Hello, in October of 23 my PSA was tested and was 4.7. I am a 59 year old generally healthy guy. An MRI was performed in February 2024. It showed a PIRADS 5 lesion. I have basically had PSA readings of 2.5 every year since I was 50 years old. After a 14 core trans perineal biopsy a very low amount of Gleason 6 was found in 20% of one core. None of the four cores from the lesion tested positive.
My PSA had dropped to 2.8 by July 2024. In September another PSA test showed an increase to 4.2. I recently met with a well known Urologist who tested me on 10/24. My PSA has now increased to 9.25 while my % free PSA has dropped to 6.8. My PHI score is 33.7. The Dr. does not seem concerned. I’ve never had this kind of rapid increase before. Looking for opinions on this. Was told that an MRI wasn’t necessary as they’re generally good for 1 year. The PHI of 33.7 means there is a 17.9% chance of clinically significant cancer. What do you all think?
Thank you,
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Muskyguy
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Get a DEXA scan. Start exercising a lot now -- aerobics, cardio, and most importantly resistance. Daily if possible. Activity like this is said to greatly reduce odds of PCA, and if you come down with it, odds of PCA getting a lot worse. Does PC run in your family?
Thanks for all the information. Your PSA will bounce around a bit, one needs to look at the long term movement and the velocity of change, how quickly is it spiraling upward.
I know your Urologist is world renown but IMO I would get a second opinion. Active Surveillance (AS) is the normal or standard course forwhat is indicated. That is until it isn't. So to ease your mind get a second opinion and maybe from a highly rated Radiation Oncologist (RO)?
Typically Prostate Cancer (PCa) moves slow so you have time thus why the recomendation for Active Surveillance. But at the same time you want to have or get diverse opinions, become educated and know your path forward. After all the chances of it going away versus getting serious is minimal.
I had this happen on my 2nd negative MRI/Biopsy(I had 3 over 18 months). Although I had lesions, none produced cancer nor did the balance of the cores. After 6 months, psa went up again. Drx said let's wait a year. I said NO. I want another MRI. We did an MRI which had the words "much improved compared to previous MRI". I made him justify another biopsy anyway strictly because of PSA/Free PSA trending up/down respectively. That's when I got my diagnosis. 1 core G8. Stay vigilant. Look at all the data. Good luck to ya!
Great advocacy on the vigilance! I believe with the sensitivity of psa it gives a heads up ahead of significant metastasis in a situation like this. Vigilance is key!
Agree: second (and third) opinions from RO and medical oncologist. I was "on" AS for 7 yrs at Hopkins. I think the uro - also quite prominent in PCa world - screwed up by not recommending treatment earlier than he did. The suspicious/cynical part of me wonders if I were an experiment, as it were. He didn't recommend treatment until PSA rose to 23. In retrospect, in what universe was that good advice? I was stupid (and hopeful, I guess) in not pushing back and getting other opinions sooner. I paid for my delay: IMRT, brachy, ADT and a yr and a half of being miserable. Now, six yrs later and holding...PSA 0.02 (nadir), steady 0.04, otherwise. T back to pre-treatment levels (250ish. Woo-hoo) Cured? Would not bet much on THAT yet. My message: you have time to make treatment decisions; get other opinions.
Thanks for all of your opinions on this. Any recommendations as to a good RO in the Northern Illinois region? Chicago is a possibility. I live approx. 1 hr. Northwest.
good morning- Ed Schaeffer at Northwestern is a surgeon, but supposed to be excellent, and seems honest. He’s got an interview with Petter Attia that deals with everything about prostate cancer. Hard to find surgeons that won’t suggest it if not needed, but they are out there, such as Eastham at MSK in NY. (He’s suggested AS for me until now). It’s worth seeing Schaefer if you haven’t.
in my prostate ca journey, the one variable I wish I had paid attention to much more closely once I started to see PSA rise: diet. I could have been and was not careful about eliminating starches and sugars and processed meats from my diet. It takes discipline but could be worth it!
Greetings Muskyguy...... "generally healthy guy"....I'm not against being healthy I just want to point out that those dirty M.Fers don't give a shit if we're healthy or not.....they're gonna eat us anyway..... That said, fight them will all the ammunition available. (Geez I think I'm losing my sense of humor)....
Seems logical many of the men who came to realize their "slow growing" PC had spread would like screening do-overs. I certainly would. (Unless of course, one is good with treating this disease as chronic illness with ADT.)
My PSA bounced up and down for years but with "clear" DREs I feel into complacency and missed the very thing we were screening for - prostate cancer. So much for my complacency (active surveillance) that allowed my cancer to grow and spread.
Ten years ago I learned about multi-parametric MRIs; you did not identify yours as mpMRI. Also, I find second independent radiology and biopsy opinions crucial. And a third if the first and second do not concur. In your case which pathology finding is correct - the one you prefer?
I find statements such as 'good for a year' dangerously deceptive . Example: this past April I had a clear liver MRI. Less than three months later additional imaging identified a 2cm metastatic lesion.
IMO do all you can to be sure you know what you are dealing with to avoid wishing you could have a do-over. It is challenging when docs (and some patients too) tell you to not dig deeper, to not worry. I hope this helps. All the best!
And what of a second radiology opinion to concur, or? Nearly seven years ago I had a Ga68 PSMA PET CT and comparative Ferrotran nanoparticle MRI. Although the Ga68 was 'clear' the Ferrotran successfully identified multiple cancerous lymph nodes.
Northwestern Pathologist looked at the one positive core and thought it was atypical cells and not cancer. First Pathologist said Gleason 6. I forgot to mention Decipher score was .17.
If I read correctly you have two different pathology opinions - of which neither align with (singular opinion ?) PIRAD 5 finding. I did seek a third pathology opinion - 2 of 3 concurred and more closely aligned with mpMRI findings. In my case my post RP final pathology turned out worse than biopsy findings - biopsy samples missed the worst bits of tumor. Hope this helps. All the best for your investigative and decision path.
(adding to profile) Yes Genomic Oncotype Dx, only testing readily available in 2015 but not yet 'approved' so no insurance. Score was low intermediate risk - but was upgraded with RP biopsy tissue; the original biopsy samples missed the worst bits (part of inconsistency between mpMPI radiology findings and path findings).
I had that the first time. Trans perineal. Now my original Urologist wants to do a transrectal in November. I asked “why not do another Transperineal” ? He said “I want to hit it from another angle”. Kind of a head scratcher! My second Urologist wants to skip imaging and biopsy and revisit in April.
You can get better samples from transperineal. I would NOT do a transrectal biopsy. The risk of sepsis with transrectal is VERY high. And I got it. My original urologist refused to do a transperineal saying "the numbers don't warrant it". I asked for a colon swab to check for any bacteria that could be antibiotic resistant, they refused. I was reluctant but finally gave in to a transrectal. They gave me one oral antibiotic 2 hrs before and that's it. 30 hrs later I was vomiting and had a fever of 104. I had sepsis and It nearly killed me. Literally. thankfully I got to the hospital in time, but spent a week in ICU followed by 2 weeks of IV antibiotic infusions at home. 4 years later and I'm still dealing with some of the effects of it. I'd stick with your second urologist.
This answer is from ChatGPT, therefore it is not a medical advice.:
"Deciding whether to go with an MRI-guided biopsy or a different approach depends on your specific case details, prior biopsy findings, imaging results, and overall risk profile. Here’s a breakdown to consider:
1. MRI-Guided Biopsy: MRI-guided biopsies, especially transperineal ones, can target suspicious areas more precisely, reducing the chance of missing a clinically significant lesion. If prior imaging or biopsies suggested specific areas of concern, an MRI-guided biopsy might provide the clearest and most direct results.
2. Transperineal vs. Transrectal Approach: Both approaches have pros and cons. Transperineal biopsies typically have a lower risk of infection compared to transrectal biopsies, though transrectal is more commonly performed due to accessibility and procedural ease. Your first urologist might be considering a different angle for better sampling or due to limitations in the initial biopsy.
3. Alternative Option (Revisit Later): If your recent PSA levels, imaging, and biopsy results don't indicate immediate risk, a "watch and wait" approach could be reasonable, revisiting it after a few months. Some doctors prefer this for low-risk cases to avoid overtreatment.
If you’re not comfortable with either approach, a second opinion from a radiologist or specialist in MRI fusion biopsies might be beneficial. They could help determine whether another MRI-guided biopsy would add significant value in your situation."
A. An MRI fusion biopsy is a technique that combines MRI imaging with real-time ultrasound to improve the accuracy of prostate biopsies. Here's how it works and why it's used:
1. MRI Scanning: Before the biopsy, an MRI scan of the prostate is done to identify any suspicious areas. MRI provides high-resolution images and can detect abnormal tissues that might not be visible on ultrasound alone.
2. Image Fusion: During the biopsy, the MRI images are overlaid or "fused" with real-time ultrasound images. This fusion technology allows the urologist to use the detailed MRI data as a guide while performing the biopsy with ultrasound. This helps them target specific areas identified on the MRI.
3. Precise Targeting: Traditional biopsies (both transrectal and transperineal) may take samples from multiple areas of the prostate, sometimes randomly, which can lead to missed areas. MRI fusion biopsy allows for targeted sampling of suspicious regions, improving the detection rate of clinically significant cancers while potentially reducing the number of unnecessary samples.
4. Advantages: MRI fusion biopsies are especially useful for patients with prior negative biopsies but rising PSA levels, or those with areas that look suspicious on MRI but weren't sampled previously. This method can increase the likelihood of detecting significant cancer while lowering the risk of sampling non-threatening tissue.
This technique can be performed through the transrectal or transperineal approach, depending on patient factors and physician preference.
Q. What is the difference between the MRI guided biopsy and the fusion biopsy?
A. The primary difference between an MRI-guided biopsy and an MRI fusion biopsy lies in how they use MRI imaging to guide tissue sampling, along with the equipment and procedural setting involved. Here’s a breakdown:
MRI-Guided Biopsy
Directly Uses MRI: In an MRI-guided biopsy, the procedure is performed inside an MRI machine. This allows the radiologist to view MRI images in real time as they insert the biopsy needle and target suspicious areas of the prostate.
Real-Time Guidance: The MRI machine provides continuous imaging, so the physician can directly guide the biopsy needle to specific lesions with high precision. This real-time visualization helps ensure that the needle is accurately positioned in the targeted area.
Typically Transrectal: MRI-guided biopsies are usually done via a transrectal approach due to the setup of MRI machines and equipment limitations, although they can sometimes be performed transperineally.
Used in Complex Cases: MRI-guided biopsies are often reserved for cases with complex or hard-to-reach lesions, as it provides the highest level of precision but is more costly, time-consuming, and not as widely available.
MRI Fusion Biopsy
Combines Pre-Recorded MRI with Real-Time Ultrasound: In an MRI fusion biopsy, an MRI scan of the prostate is performed prior to the biopsy. During the biopsy itself, these MRI images are fused with live ultrasound images in a separate setting (usually not inside an MRI machine).
Fusion Technology for Targeting: The pre-recorded MRI data helps the physician to "fuse" detailed MRI images with real-time ultrasound, enabling them to identify and sample suspicious areas more accurately than traditional ultrasound alone. This is especially useful for targeting specific lesions found on MRI.
Performed in a Standard Clinic Setting: Since the biopsy is done using ultrasound in a clinic or procedure room, it doesn’t require an MRI machine during the procedure, making it more accessible and less expensive.
Flexible Approach: MRI fusion biopsies can be performed using either the transrectal or transperineal route, depending on the physician's preference and patient needs.
In Summary
MRI-Guided Biopsy: Real-time MRI during the biopsy, more precise but less commonly available.
MRI Fusion Biopsy: Uses pre-recorded MRI fused with real-time ultrasound, more accessible and typically faster.
Both approaches aim to improve the accuracy of prostate biopsies by targeting areas more likely to harbor clinically significant cancer.
I was in the same boat in 2020 and all the same worry and panic. I was diagnosed with 3 cores Gleason 6 & My urologist told me basically that radical prostatectomy was my ONLY option. He stated that radiation wasn't because of my age and that if the PC returned, surgery wouldn't be possible I was 55 and my psa was 5. needless to say, I freaked! So I did some massive research and found many other treatments available. Of course treatment options are based on your scores - Gleason, number of positive cores, and tumor(s) grade. Active Surveillance is a TREATMENT option - and only when I brought this up to my urologist did he reluctantly acknowledge this! So then I got multiple other opinions - a new urologist, an oncology surgeon and a radiologist - all of whom, after reviewing my scores, stated they would not recommend treatment at this time. The radiologist said he COULD if I really wanted, but didn't recommend it. There are newer treatment options like HIFU - High Frequency Ultrasound and FLA - Focal Laser Ablation, both of which target specific cancer areas of the prostate and don't destroy all the tissue, so men don’t typically have urinary incontinence or ED. The one side effect is dry orgasms - but hey, dry orgasms are better than no orgasms.
I would really recommend getting a second opinion and direct look at the biopsy tissue. you can send your biopsies to Johns Hopkins for an addition direct review of the tissue. It costs about $300 and is all done through the mail. Keep in mind this can cut both ways, as they could come back with a higher grade of cancer, same, or lower - all of which can help guide you in your treatment decision. I sent mine there and they came back confirming the Gleson 6 score but downgraded the cancer to only 1 core from 3.
In addition, I had genomic testing on the tissue. This came back with LOW RISK of it growing and metastasizing.
I am currently still on active surveillance and I have annual MRI's and I get second opinions by a radiologist and urologist on these as well, as UCSF had made an error in the report for my second one, saying the lesion was somewhere it wasn't previously. You really have to manage your care and NEVER take one persons opinion as gospel. People make mistakes.
By the way, please be careful with MRI Gadolinium contrast. In my first annual MRI it made me very sick and I'm still dealing with the effects of it 3 years later. It's a radioactive metal. They say it clears your body in 24-48 hrs. However, not all of it does. It's like mercury, it stays and is cumulative. So the more MRIs you have the more contrast is in your body and could make you really ill. MRI resolution has gotten pretty advanced so they don't need it to read the images. The may say you do, but that's because that's all he knows. Have your MRIs don'e on 3T or above machines.
I've had no change in the imaging in 4 years and if I'd listened to my first urologist, I could possibly be suffering through some awful side effects now. That could change, but I'm staying the course for now and monitoring.
Keep in mind that PC is a slow moving disease so taking a few months to research and get educated is ok. More men die with PC than from his. Your score of G6 in 1 core is really good. I wouldn't panic on the PSA score yet. The Chair of UCSF Oncology Urology said to me he's not concerned until the PSA rises above 10.
This post highlights an approach to prostate cancer management that emphasizes patient research, multiple opinions, and the importance of considering various treatment options. Here are some key points from his experience:
1. Second Opinions and Biopsy Review: Seeking a second or third opinion, particularly at reputable centers or with specialists in different fields (urologist, oncologist, radiologist), can provide a well-rounded perspective. Sending biopsy samples to a place like Johns Hopkins for a second review may offer more insights into cancer grade and aggressiveness, and it could refine the treatment decision.
2. Active Surveillance as a Treatment Option: For certain low-risk prostate cancers, active surveillance—monitoring the cancer with regular checkups, MRIs, and biopsies—is a viable alternative to immediate treatment. This approach is particularly considered for Gleason 6 cancers with a low number of positive cores and no aggressive tumor features.
3. Alternative Treatments like HIFU and FLA: High-Intensity Focused Ultrasound (HIFU) and Focal Laser Ablation (FLA) are less invasive treatment options that target only cancerous portions of the prostate, potentially reducing side effects like incontinence and erectile dysfunction that can accompany surgery or radiation.
4. Importance of Genomic Testing: Genomic tests on biopsy tissue (like the Oncotype DX or Prolaris test) can help evaluate the cancer’s risk of growth and metastasis, offering more insight into whether active surveillance or treatment is more appropriate.
5. MRI Considerations: Monitoring prostate cancer often involves regular MRIs. Some patients are cautious with MRI contrast agents, like gadolinium, due to potential side effects and cumulative exposure risks. In many cases, high-quality 3T MRI scans can provide clear images without contrast.
6. Prostate Cancer Growth Rate: Prostate cancer, especially lower-grade forms, is generally slow-growing, so patients often have time to consider their options, research, and avoid hasty decisions.
For those with early-stage, low-risk prostate cancer, this experience illustrates that a thoughtful, multi-opinion approach can lead to more personalized, balanced decisions and may help avoid unnecessary treatments.
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