How do you and the M.D. decide whether or not your prostate specific antigen PSA tests reflect that a biopsy/cystoscopy is needed?...

How do you and the M.D. decide whether or not your prostate specific antigen PSA tests reflect that a biopsy/cystoscopy is needed?... when there's also BPH benign prostatic hyperplasia.

3T mp MRI 3 Tesla MultiParaMetric Magnetic Resonance Imaging with external coil is less invasive than biopsy/cystoscopy.

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  • I can help explain if you would give details of your situation - how big is your prostate? what's your PSA pattern? any other biochemical tests? family history? DRE results? ultrasound results? urinary symptoms? Have you had a first negative biopsy?

  • That's a good question. I urge everyone who is diagnosed with a "high" PSA to think very carefully about having their prostate removed. Back when I had mine done I was extremely stupid and did not fully understand all the adverse things involved. My doctor did explain certain things to me and then gave me several booklets to read. He also told me that if I decided to go with radiology instead of having the prostate removed that it would not be feasible to have it removed later on should the radiation not work. As I said I was just stupid. Ask, ask, ask, read, read, read everything you possibly can on the topic and get a second opinion. I sometimes think that these doctors just want to do the surgery for the money. I will say however that everyone I spoke to said that my doctor was one of the best in his field. So I figured he knew what he was talking about. I've now been alone for 13 years. Please make sure that you think very carefully about t his.

  • I think it depends on your doctor and his experience with MRI guided biopsies. In my case, the MRI was never even discussed. I think your question is much like asking for a recommendation from a urologist or a radiation oncologist. The urologist will typically favor a surgical approach while a radiation oncologist will suggest radiation. It's what they know and what they have been trained in. Needle biopsies are far more common and what most doctors are familiar with, so that's what they will recommend.

    But to distinguish between BPH and possible cancer, usually the DRE will help differentiate. Also, very high PSA would suggest cancer.

  • My situation may mirror what you're questioning. I had an elevated PSA (in the range of 9.0-12.) fora good ten years. Annual tests showed it remaining stable within that range until December, 2016. At that point, a test (during annual physical) showed it had risen to 20 since an earlier one in June. I had also been dealing with a BPH situation becoming more problematic (urgency) in the last couple years so taking medications to try to mitigate some of that.

    With the PSA increase, my urologist ordered an MRI. The imaging revealed three small spots in the transition zones (i.e. buried deep in the gland) that were questionable but not necessarily alarming. My choice, at that point, was (1) wait and watch to see if there were changes or (2) do an MRI guided biopsy. I decided to go option (2) and the results were Gleason 3+4 on two and 3+3 on the other targeted mass.

    In my case, the three nodules were small (all less than 1 cm) with none close to the capsule wall. With an enlarged prostate (mine then about the size of an orange), none of those nodules would be detected with a DRE. It would be like trying to feel a hard pea that had been stuffed inside a whiffle ball.

    A biopsy (non MRI guided) is a bit like poking a needle into a mass in random locations to see if you hit anything of interest...you may or may not. The MRI identifies spots of differing tissue density and the MRI guided biopsy can target the needle directly to those areas. With a normal (walnut sized) prostate, the chance of hitting a questionable nodule is greater than with an enlarged gland; there is simply more mass to poke into and a greater chance of missing something small, but malignant.

    With this information, I interviewed both a surgeon and a radiologist before deciding on the surgical option. Two things drove my decision. First, with radiation, if the cancer was not fully eradicated, surgery would not be a subsequent treatment option. I was also concerned about adjacent tissue damage that might pose future problems, particularly in the colon. Also, radiation was not going to resolve the urinary issues associated with BPH so that would remain an issue.

    Second, surgery would likely catch all my cancerous nodules and remove them before getting near to the capsule wall and/or escaping the capsule. The urinary flow impediment would be resolved without need for a TRUS or other procedures. The downsides are the elimination of the ability to produce semen (post-op orgasms are dry) and potential erectile dsyfunction.

    So, back to your original question: How do you and your doctor decide? This is how my doctor and I approached it. This stuff is not a fast growing cancer so take your time to question, discuss and learn...then decide.

    Ken