Rising PSA - Scan or Biopsy

[Pres21]

In 2010, I had an elevated PSA of 4.93 and a biopsy that generated a Gleason score of 6 (3+3). At that time, my urologist was suggesting that I choose a radical prostatectomy or radiation. Instead, I elected for AS, and my pcp referred me to a clinic that offered AS. In 2014, my PSA increased to 6.8 and my oncologist put me on Proscar and Cardura. The PSA dropped to 2.4. My oncologist continued to monitor my levels, but, after a couple of years, the cancer treatment center closed their local clinic. I continued to have my PSA monitored by my pcp. However, at the end of 2019. my psp also closed his private practice and retired. Faced with finding a new pcp, I decided to join a local HMO. Over that past two yers, they continued to monitor PSA, However, it has now crept back up to 6.94. Using the Sloan Kettering calculator and the past three PSA results, the doubling time is about 8.5 years.

I am now 74 and have been referred to a new urologist by my HMO. This new urologist feels that my meds mask my true PSA and that the value is really closer to double of the 6.94 value. He wants to perform a biopsy. On the other hand, member of the HU community has suggested that I might want to obtain a scan to determine if the cancer cells have spread outside the capsule. A local clinic is offering the Pylarify scan. However, I have not been referred to them by my HMO. I understand that the cost of a scan would probably not be covered by my HMO.

Are there problems associated with either the biopsy or the scan. I am looking for recommendations on how to proceed.

Thanks in advance to the entire HU community.

[Tall_Allen]

A PSMA PET is totally inappropriate. It is for high risk men. An mpMRI and targeted biopsy are appropriate.

[Pres21 in reply to Tall_Allen]

TA: Thanks for the input.

[Javelin18]

Since you had a biopsy, you're probably familiar with the side effects of that. I had irritation and pain in my prostate, with blood in my urine for about a week. I haven't had side effects from any of my scans.

I think after much time has passed, it's good to know the state of the cancer. A biopsy will tell you what is happening with the primary tumor,but not if it has metastasized. The treatment plan will be different if it has metastasized, so that argues for the scan.

Since your HMO gate keeper won't request it, you'll probably have to pay out of pocket. The out of pocket cost for a PSMA PET is $3,300 at UCLA. I'm not sure how much an Axumin or FDG scan would be out of pocket.

[Pres21 in reply to Javelin18]

Javelin18: Thank you. As you mentioned, I have been in AS for several years, and things have changed. I am in the Seattle area. One of the major clinics in the area is reported to be offering the Pylarify scan. Do you know how a P-scan compares with other scan proceedures? I appreciate your comments.

[Javelin18 in reply to Pres21]

The Pylarify PSMA PET scan is the most widely available scan for PSMA expressing cancer. PSMA is a surface antigen that can be used to show the location of prostate cancer cells within the body. It is more specific than Axumin or FDG PET scans, which show cells with high metabolic activity.

Cancer cells are very active, so they show up with Axumin or FDG tracers. These tracers also show non cancerous cells with high metabolic activity. PSMA PET scans show greater contrast with healthy tissue, and show smaller lesions than can't be seen with Axumin or FDG PET scans.

Since I'm not a doctor, I can't say whether a Pylarify is appropriate for your case, but a targeted biopsy will tell you how the tumor has changed over time. Newer biopsy procedure uses an MRI to guide the location where samples are taken.

[Pres21 in reply to Javelin18]

Great info. While I have a lot to learn on the subject, this is certainly a start. Thanks for taking the time and thanks for sharing.

[addicted2cycling in reply to Pres21]

If you go for a scan make sure it is a 3TmpMRI and not the older and less revealing 1.5T. ALSO be aware that if the more accurate and complete trans perineal biopsy, not the older and inferior TRUS, shows ONLY low volume 3+3 then AS is becoming more widely accepted since 3+3 rarely metastasizes. ALSO understand that other issues besides PCa can sharply elevate PSA.

I am not a doctor but did stay at a Holiday Inn Express. Good Luck and keep us posted.

[Pres21 in reply to addicted2cycling]

Thanks for taking the time to respond. Your insight is greatly appreciated.

[leach234]

Are you a fool? Get the biopsy!

[Pres21 in reply to leach234]

Thanks. Yes, a biopsy sounds like the logical step.

[Hidden]

I second what TA said. Worked like a charm for me.

[Pres21 in reply to Hidden]

Thanks for the input.

[Justfor_]

You are in the middle of a Catch 22 terrain. Urologists make their living by performing biopsies. Radiologists have set foot into this lucrative domain by mpMRI. Even if you get a PIRADS of 5, which is way more indicative of your state than a blind biopsy, you won't find any urologist to treat you without a biopsy. They will tell you: "Just to make certain and assess your condition better". Yet, their drive is purely to safeguard their professional rights that will not surrender, period. So, you have to pay the two ferrymen, do first the mpMRI and then go for a targeted (also called fusion) biopsy. Based on the two you will get a clue whether Pylarify could provide any additional info.

[dentaltwin in reply to Justfor_]

Did anyone suggest a "blind" biopsy?

[Justfor_ in reply to dentaltwin]

The term biopsy without any additional distinction is blind so that it is distinguished from the one referred to as targeted.

[Pres21 in reply to Justfor_]

Justfor_: I like the "Catch-22" comparison. My interaction with my first urologist (in 2010) was very frustrating. It did not create any belief that he gave any value to my QOL. However, I agree that a mpMRI followed by a targeted biopsy may be the wise course. Thanks for your comments. Much appreciated.

[leach234 in reply to Justfor_]

You sound paranoid

[Hidden]

I used the state health system in NZ. PSA was 10 to 12 for three months - the entry point for an over 70 year old into the state system here.

First step was an MRI which the confirmed the presence of cancer which the radiologist classified as PIRADS 5. The scan was viewed by the oncology urologist who diagnosed the cancer as T3b. Next step was biopsy which came up with a Gleason score of 4 + 3. So localised spread only, and serious, but not very serious - yet. Treated by ADT and EBRT.

My advice, for what its worth, is to do the MRI and biopsy first. If these scores are higher ie the cancer is a T4 and or the Gleason is 8, 9 or 10 then it may be advisable to ask your oncologist about getting a PET scan but, I would suggest, not as a first step.

[Pres21 in reply to Hidden]

Thank you for sharing. Info such as this helps me to make more educated choices. Much appreciated!