Does this sound right? Any advice appreciated.

[Biddity]

My dad, 82 yo male had a previous PSA score that hovered around 3 and then went up to 5. Had MRI/CT which came up clear last year and a prostate biopsy (11 samples, noted prostatitis and BPH) in September last year which was also clear. Took PSA again in December 2023, it jumped to 15. Took PSA in February, score jumped to 25. 4k test done, results are 30% which puts him in the high risk category for aggressive cancer. Took PSA again and it went up to 30 so doctor ordered another biopsy. Biopsy came back clear (standard biopsy, 12 punches). Doctor is still convinced it's cancer due to PSA jump and 4k results mentioned previously so he has ordered a PSMA PET scan and discussed treating with goserelin or bicalutimide depending on how that test goes. Does this sound right or should he get a 2nd opinion? Doctor is also conferring with doctor who did recent biopsy. Both doctors are urologists not oncologists, does that matter? Thanks in advance for any thoughts/advice.

[Tall_Allen]

It doesn't sound right to me. His rising PSA seems to be entirely due to BPH and prostatitis. There is a test called "Confirm MDx" that can be done on biopsy tissue when the biopsy is negative. It virtually guarantees that no means no. It is improbable that significant cancer was missed on both biopsies.

mdxhealth.com/confirm-mdx-f...

[Biddity in reply to Tall_Allen]

Thanks for the tip! I forgot to mention the doctor prescribed 1p days of Cipro to see if it may be an infection but the PSA number continued to rise.

[Tall_Allen in reply to Biddity]

Prostatis does not respond to antibiotics.

[Biddity in reply to Tall_Allen]

Ah ok. So is it possible that a fast rising PSA number could just be due to prostatitis?

[Tall_Allen in reply to Biddity]

Yes, it's likely based on biopsy evidence of chronic prostatitis.IMO prostatitis never fully goes away. It just relapses and remits forever.

[MJCA]

Trust Tall_Allen. One question, if dad was diagnosed with prostatitis was he put on any meds such as Ci-Pro?

[Biddity in reply to MJCA]

Yes he was. No affect on PSA.

[MJCA in reply to Biddity]

That’s good. The PSMA PET will be the key indicator.

[Justfor_]

If PSMA PET scan returns negative, at such an elevated PSA, it will be 95+% certain that he doesn't have PCa. Anything else carries less weight.

[Biddity in reply to Justfor_]

So you think he should do the PET/CT?

[Justfor_ in reply to Biddity]

On another thread I argued that if someone has a multiparametric MRI assessement of PIRADS 5 and a positive detection on a PSMA scan, there is no reason to have an invasive biopsy. Of course, urologists make a bulk of their living by performing biopsies and they just wouldn't surrender such a steady source of income to radiologists. Bottom line: PSMA PET CT is the best tool in the toolbox. Any one arguing differently is pushing low quality propaganda.

[9020B in reply to Justfor_]

Biopsy will give Gleason score. Is that not a good reason?

[Justfor_ in reply to 9020B]

It is of secondary importance. A PIRADS 5 and PSMA+ will certainly not be GS 3+3. If you check any nomogram GS 8, 9 and 10 are treated as one class. Some go further to include within said class 7B or 4+3. Primarily important parameters like metastases, node invasion, SVI, EPE etc that give a better picture of how much PCa has advanced aren't provided by biopsies.

[9020B in reply to Justfor_]

You wrote "A PIRADS 5 and PSMA+ will certainly not be GS 3+3." Can you provide a study that confirms this? The studies I found seem to say PSMA uptake can be any GS. I do know that my PIRADS 5 biopsied at 3+3. Post RP pathology was upgraded to 3+4 with 20% grade 4.

I did not get a PSMA PET as these scans were not commonly approved in cases like mine in 2021.

As for following the money, a prostate biopsy in my area seems to be about one third the cost of a PET scan.

[Justfor_ in reply to 9020B]

Sorry, I am not the flock follower type of person that will take any "study" for granted. In my derision making my personal assessment of the objective facts prevail any "study". But, you don't have to look any further than your personal case. If you believed firmly in the 3+3 biopsy outcome you wouldn't have had RP. It was the PIRADS 5 that made the difference and justified your action taking by the later upgraded 3+4. As to the follow the money, urologists that are the principal advocates of biopsies don't care about the total price. They care about their own cut. PSMA PET in my area is burdened by >60% from the cost of the radio pharmaceutical and of course there is no comparison on the running, maintenance and amortization costs of a PET scanner compared to an ultrasound biopsying device. At the end of the day the labour induced cost of a biopsy is much-much higher than that of a PET scan.

[9020B in reply to Justfor_]

You wrote "If you believed firmly in the 3+3 biopsy outcome you wouldn't have had RP. It was the PiradS 5 that made the difference and justified your action taking by the later upgraded 3+4."

Not true. I had 8 of 12 cores with 3+3. Several were 90%. I was well out of AS territory.

Again, what makes you think those scans can preclude 3+3?

Regarding cost, do you have any idea what a PET scanner cost?

[Justfor_ in reply to 9020B]

"What are the probabilities of a 3+3 prostate Gleason score to render a PIRADS 5 multi parametric MRI. Please supply relevant links.

ChatGPT

The probability of a Gleason score of 3+3 (which indicates Grade Group 1 prostate cancer) resulting in a PIRADS 5 multiparametric MRI (mpMRI) is relatively low. PIRADS 5 indicates a high likelihood of clinically significant prostate cancer, typically corresponding to higher Gleason scores.

Gleason score 3+3 is considered low-risk prostate cancer. Studies have shown that lesions with Gleason scores of 3+3 are less likely to exhibit the characteristics necessary for a PIRADS 5 rating, which often identifies more aggressive and higher-grade cancers. For instance, PIRADS 5 typically correlates with higher Gleason scores such as 4+3 or greater, reflecting a more significant likelihood of aggressive cancer​ (BioMed Central)​​ (Sperling Prostate Center)​​ (SpringerLink)​.

Additionally, the use of Apparent Diffusion Coefficient (ADC) values in mpMRI helps differentiate between low-grade and high-grade tumors. Lower ADC values are associated with higher Gleason scores, making it unlikely for a Gleason 3+3 tumor, which tends to have higher ADC values, to be classified as PIRADS 5​ (SpringerOpen)​.

For more detailed information, you can refer to the following resources:

Cancer Imaging Journal on PI-RADS and Gleason Scores

Sperling Prostate Center on PI-RADS and Gleason Scores

Insights into Imaging on ADC Values and Gleason Scores"

[vintage42]

"... Both doctors are urologists not oncologists, does that matter? "

That is an interesting question. Can a urologist be, or become, an oncologist?

After radiation, my MO referred me to my long-time urologist for follow-up testing and office visits. After a few years, the urologist tranistioned from the urology department to the oncology department of his large organization. He quickly filled his calendar, and when I showed BCR, he took me with him. I had continued to use the original MO for second opinions, but he finally said he didn't like that, would not be on a team, and I had to chose one doctor.

My urologist/oncologist seems as knowledgable, and more aggressive, than the MO was, so I am staying with him. Can one doctor be both, at least for prostate cancer?

[Grandpa4]

I would get a prostate MRI. That way when you biopsy you can make sure the needle is in the area of interest.