A close friend age 65 recently had his first PSA test from his first primary care doctor and it came back at 6. Doctor said that was not unusual given his age and likelihood of having an enlarged prostate. I was alarmed and insisted that my friend immediately see a urologist so he did. But the uro just ordered a needle a biopsy for next month. Neither doctor performed a DRE which I thought was unusual.
My friend's insurance is Medicare Advantage so he can't go to the doctor of his choice. Questions:
1. Isn't a PSA score of 6 problematic at any age?
2. Can he/ should he, switch from Medicare Advantage to regular Medicare with Blue Cross supplemental so he can get better care? (That's what I have and they pay for everything no questions asked.)
3. What are his biopsy options? Just needle biopsy or aren't there other types less invasive?
4. Given the high PSA could he just request a PSMA scan?
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PSA of 6 may OR may not be a problem. With age ,PSA rises and PSA depends on size of prostate gland. If his Prostate glans measures 30 ml then his normal PSA can be up to 3.0.If his gland measures 50 ml, then normal PSA can be up to 5.0 and so forth.
Going straight to biopsy is senseless in my opinion. The first step should be Multi parametric MRI of the prostate and in results if it comes that his Pi-RADS are 2 or 3 then it practically rules out prostate cancer and there is no need for Biopsy. This special MRI is more accurate than Biopsy because biopsy only pokes needles in a few areas and is likely to miss cancer cells.
PSA of 6 can be caused by Benign Prostatic Hypertrophy which occurs in every man after age of 60 .Some men have it at 60 others can have it at 75. But eventually all men end up with enlarged prostate (benign) The other cause of higher PSA id prostate Infection /inflammation which is also a non cancerous condition.
Not performing a DRE is substandard care . If in DRE ,prostate gland feels soft and boggy that indicates either prostatitis or BPH. If gland is firm /hard with nodules, it raises the chances of prostate cancer.
Multi parametric MRI is non invasive ,accurate test but it costs $1000 to $2500 depending on imaging center.
Honestly, if I was in your situation, I will refuse Biopsy, insists that a DRE be done and PSA test repeated. If Insurance does not pay for Multiparametric MRI and there is no financial
difficulty, paying out of pocket can save lot of unnecessary invasive procedures. If PI-RADS come above 3.0 on MRI, Next step should be a Tc Bone Scan which costs about $200 to $300. Make sure to check your serum Alkaline phosphatase as it is a good marker for bone mets.
My urologist refused my asking for MRI, I asked four times, he raised his voice over mine four times. I went elsewhere after he did the biopsy which came back positive.
When another hospital did the MRI they saw I already had seminal vessel invasion and extra prostatic extension.
1. No. if he has a very large prostate, it can be normal. If his PSA density > 0.15 it is suspicious (PSA density= PSA/prostate size). If suspicious and he does not have a history of prostatitis, he may want to ask for a Prostate Health Index (PHI) blood test.
2. Up to him
3. I think all biopsies should be transperineal instead of transrectal. That is the direction things are heading.
4. No- PSMA is not approved for undiagnosed men. Even if it were, it isn't a good idea.
RE: your 1. point: I seem, as too often happens to me, to have fallen through some cracks in the Pca picture, including the time a Pca post doc intern ignored/dismissed my complaints about abnormal pain as he massaged my prostate in preparation for a blood test. (and in many other aspects around my health issues/experiences). My PSA increased from 4-8, while I was also dealing with an enlarged prostate, bad enough to significantly decrease my urine flow. As my PSA edged up, I had several digital rectal exams and 2 prostate ultrasounds, all with "unremarkable" results. Within a month of that, when PSA reached 10, I paid for my own MRI in Buffalo (because I sensed there was a problem, and my Canadian docs dismissed my concerns, and so I could not get a req for an MRI there) The MRI confirmed 2 very large tumors in my prostate, which surely had already advanced to detectability while my PSA was relatively low.
This is not to dispute your point, just to share my experience. I am an avid follower of your posts. Cheers
First, it sounds to me like he should find another Urologist. He didn't perform a DRE and has already scheduled your friend for a biopsy which is bizarre. Many things, including infection can cause a rise in PSA values. A very large prostate often emits more PSA but a 6 needs to be investigated. I went through this four years ago and I believe my Uro. did a good job with my testing at the time. First was a repeat PSA check and DRE. I then had a 4K Score test followed by a 3TmpMRI which showed two Pirad 4 lesions. THEN, I had my biopsy. BTW, my prostate was huge (152cc), my PSA was never over 5.4 and I was diagnosed with quite a bit of gleason 3+4=7 prostate cancer.
I had a Medicare Advantage HMO plan through United Health and they paid for me to see several Urologists, paid for my MRI, 4K test, biopsy, everything. Clearly, not all Medicare Advantage plans are equal but his might pay for more than he thinks. Please, strongly advise your friend not to lead with the biopsy. That would be a mistake and I believe plenty of guys here will say the same thing.
Good question. For me, the biopsy was very painful and there are risks involved as well. I ended up having my prostate surgically removed but the pain from the biopsy was much more severe than anything from the prostatectomy. Biopsy is just over-kill at this time. Your buddy may end up needing one but first he should have another PSA test (in a perfect world, after a course of antibiotics), a DRE, then either the test Tall Allen suggested or the 4K test I had, then an MRI. At that point, if a biopsy is warranted, he will have to have it to confirm the presence or absence of significant prostate cancer. I visited five Urologists before deciding to have my RP. I fully believe they love to do biopsies and they love to do surgery. You are clearly a really good friend. There are lots of smart and experienced guys on this site; I hope more will stop by and share their opinions.
These biopsy’s are commonly given using the anesthetic propofol. It’s what they typically use for colonoscopys. Unless you are allergic to it I don’t understand why your doc didn’t offer it. I didn’t feel a thing and came out of the biopsy procedure feeling like I had the best sleep.
Yes, I have actually had two biopsies. The first was in 2012 when I had a rise in PSA and it was eventually determined the reason for the rise was a UTI. No anesthetic was used and it was really painful. All cores negative. When my PSA rose again in 2018 I insisted on anesthetic for my biopsy and it was pain free. The 2018 biopsy showed significant G7 PCa, I had RP and am doing very well.
The biopsy I had in 1999 was extremely painful. So much so I told joking the old man doctor who did it that I felt like kicking his but. He was not amused. I am sure he was not aware . My story. Just recently an oncologist wanted to do a biopsy and I told him no that it was not necessary and have not gone back.
Thanks everyone for all of your input and to anybody else with experience would you please continue to contribute your opinions. My friend is going to be monitoring this thread and this is very helpful to him. Naturally he’s very concerned about this matter and hopefully everything‘s going to turn out fine with no cancer.
Was there just the one test? Was free PSA measured?
Dr Walsh "If your PSA level is above 3 or you have a prostate exam with a suspicious lump or hard spot you need additional testing. You can proceed directly to biopsy or consider a second line test to help determine if a biopsy is really necessary. ...
"what matters is a significant change over time, ... For men with PSAs greater than 4, an average, consistent increase of more than 0.75 ng/ml over the course of three tests is considered significant. Say that over eighteen months, a man's PSA level went up from 4.0 to 4.6 to 5.8 ng/ml. Clearly, something is going on here. ...If you have a PSA level between 1 and 4 and it is consistently rising faster than approx 0.4 ng/ml a year, you should get a biopsy. ... Several large studies showed that men who had a PSA velocity of 2 within the year before diagnosis were much more likely to have an aggressive form of caner...
"if the free PSA is less than 10%, it's more likely that most of that PSA is coming from cancer, that the caner is significant in size, and that it will prove aggressive. ... evidence shows that free PSA can predict which tumours will be aggressive - and need to be treated as soon as possible ..In ... Johns Hopkins study using the large database ... urologist ... compared blood samples ...and found that fifteen years before cancer was diagnosed, all the men who turned out to have aggressive prostate tumours had levels of free PSA that were lower than 15%. Men with slower growing, nonaggressive cancer all had free PSA levels greater than 15%. This landmark study suggests that free PSA percentage may be an excellent predictor of aggressive tumours that will need to be treated."
In the UK gp’s have guide lines by age, 60 to 69 psa 4.5 age 70 psa over 6. At age 69 I had DRE which was said to be normal. Sadly I didn’t know of this site at the time or my situation could have been dramatically improved, some of these guys have great knowledge! My psa at 69 was 5.7 GP prescribed various medications for nocturia, referred to colonoscopy etc. After 2 years psa was 11.2 found my own oncologist (via the colonoscopy consultant as I had no trust in GP).
The testing began with 1. DRE 2 MRI with contrast 3 full body scan ( radioactive dye) 4 various blood tests and finally a guided needle biopsy with local anaesthetic. Transrectal - jumped somewhat as the needles went in but not that bad! Except it was a female doctor with 2 nurses playing with my backside.
So in my opinion biopsy should be way down the list. Don’t put things off I was diagnosed with PC metastatic gleason 9.
I took legal action against GP and won. Best of luck
Excellent set of questions!! when I was 64 my PSA was 6.5, I was sent to urologist and sent to get a needle biopsy and it came back negative , 2 years later PSA was 9.5 and an MRI was suggested and thats when the suspicious activity showed up. In restrospect I wish the urologist would of given me a DRE first (logical, right) first and had told me of the MRI . I was told it wasn't availible then (which i doubt) and I was quite ignorant about all this . I considered the first biopsy now totally unneccesary , and it possibly gave me a false sense of confidence that i was ok .(maybe i was) I do feel now that that first biopsy was a shot in the dark,and uneccesarely invasive . MRI for me is the way to go . Also after that ,I went to another urologist who did a DRE and pretty accurately told me what my situation was .Ironically , I received the DRE last (not logical) . When I needed a Multiparametric MRI and fusion biopsy , I did pay out of pocket( 1200 euros here in Spain ,) but worth it. I really wish I had asked that question here and read the advice that are in LearnAll and Tall Allen's posts. I agree with their knowledgable suggestions.
I would go to another urologist in your medicare advantage plan, maybe from a large practice. I'm very surprised a DRE was not performed, that is always done at his age. My urologist ordered a prostate MRI before the biopsy and I think that would be the correct thing to do first.
I think that this is what gives PSA testing a bad name. It has been said many times before - PSA is not cancer - it is natural within certain age related boundaries. To put things in perspective my first PSA reading was 1000 but there are loads of folks on this site worrying about values less than 1.0, and worry is a particularly useless emotion . What is important is long term changes in PSA - ie it keeps rising. If that happens then a biopsy might be good - but nobody should be using transrectal biopsy these days, insist on transperineal - its easy and not problematic - its guided by a rectal ultrasound (I think), uses local anaesthetic, and gives reliable results - especially if guided by the CT/MRI scans.
Medicare Advantage plans are to mimic Medicare. He can file a grievance with the insurance company or the Ombudsman for the State. I had my first PSA at 59, DRE was negative PSA was 15.4. He needs to advocate for himself.
Regarding switching from an Advantage plan to a supplement, he may have to have a physical to qualify. But I believe supplemental plans give far more choice than Advantage plans, because they can be used at any facility or doctor that accepts Medicare, and if Medicare approved a procedure, the supplement has to pay their part.
Biopsy +1. I know men with high PSA and no cancer. I was low PSA and stage 4 cancer. The only way to settle it is a biopsy.
The biopsy is extremely unpleasant. See if they will give him propyfol or something like that. If not get whatever painkillers you can get your hands on and give him an ice bag to sit on.
Thanks again guys. I forgot to mention that his original primary care doctor did put him on antibiotics then retested for the same result. I'm just surprised that neither doctor performed a DRE at the first signs of high PSA.
Some things about biopsy. TransRectal can be painful for some but not at all for others. Minimal risk of infection so antibiotics are usually given. Also an Ultrasound probe is inserted in the rectum to help locate points of concern. In my case some were calcium deposits. Others Cancer.Another biopsy method is Transpirenial (sp) where the needle is guided by a 3D ultrasound probe. The needles are put in, often, with a template, and samples are taken from areas of concern. Yes pain medication is used because the needles go in the area between the rectum and testicles. As many as 18.
This method is preferred and used for Brachytherapy treatments. Very good but pain meds will be given.
Remember this - we are each different in pain tolerance.
I had a 3 that spiked to a 4 in one year. That was cause to have a needle biopsy and a DRE (not at the same time thank goodness). If I had to do a needle biopsy again I would insist on the doc knocking me out (even using a 2 by 4)…
I agree with several others here....get a DRE first. Then if that is questionable, get the MRI, then the needle biopsy. My husband had a PSA of 1.5 to 1.8 for 5 plus years (age 62-67). He let his doctor get by with not performing a DRE at those annual visits because he really didn't want to go thru that and the doctor "always seemed rushed". When he had his next annual (Apr. 2018) with a new doctor, his PSA was still only 2.4, but the doctor did a DRE and found a hard nodule. He immediately scheduled him with an urologist who did a biopsy without the MRI (against my advice). Found several positive areas and given Gleason score of 8; had RP in Sept. 2018 and the biopsy from removed prostate came back with 4 different areas with cancer (1 more then biopsy picked up) but contained.Sorry so long....but I tell everyone that a DRE is necessary and should be insisted upon. A low PSA doesn't tell the whole story!!
I would check it out with one of the methods people are mentioning, though a DRE may or may not find pc. My general practitioner referred me to a urologist after prescribing Flomax because I was getting up a lot at night to go to the bathroom. My psa had been coming in under 5 at the time. I put it off a few months because of Covid, finally scheduled an appointment with the urologist, he did a DRE and said everything feels normal but let's get another psa reading. This time my psa came back at 7.5. So I had the transrectal needle biopsy done with ultrasound and they found 6 Gleason 9 readings out of 13 samples and a tumor. I really didn't feel much during the biopsy because the doctor game me a pain deadening shot in the area before taking the samples; I just felt a sort of dull pressure on the area during each sample taking.
My husband had his first elevated PSA in 2003 at age 55. His PSA had rocked along at slightly <4 for 5 years until it bumped to 6 in 2003. He had a TRUS, all cores negative, already had BPH. From 2003 - 2014, he had 11 successive years of negative TRUS biopsies, bouncing PSA, and increasing BPH, which was always blamed for the rising PSA. His prostate grew to 125+ grams so he was advised to undergo a simple prostatectomy right after a biopsy that put him on a catheter until he could have the surgery. PSA 14. An extremely well-known surgeon in Celebration, FL, agreed to do the simple even though all biopsies had been negative and all DREs normal. Even knowing the PSA was 14, the surgeon did not order his own 3t mp-MRI. Pathology showed a tumor hiding in the huge prostate, Gleason 3+3. Margins were clear. The surgeon was absolutely positive that he "got it all." That wasn't to be. In 8 years, he has had 2 surgeries, one a salvage on recommendation of the well-known surgeon, 2.5 years of ADT (Casodex <and tamoxifen>) and 39 RT. Out of the 11 biopsies, my husband never had more than needle anesthesia and never any pain at all until the very last one (uro with fat hands). Over 8 years, it hasn't seemed to us that prostate cancer follows any rules. One person above covered all of the possibilities. I would pass along his observations and recommendations to your friend. I wish him no diagnosis of PCa!
Something to learn here. Don't ever EVER get a Medicare Advantage plan. I said Never when on Medicare. Don't believe Jimmy Walker or any of the celebrities advertising for it. You give up all your Rights to affordable care anywhere you want. There is no free lunch.
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