that's the way it is.
I certainly wish you all the best with this.
terryw
Posted
I wrote a detailed response to your comment but for some reason the site said there was an error and dumped it, so I'll try a shorter version. Your psa is very low, mine was 4.6 at 66 and I was told it should be at least 5 at 70. I'm now 72 and the last few years it has been between 6 and 7, probably because of a slightly enlarged prostate on examinations, and I suspect I've had BPH since my 60s. With your psa I would want a damn good reason to have a biopsy. If I was you I would be wanting to asking a lot more questions before I agreed to a biopsy. I wish you well, and hope the Patient site likes this post.
sushilc44 terryw
Posted
However I thank you for your helpful response and it certainly cleared lots of doubt.
carl05115 terryw
Posted
Dear Terry W. My name is Carl and I have posted a number of times on this site. Occasionally I take a break because I find the sharing so profoundly biased and feel that many people seek life altering treatment that isn't based on medical necessity, but rather is based on the belief in emotional reassurance via medical intervention/treatment. Like you, I have hesitated to seek treatment based on the reading that I have done. By the way, I too am 70 years old. I have had three biopsies and my prostate gland has been "stuck" a total of 24 times. The first biopsy was when I was twenty years ago at the age of 50 and my PSA was nearly 10. The second biopsy was about two years later. Neither biopsy found cancer. I'm certain that cancer was present 20 years ago, but the needles missed it. I am thankful it was missed because I likely would have pursued treatment at that time and I am since very happy that I did not. Over a decade ago when my PSA had climbed to over 20, I opted to get another biopsy, although there was already a chance that the cancer had escaped the prostate. This time I opted for a color guided biopsy and I watched as they stuck "hot spots" eight times. Two hit cancer, Gleason 3 + 4. I am now 70, have identified my PSA doubling time as just under five years, and believe that I have a very slow growing cancer. My PSA is over 100. I have no symptoms. I enjoy my life, have come to see cancer as an ever present companion. I estimate that I may die of prostate cancer at around 87 years. My father died of a heart attack at 51 so I've already had nineteen more years than I thought that I would. Cancer is my "old man's disease" and I anticipate dying with it or from it as a very old man. We'll see, and in the meantime I am living my life to its fullest. I wish you the best with your decision, and would strongly suggest that you read and read and not let fear be your guide.
terryw
Posted
Hi Carl Thanks for sharing your experience. I posted my final answer to my question a couple of months ago - that I'm not going ahead with a biopsy unless I get some symptoms or some other indication - but I'm glad to say that I didn't have your experience of psa testing in my 50s. If I had I would certainly have done what you did and got a biopsy. Like you my psa is not increasing fast - up about 40% in around five years, and pretty static between 6 and 7 over 18 to 24 months of testing, which certainly suggests to me that if I have a tumour, which I may well have, then it seems to be growing pretty slowly.
I think you are absolutely right to make a decision based on your circumstances and get on with living and ignore the pc. I'm doing the same and wish you all the best.
annie1963 terryw
Posted
Sorry to interrupt, but George indicated "moderate to slight radiation" with an MRI. MRI has NO radiation. It is Magnetic Resonance Imaging. I am an MRI specialist and please note that anyone reading his comment has been misinformed.
NeilMiller terryw
Posted
Your stats and analysis seem very similar to mine. Basically an extremely small % of patients who have an Mri and subsequent targeted biopsy (which i had), or just a shot in the dark biopsy, will then have been saved from a life threatening cancer. With that thought in mind, and previously having had a biopsy that was rather painful in the late 90's, I avoided all requests for 5 years to have a biopsy even with a 9.5 psa...high but nominal fluctuationd over the years. I was 60 last year when I decided to say WTF, and do it rather than always have it on my mind. What I found was an 18 core biopsy in 2015 at UCLA, Los angeles, was far smoother, easier and less painful than I ever imagined. Psychologically I'm glad I went for it because I don't live with "should I or shouldn't i" as of that biopsy no cancer was found. Other facilities told me I likely have cancer. Lots of misinformation, guessing, good stats bad stats, etc etc. If you constantly have it on your mind, you "might" want to just do it and get it over with....yes nominal risks, though big, but living a life of worry is a risk as well in my opinion. I'd say, if you can be cool and not worry, let it go. Chances and odds are that us 60-70 year Olds are more likely to die of something else. Now that I've confused the heck out of you....Goodluck and have a good day! Lol.
dan40981 terryw
Posted
I'd do an MRI prior to a biopsy. this will help isolate any area's of concern within the prostate. The Biopsy it's self is not to be feared.. I was surprised how easy it was, there was some discomfort but not the horror stories you here. Grab your skin up from the elbow and slightly pinch! not any worse than that.. I stopped bleeding from bowel movements withing a day or two.. Semen contained blood for about a month, remember that when having sex and be sure to where a condom.. My next psa was actually down slightly but the results were conclusive enough that I'd just as soon they take it out..
romneyj terryw
Posted
I wonder what you did in the end?
One of the issues is the clearly the fear of a TRUS guided biopsy. I would agree with what has been said below - in the past this was a painful procedure but now it is always (I believe) carried out with a periprostatic nerve block. It isn't such a bad procedure and I would have no fear going for a repeat biopsy. Statistics that you quoted anre made up over a long period and are not valid for modern units with combinations of antibiotics.
The biggest problem with leaving this disease is that your options get reduced further and further. Everything has already been said below. Whatever you decide(d) though I do wish you well. I too had been talking myself out of going for a biopsy and all that could be involved forward of that.
terryw
Posted
Hi Romney
I posted my final decision on this thread 4 months ago. I decided not to have a biopsy. That wasn't primarily because of concern about biopsy side effects - though there's up to 3% chance of having an aggressive tumour and up to 6% chance of being seriously ill after a biopsy! Mostly, with no risk factors at all in my case, I felt there was insufficient justification for me to embark on a course of action involving some risks from the biopsy and risk of 'over-treatment' which could, might, seriously affect my life. So I didn't!
Most tellingly, a consultant told me that my 4.6 psa at 66 had been raised, and if I had seen him at that age he would have wanted to do a biopsy then. If I had had an aggressive tumour back then, 6 years ago, I would be dead now, so obviously I didn't have, I probably do have a tumour, but it is clearly slow growing, so I'm leaving it to do its own thing while I do mine.
That's very much a personal decision, and obviously not right for everyone, but I believe it's the right decision for me, and if I turn out to be wrong, then I'll have lived my life my way in the meantime.
I wish all the best to you.
Hank52118 terryw
Posted
I came across this thread because I have been asking myself the question mentioned at the top – "should I have a prostate biopsy?" My PSA level is 23, and pending a second test, my urologist has suggested the procedure. Impressed by the thoughtfulness of the contributions, I decided to post my case to see if anyone can help me make my decision.
I am 57 years old. Six months ago I started experiencing intermittent pain around the genital area. I saw a urologist, who gave me rectal examination, a sperm test, a urine flow test, and an ultrasound of my prostate. She ruled out cancer, diagnosed prostatitis and put me on cipro. But after two three-week courses, there was no improvement. She eventually gave up: she said there was no nothing wrong with my prostate; whatever I had was not a urological problem.
By that time I had read up on my symptoms and was aware of "chronic non-bacterial prostatitis". I started meditating and have found it helpful. The pain is now less frequent than it was over the summer (one or two bad days a week as opposed to most days) and I feel more able to control it.
But it is a very long journey, and last month, before giving up on conventional medicine, I decided to seek another expert opinion.
The second urologist was very quick to dismiss my hyperactive mind as the cause of my problem and to reclaim my body for science. His words struck me: "I have a type-A personality too, but just because we are nervous it doesn't mean there's nothing wrong with us." He prescribed a PSA test (expressing surprise I hadn't been given one already) and an MRI scan.
I saw him again two weeks ago, after the results came back. He had a "ah-ah " look on his face. My PSA count was 23. He said this could due to be various things, but the MRI scan had not ruled out cancer. He put me on doxycycline for 10 days. I am to see him in another four weeks, after another PSA test. Depending on the result, he might prescribe a biopsy.
Since then I've been weighing the pros and cons. I think the urologist will push for a biopsy if my count – as is likely – remains high. This thread has given me a lot to think about. Britain's NHS leaflet says the decision needs to be weighed carefully. The US Preventive Services Task Force – which I learned about on this forum – says the risk of sepsis and other complications is high and suggests extreme caution.
The following factors make me wary of a biopsy in my case:
a) there is a ready and benign explanation for my very high PSA count, prostatitis (but could the non-bacterial kind cause this elevated count?);
b) I am continuing to feel better - not sure if the doxycycline helped: the pain is less after the 10-day course, although it could be the continued meditation;
c) even if I have cancer it is unlikely to kill me any time soon.
On the other hand, as many on this forum have mentioned: a biopsy may not be all that bad, and a small price to pay for a degree of certainty.
I would be thankful for any advice. And maybe someone could suggest questions I should ask my urologist before I make up my mind.
Hank.
gale10132 terryw
Posted
Hank52118 gale10132
Posted
Vermont007 terryw
Posted
I came to this Forum/Thread solely because the PCA3 Urine Test was mentioned. I'm not a Brit, and though I'm nearly 70 years old, I'm fairly new to this whole discussion. I've read much material on this subject matter, and have some specific questions that may have been answered already; but I didn't detect the answers.
Firstly, I get my medical care through Veteran's Affairs (VA) in the US. I'm a Viet Nam Combat Veteran (1960s) and was subjected to some Agent Orange Defoliant (which some suspect may relate to Prostate issues) while in Viet Nam in the 1960s . . . . which may have something to do with my situation. I mention the VA because the bureaucracy in it seems similar to what the Brits experience with the NHS.
I had an un-requested PSA upon intake with the VA in 2013, and received a score (?) of 1.52 which seemed quite normal. Now, in 2016, I had to request an update of the PSA myself, and was (originally alarmed) that it had spiked up 8.91; and I was referred to a Urologist.
The VA seems to treat the PSA result as a Cancer marker . . . . which I have since learned it is not. The Urologist did a DRE (digital rectal exam) and found assymetry - one lobe slightly enlarged; but no palpable bumps or other irregularities, and ordered another PSA that same visit.
This third (3rd) PSA came back at around 7+; but we both realized that a PSA blood test SHOULD NOT be taken immediately after the Prostate has been manipulated in the DRE, and so that 3rd PSA is virtually worthless (although I am somewhat comforted by the fact that the score is DOWN despite the manipulation during the DRE.
She (the Urologist) is saying that the next step in the VA Protocol to conduct a TRUS, or an Ultrsound Guided Trans-Rectal Biopsy. That's where we come to a disagreement.
I have come to learn that the Prostate is the ONLY organ in the human body that is biopsied prior to any imaging (X-Ray, MRI, Sonogram, PetScan et cetera) and that typically, 12 Core samples of Prostate Tissue are taken for examination, often regardless of whether any lesions, tumors, or other irregularities are discovered.
Having read about botched biopsies (and indeed, surgeries) I'm not too enthusiastic about this procedure .
I discussed the PCA3 Urine Test, which actually tests for Cancer Markers; but the VA protocol is to ONLY offer such a Urine Test AFTER at least one negative biopsy, meaning all twelve (12) cores showed no malignancy) . . . . even though the PCA3 is by far, less expensive the TRUS Biopsy.
I am considering contacting an independent Urologist to have the PCA3 Test performs, and pay for it myself, much to the chagrin of the VA Personnel.
In the course of researching the availability of the PCA3, I also ran across an even newer test for Prostate Cancer referred to as the MIPS which combines the PSA and the PCA3 for use BEFORE any invasive biopsy is authorized.
I'm also gathering up information on the Multi-Parametric Magnetic Resonance Imaging (MP-MRI) screen biopsy procedure, which also has an advantage of more specifcally identifying the actual presence of a malignancy . . . . not just an enlarged Prostate Gland.
Well, that's enough for a 1st Post for this Yankee . . . . I'm just surprised that this part of the Medical Industry seems to be still in its infancy, and that these biopsies appear to be shooting into the dark One guy reposted having had 4 sets of 12 core biopsies taken before they found one (1). It seems they just kept on poking holes until they found something . . . . or caused something !
That same guy reported that when they performed the procedure to attempt removing the cancerous portion of his Prostrate, all of the punctures of the Rectum and the membrane surrounding the Prostate Gland had healed together, so that more than half the time in surgery was consumed by efforts of the Surgeon to peel the Rectal wall away from the Prostate !
I know I'm just rambling on here, and most of the participants on this Forum have have more of a solid diagnosis than I, and I haven't accepted the fact that I could have cancer . . . . but I'm not taking any chances going off in the direction of assuming that I do. You can break a part of your car or your house and go buy a new car or a new house . . . . you only get one chance with this aspect of your body.
Regarding these advanced tests that are not in the VA's protocol, I'm going to contact the Laboratories themselves and then ask if they can refer one of their participating Urologists to me . . . . not vice-versa.
And by the way, I think both the PCA3 and the Mips must be preceded by an aggressive DRE to loosen any potential cancer cells for inclusion in the subsequent Urine sample.
Any thoughts on this will be appreciated. I'm going into the VA for one more PSA in early January (with no more DREs), and then I'll signal to them why I'm not swayed by their protocol. I'm right now just trying to get my thoughts organized.
ES28567 Vermont007
Posted
First of all, thank you for your service. I think your logic and approach are spot on. Don't let them dictate to you based on their protocols. Also, the PSA can be manipulated and will be falsely higher not only from a DRE but also from ejaculation within 24 hrs. and also from riding a bike. It is good you are looking at other tests such as the PCA3. Be aggressive in determining if you have cancer but Don't let them do a biopsy without first doing a MRI to see if there are "areas of concern" and then use the MRI for a guided biopsy if needed.
You must be you own best advocate. Do your own research and Do not take the recommendation of just one urologist. Seek out several opinions. You only get one chance at this. If you do have cancer. It is usually slow non aggressive and you probably won't even need to worry about it. If it is an issue, don't panic, you have time (in most cases) to research and determine the best option for you. A prostatectomy should be one of the last options but is usually the first recommendation always made by a urologist.
Just my opinion.
jwrhn1951 Vermont007
Posted
I am also in the VA system and I am quite happy with the care I have recieved, its been top notch. But I must say the urologists seem to have the idea that all of us from the Vietnam era with a high PSA are presumed to have PC and they want a biopsy.
They started doing PSA's back in 2005, its risen over the years but not very fast.
03 January, 2005 2.70
12 December, 2011 6.40
09 November, 2012 7.60
08 January, 2014 7.00
14 January, 2015 8.10
20 April, 2015 10.00
06 July, 2015 9.10
19 January, 2016 10.02
15 July, 2016 8.68
20 October, 2016 11.18
I first refused my first biopsy back in 2012 due to the various comorbidities I have. My PCP askes if I will I get a biopsy annually but she knows I have no intention of doing so. I started having issues with urinary retention as well as pain and numbness in my arms and legs last summer. An October MRI showed moderate spinal canel narrowing and severe nerve impingment on my right side. So they scheduled me with consults with nuerosurgery and the urologly to try to figure out whether urinary retention is caused by the nerves or BPH or a nuerogenic bladder or something else as I've had problems with self catherization.
Nuerosurgery scheduled me for an appointment no problem, but Urology insisted that I have 2 appointments the first for a consult and the second two weeks later for a biopsy. I told them there was no way I would have a biopsy and it was a waste of time to schedule the second, but go for it if thats the only way I can get the initial consult.
As I say, I'm quite happy with the quality of care I have recieved with the VA and I'm confident that they will address the retention issues once I get there but its wierd that they insist a biopsy be scheduled to get a initial consult.
Vermont007 jwrhn1951
Posted
Thank you for that reply, and your PSA history. Did the VA ever offer any form of Prostate imaging to ascertain whether there's any form of lesion or tumor in that area.
Proposing an annual biopsy (12 core I presume) without creating a target array still sounds a bit bizarre to me; especially when it is understood that the 12 needle biopsy cannot reach tissue at the apex of the Prostate anyway.
Your experience with the VA far exceeds mine. Though the VA helped me obtain 2 college degrees and buy my 1st house, I only learned of my eligibility for VA health care AFTER I turned 65 and signed up for Medicare. Most of my life, I've carried Catastrophic Health Insurance with a $25,000 Deductible, so it's been almost like self-pay. Only in 2013 did I discover combat veterans from the Viet Nam theater had some eligibility, so I'm not complaining about anything EXCEPT this sequence of events in the diagnosis of Prostate issues.
The VA also told me that there is a relationship between exposure to Agent Orange and Prostate problems . . . . I've never had that explained. I do have some peripheral neuropathy in my hands which causes pain after any repetitive physical activity; but it's not debilitating. VA says that it's not compensable unless the symptoms arose within 1 year of exposure . . . . and mine didn't erupt until about 1980, 13 years after I left DaNang, so I never pursued it. Do you know more about the connection of Agent Orange to Prostate and Nerve complications ?
My Urologist says that they used the PCA3 Urine Test in a private clinic where she used to be employed in Urology; but she became mum about it being available within the VA and clammed up (not part of the protocol) so I'm thinking of asking her to refer me to her former employer and I'll pay for it myself; I'm used to that, and I'd like to verify that there's a reason to be concerned about an actual malignancy, not just a high PSA.. I think she regrets leaking this prior experience with the PCA3; but I've got to look out for #1 . . . . I can't do much to help #2 if #1 isn't taking care of himself !
Thank you for your response. I think I'm needing to constantly double check my thought pattern on this matter, and getting the feedback from others (without an agenda) certainly helps !
jwrhn1951 Vermont007
Posted
In my particular case I've been content to Watch and Wait so I have not asked them to do any kind of imaging. or anything else related to the prostate, for that matter. My PCP has a high degree of suspecion that I probably have PC, so whenever I have a new pain pop up she schedules me for imaging to check for mets. A CT once showed as a secondary finding that the prostate was enlarged with central calcification. I'm currently taking Finseteride to shrink the size of the prostate, I suppose I'll find out more from the Uro's in February.
As far as AO. In about 2008 the VA changed its policy to include presumptive exposure for anyone with boots on the ground. With a diagnosis of PC you could be eligible for a SC disability rating. I'm not familiar with the details but there is a site called the Veterans Benefit Network (VBN) that has lots of guys that are experts on the process, might want to check it out, also you local VA office might be helpful as well as the local VFW. I don't think they will give a diagnosis of PC without a confirming biopsy, and therefore no SC rating, so that is probably the hook that get most guys to have the biopsy...
I've been in the VHC system for a long time, if you make a request for a particular treatment, make sure it is documented in your records. Each VA hospital has an Veterans advocate that can help to resolve treatment issues. You might consider contacting them if things don't get resolved to your satisfaction.
BTW do you have a My HealthVet account. If not, you need to get one next time you are at a VA facility. Then you can download your medical records with BlueButton, it's not a complete file, still have to go to medical records for that, but I find checking the patient notes in particular keeps me updated.
Good luck