Active Surveillance Still a Good Option?

[ironmanburg]

Hello, I (70 y/o active white male) was diagnosed with PC last October and I recently had my 3rd prostate MRI within 2 years. The results of the latest one was similar to the other 2: IMPRESSION:

Benign prostatic hyperplasia with peripheral zone scarring. PI-RADS2. Elevated PSA density, increased from prior study. Continued follow-up is recommended if repeat biopsy is not elected.

Prostate Bx results: 10/29/2021

SUMMARY DIAGNOSIS:

1. (LEFT LATERAL BASE, BIOPSY); BENIGN PROSTATIC TISSUE

2. (LEFT LATERAL MID, BIOPSY); BENIGN PROSTATIC TISSUE

3. (LEFT LATERAL APEX, BIOPSY); BENIGN PROSTATIC TISSUE

4. (LEFT BASE, BIOPSY); ATYPICAL

5. (LEFT MID, BIOPSY); BENIGN PROSTATIC TISSUE

6. (LEFT APEX, BIOPSY); ADENOCARCINOMA

7. (RIGHT BASE, BIOPSY); BENIGN PROSTATIC TISSUE

8. (RIGHT MID, BIOPSY); BENIGN PROSTATIC TISSUE

9. (RIGHT APEX, BIOPSY); ADENOCARCINOMA

10. (RIGHT LATERAL BASE, BIOPSY); BENIGN PROSTATIC TISSUE

11. (RIGHT LATERAL MID, BIOPSY); ADENOCARCINOMA

12. (RIGHT LATERAL APEX, BIOPSY); ATYPICAL

I was going to return to the Urologist for a 2nd prostate bx in October 2022 and go from there, but I had bilateral total knee replacement surgery on 7/27/22 and my Urologist and Ortho guy said we needed to wait for 6 months before I have the bx. So, my Urologist scheduled another MRI in December and office visit in January. I've had 3 MRI's (07/20, 05/21 and 05/22) with similar results from each one:

IMPRESSION:

Benign prostatic hyperplasia with peripheral zone scarring. PI-RADS 2. Elevated PSA density, increased from prior study. Continued follow-up is recommended if repeat biopsy is not elected.

My most recent PSA was 8.5 (and this is what scares me) and free PSA was 21.2 and this is where I am beginning to think I may need to start thinking of treatment. I might add that this PSA was done at the VA hospital lab, and I had been on painkillers, NSAIDS, supplements and had 2 pints transfused during my hospital stay. It seems the results at Quest lab are usually lower than results from the VA lab. I know we are all different, but I wanted to get an opinion on where to go from here from those who have traveled a similar path.

Date/PSA/Free PSA

8/31 8.5 21.2% (VA lab)

5/22 6.7 16% (quest lab)

2/22 7.1 18.3% (VA lab)

7/21 6.4 17.2%

2/21 5.4 22.2%

1/21 5.1 25.5%

6/20 4.6 19.6%

2/20 4.5 24.4%

Thanks,

David Burg

[Tall_Allen]

Why would you consider treatment with low risk PCa and a PIRADS=2?

[ironmanburg]

The PSA trending up worries me.

[addicted2cycling in reply to ironmanburg]

ironmanburg wrote --- " The PSA trending up worries me. "

1st - Appears to me, that the biopsy was a TRUS and as such by design misses import areas of the prostate and also since it is done rectally has a higher incidence of infection compared to a Trans Perineal biopsy. IMO, you should INSIST that future biopsies are TP. note: forget the preceding reply if it was a TP biopsy :0)

2nd - Other factors can raise PSA besides PCa. You could have a 3TmpMRI to view prostate before another biopsy in addition to other NON-INVASIVE Tests via blood and urine sampling.

3rd - Take a chill pill and RELAX UNTIL further investigation.

[ironmanburg in reply to addicted2cycling]

Thanks. I will get the trans perineal bx the next time.

[Currumpaw in reply to ironmanburg]

Uh huh--a real time, in bore, trans perineal biopsy by someone who is experienced and has a rep in that area. If you have to pay for a mp 3.0T MRI with the real time trans-perineal biopsy yourself, do so if you can. When going into battle, the strategy developed will succeed or fail based upon the value of the reconnaissance. It all starts with the MRI and biopsy. You want the best. The trans-perineal allows areas of the prostate to be biopsied that the TRUS doesn't. An experienced doctor only biopsies that which is suspicious. 12 cores, again and again-- I read 12 cores. Biopsies can cause damage. Depends on who does biopsy and if they hit a nerve bundle. Copy all between the lines.________________________________________________________________________

Large review study finds low risk of erectile dysfunction after ...

health.harvard.edu/blog/lar......

________________________________________________________________________

An excerpt:

"The data from this research provides some reassurance on sexual outcomes following a single prostate biopsy," says Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Medical SchoolAnnual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org. "Some smaller studies have indicated that the risk of experiencing erectile dysfunction may increase with multiple prostate biopsies. In clinical practice, we are attempting to decrease the actual number of biopsies performed by substituting with prostate MRI scans, especially in men being monitored for cancer progression on active surveillance."

Some smaller studies? There isn't that much interest in unfortunate damage caused to a small percentage of men from multiple, less than stellar biopsy methods. Some of us started with the 12 core and "advanced" to biopsies with the number 2 and 3 as the first numbers. Also, the old Artemis biopsy that was used was guided by a 1.5T MRI taken hours previously with the image which was chosen fused to an ultrasound screen.

Then the fluoroquinolones which have caused much damage to men who have had biopsies. Cefdinir and Rocephin can be used rather than the fluoros.

Currumpaw

[tsim in reply to Currumpaw]

Speaking of MRI in bore, do you know of anyone that had their insurance pay for this as yet?

[Currumpaw in reply to tsim]

I didn't have an in bore. It was, perhaps, not offered at that time. I paid ~ $3,600 for an Artemis biopsy in 2014 plus a somewhat hefty three figure amount for the pathology results.

I do believe that you can have an in bore for less but a trans-perineal probably increases the $$.

What is your life worth to you and the quality of the remaining years of your life worth?

I'd rather pay someone at the top of their game than be a part of someone's learning curve.

Faulty intelligence has toppled superior armies.

Currumpaw

[tsim in reply to Currumpaw]

I had an in bore in 2018 at Sperling Med in Delray, $5K. Best money I ever spent. The adoption of inbore is going fairly slowly I believe because of a small pool of experienced physicians performing them and of course you need a 3T with pelvic phased array coil found usually at the larger centers. I think a few more places are doing them Brigham and Womens, Seidman at Cleveland Clinic, I think UCLA and another private place in SoCal.?? Yale Med... You were fortunate enough to have a fusion mapped procedure, best tech at the time. I really feel bad for some of my friends that had to endure the many times multiple ultrasound only biopsies, some real horror stories. That's why I was wondering if you knew of anyone that had it covered.

[Currumpaw in reply to tsim]

I don't know if there is coverage a mp 3.0T MRI, in bore, trans perineal biopsy. I had previously had the 12 core TRUS and a 27 core Artemis. The MRI. a 1.5T with contrast, was done in the morning. The doctor reviewed the results with me pointing "suspicious" areas. He told me that he couldn't tell the difference between biopsy scars and a lesion. He was and maybe still is considered an expert at what he does. He proceeded to take 32 cores, probably all the scars. The pathology report stated that all cores were benign One a core contained seminal vesical

I had been diagnosed by a chiropractor as having had an adverse reaction to the fluoroquinolones used as a prophylactic in August. This biopsy was the following December. I called his office and reported the adverse reaction diagnosis to the fluoros in August--as soon as I left the chiropractor who had told me to be sure to inform him so that the fluoros wouldn't be used again, Before the biopsy he mentioned that he too had, had a shoulder injury and therapy helped him--the golf game--it will be an okay type thing--trust me. The routine was six 500 mg Cipro pills, two the day before, day of and day after and also, as the nurse told me when I asked, "A humongous intramuscular shot of Levaquin". Mixing the two fluoros together may have exacerbated the damage they caused. I had limited use of both my shoulders and a SI ligament in my back was very painful. The chiropractor who had began her practice when fluoros first came out told me that over the years, it was her observation that her patients who had been given fluoros had old return. Old injuries were the most susceptible to these drugs. The injuries would come back as if they had just happened and even worse. For me, moving, exercise--forget it! Daily chores were a challenge. Sleep? Sleep was at best maybe an hour at a time before I needed to move because of pain. It was nearly four years before I found that things I took and did began to heal me. I doubt that I will ever be the same and I have lost those years.

Biopsies with large numbers of cores can themselves be damaging. Scar tissue doesn't heal as well tissue that has never been damaged.

Don't think the Artemis biopsy sets any type of standard. It didn't for me.

Currumpaw

[ironmanburg in reply to Currumpaw]

Thanks.

[Watemote]

Hi, sharing my experience which seems relevant. My biopsy last year showed only 2 of 12 cores positive with Gleason 3+4 and low percentiles of Gleason 4, but one positive core was on the right and one was on the left. This put me in higher risk 2c category because the assumption is there is a large undetected mass of PC connecting the two side of the prostate. I opted for immediate RALP and the assumption turned out to be correct. The primary 3+4 tumor was quite large pressing on the urethra on one side and pushing out of the capsule on the other. My surgeon took two extra hours to try to get me negative margins but I ended up with a small positive margin. So, I am now in category 3a which is upsetting but doesn’t change the long term outlook very much. I have been undetectable with ultra sensitive PSA for the last four quarters but have been led to expect recurrence and followup radiation treatment eventually.

If I had a handy time machine I would have pressed for more tests prior to surgery. If it could have been determined that my PC was out of the capsule I would have opted for radiation and likely avoided the double whammy of first surgery and then radiation anyway. But, as, hopefully, more negative PSA readings come in I’m more at peace with my choices.

[ironmanburg in reply to Watemote]

Thanks. I was offered radiation when first diagnosed but decided to wait. I’m leaning towards having it done now just to get it over with.

[Currumpaw in reply to ironmanburg]

Before you make a decision, read, educate yourself. Some treatments prevent other treatments in the future if needed. Once the word is spoken, once the window is broken, they cannot be undone.

When YOU make your informed decision based on what the quality of life and success rate of the treatment you choose allows, don't look back. You cannot change whatever side effects might result from the treatment. But do be aware of what other treatments can be done if the initial treatment fails. Most men here, are here, because their initial treatment has at least to some degree, is failing or has failed.

Currumpaw

[ironmanburg in reply to Currumpaw]

I will. Thanks.

[Teufelshunde]

You have another item to consider. With your recent knee replacement, I would not have any biopsy for at least a year, especially since there does not appear to be a big need per TA. You want no skin piercing where bacteria as simple as P acne or staff can invade and attach to your implant. Once bacteria adheres to metal, the body no longer fights it, and it will just grow. Result will be a revision where they take old out and put another one in. Had a friend that had that happen twice and had to have amputation. I had it happen to my hip replacement twice. Good for now but if I were you, I would be on antibiotic like doxycycline before and for months after if you decide to get biopsy.

[ironmanburg in reply to Teufelshunde]

Thanks for the info.

[aceace12]

im with tall allen here .... good luck ....

[JWS13]

What was your gleason score?

[ironmanburg in reply to JWS13]

3+3

[ironmanburg]

I had another MRI in January 2023 and showed the same thing as the other three, all about the same, Pirads-2. My concern is my rising PSA since August , 8.0, 10.5 and then 11.5 this week. I do have another surveillance biopsy next week but this rising PSA concerns me. Lab says they don't check Free PSA when PSA is over 10. Any insight is appreciated. Thank you.