Preparing for my Urologist Appointment re Increased PSA -- Including possible biopsy questions

[boomerguy]

I am preparing questions for my upcoming urologist appointment to discuss increased PSA. Any guidance that you veterans of these battles care to give would be appreciated.

My total PSA is now 5.2 with 18.5% free. Eight months ago my PSA was 4.4. (21 months before that, 3.9.) An mpMRI six months ago showed a PI-RADS 2 lesion (0.8 x 0.6 cm, in the transition zone) but also a non-worrisome PSA Density of 0.09. An ExoDx test that I had seven months ago showed a reading of 33, which is in the not-automatically-safe category – vs a reading of 13 five years earlier. I am 68 years old and have traditional Medicare coverage. I know that recent ejaculation or bike riding can affect PSA; those are not factors here.

Six months ago, the urologist and I talked about the possibility of a biopsy, and I have a feeling that with the increased PSA this will be the time to do it. (If I retake the PSA very shortly, possibly as part of a 4K score test, and it is back down to the 4.4 where it was 8 months ago, maybe it would be worth delaying the biopsy, but my gut feeling is to get the biopsy done as soon as possible regardless. Any thoughts would be welcome.)

I know that the urologist uses the transperineal approach. I am pretty sure he uses ultrasound and/or MRI guidance, but I don't remember whether he said he uses fusion or not. I will ask him at the appointment.

Several questions:

Does it matter whether a fusion biopsy is performed by a urologist or an oncologist? If it is valuable for it to be done by an oncologist, I could investigate resources in my area (Central New Jersey and vicinity) but I am guessing that might introduce a delay. I believe that my urologist has a 2 to 3 week lead time. He does the biopsies one day a week and I am guessing he has done a fair number but I am not sure. There is a Memorial Sloan Kettering location not too far from me but who knows how long the wait time to get a biopsy would be (I could try to find on Monday but I doubt that they would tell me over the phone). Hackensack Meridian may be another option.

Are there particular characteristics I should look for when evaluating a doctor and a facility for doing a fusion biopsy? e.g. Systematic plus Targeted? Number of cores? Or are these decisions all pretty standard these days?)

For most fusion biopsies, is the MRI performed right before the biopsy, or is it done, say, a few days in advance?

I believe that most places do fusion biopsies under sedation but some use local anesthesia. I handle pain pretty well (I once had part of a toe amputated under local). I may be able to avoid having to get medical clearance if I use local, and maybe I could drive myself home. Any opinions?

If there are any other questions anyone feels I should ask the urologist at the appointment, it would be appreciated – as would thoughts on anything else I mentioned here. Thanks.

[Tall_Allen]

There is nothing to target on a biopsy, and your increasing PSA is probably attributable to mild BPH. Don't create problems for yourself.

[allie2020]

I sure do think you should have the 4KScore test WAY before a biopsy. If TA says there's nothing to biopsy, that is significant.

[WilsonPickett]

I have one thing to say: Sloan-Kettering.

[HopingForTheBest1]

I would, and did, have the 3T MRI Fushion guided biopsy performed by a urologist. Too many risks and inaccuracies by having a biopsy done in the urologist's office. You will get sedated, probably at a same day outpatient surgicenter. No pain or discomfort after.

[Bethpage]

I thought I read in this HU forum around 6/21/23 that MSKCC is no longer performing biopsies for patients without a prior positive diagnosis of PCa?

[dentaltwin in reply to Bethpage]

That was my brother's experience; he went to NYU for an MRI and is scheduled for biopsy on Thursday after being turned away by MSKCC. He may or may not switch over to MSKCC if he needs treatment.

I must say I'm mystified--a cancer center that does not diagnose cancer (at least not PC).

[Bethpage in reply to dentaltwin]

You may actually have been the member who commented back in June!

[dentaltwin in reply to Bethpage]

Probably was. Found out yesterday an old friend had the same experience.

[Bethpage in reply to dentaltwin]

It makes no sense. I guess MSKCC doesn't want new patients.

[Photographerhere]

your doc may be a top doc. But in general my advice is seek the opinion of a urologist and radiation oncologist at a top medical research university. Think Sloan Kettering, UCLA type places. It’s worth the plane trip if you are not within driving distance. A top doc will lay out all the options for you, including watch and wait. I. Meantime, there not a rush with prostate issues, anotehr couple of weeks won’t make any difference

[j-o-h-n]

From my understanding as a long time PaYtient of MSK they don't do the "run of the Mill" biopsies..... They usually only accept proven Pca PaYtients. So find the best Urologist who has done tons of biopsies as your surgeon. BTW Doctors normally do not like to use any type of sedation when snipping your Prostate. For me it was not really painful just a hard pinch here and there. BTW If the doc is willing to put you out...... take s/he up on it.....If you do have Pca I would then go to MSK for treatment...

Footnote: My original doctors told me if there is a surge in your Psa within a year that normally is one of the signs to get a biopsy, Normally 4.0 + is the gold standard for a biopsy.

I'm Old and Dated and I may be off base...... but I'm still on third trying to steal home.....

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 09/10/2023 4:59 PM DST

[dentaltwin in reply to j-o-h-n]

My brother, who is scheduled to have a transperineal bx on Thursday at NYU, will be getting sedation. When I got my TRUS bx at MSKCC 5 years ago, they used only local anesthetic. I have no idea if this is standard practice or specific to NYU. Maybe transperineal is more painful. My TRUS bx was bad enough. I really should have stopped them and made them reinject me.

[j-o-h-n in reply to dentaltwin]

I can only guess about the trans procedure*......But here's what I did for my open biop. I contacted an old American Indian Chief (not politically correct) who sent me one of his old bite sticks....I bit down on the stick during my biop procedure..... Helped......(had to return the stick with a check).

*Tell your brother that's his trans should be less painful than an extraction...(I think)...

Before the procedure of your TRUS you should have warned the Anesthesiologists that if during the procedure you grabbed him by the balls he should up the gas or stop the procedure. (Mama's quote: a stitch in time saves nine).....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 09/11/2023 5:19 PM DST - Remember

[lpol83712]

Scoring for Dynamic Contrast-Enhanced Imaging is utilized at UCLA as follows: a peripheral zone lesion will only be considered positive if it corresponds to a focal abnormality on T2-weighted and diffusion-weighted imaging and

enhances earlier than (not contemporaneously with) surrounding normal peripheral zone tissue.

Appendix (based on UCLA data/publications)

Overall MRI sensitivity for prostate cancer detection = 47%

Sensitivity for tumors > 1 cm or for Gleason > 3 + 4 = 72%

In-Bore MR-Guided Biopsy CDR MR/US Fusion Biopsy CDR

PI-RADS 2: 7% PI-RADS 1/2: 15%

PI-RADS 3: 44% PI-RADS 3: 23%

PI-RADS 4: 63% PI-RADS 4: 64%

PI-RADS 5: 94% PI-RADS 5: 80%

1. Eur Urol 2019;75(5):712-720

2. Radiology 2017;283(1):130-139

3. Cancer 2016;122(6):884-892

4. Abdom Radiol 2016;41:954-962

5. Eur Urol 2015;67(3):569-576

6. Am J Roentgenol 2015;1:W87-92

Didn’t copy as easy to read. The in bore biopsy is in actual MRI magnet machine. The number underneath is from the MRI ultrasound fused Pirads2 may have so low a yield to defer biopsy but if PSA is dictating biopsy then I would have fusion biopsy plus template biopsies. Just Pirads 2 alone is usually followed but you can see UCLA numbers for MRI detection and MRI detection of significant disease so there are misses and that goes into clinical decision making.

[boomerguy]

Thank you all for the the replies. Keep those cards and letters coming. I plan to update after my appointment.

[boomerguy]

The urologist said to get a 4Kscore blood test (which includes a PSA) in 3 months. If I had the choice I might self-order a PSA in 6 weeks, but New Jersey is one of three states (NJ, NY, RI, last I saw) that thinks its residents can't be trusted with the option to self- order blood tests. Maybe I can find a doctor licensed in New Jersey, even an online family practice doctor, to order it. Anyway, I'm glad to hear that my urologist's concern is fairly minimal. Thanks again to all who replied.

[allie2020]

I think that all sounds good. I had the 4KScore test and it was an important part of my diagnostic process. Maybe you could talk your Uro. into moving up the 4K test to two months instead of three?? I get all of my ultrasensitive PSA tests through my GP and it is very simple. It's a difficult thing to decide exactly when a biopsy is warranted. My first biopsy was w/o anesthesia and it was very, very painful. My second was with anesthesia and was a piece of cake. Good luck.