231211 ART mpMRI Accuracy Detecting Serious PCa Revised Criteria for Biopsy
I am a big proponent for use of a mpMRI during AS (active surveillance). I also believe it has a place in the routine monitoring of PCa in men who have not been diagnosed with PCa. I had PSA’s well below 4.0 and neither of my two Urologists found an anterior tumor that occupied 33% or one third of my prostate via DRE (digital rectal exam)…it was located on the front part of the gland and you could not feel it via the back side of the prostate…who knew?
Well I do now and my Sons are not going to suffer that error. My URO’s should have done a mpMRI to rule out an anterior tumor when they saw that my PSA kept rising month by month, year by year. They also should have considered family history; my Dad and my Grandfather both had PCa. Based on family history and a steadily rising PSA I should have been scanned at a PSA of 2.0 NOT 4.0.
I have said elsewhere that PSA 4.0 level thresholds are obsolete; its meaningless…it was taken from the original cohort of men in the 1980’s landmark study that established PSA as a marker for PCa and is simply 2 times the standard deviation of the PSA that those men had! Its not based on any science or follow on study…its baffling that URO’s still use PSA of 4.0 as a “safe limit.” Its not; take my word for it. Waiting to scan and treat men and allowing PSA to rise is the #1 cause of lawsuits registered by the Harvard Medical School for its graduate URO’s…but we don’t learn.
Now I see that mpMRI’s have their limitations; their NPV (negative predictive values – chance that they are correct) is closer to 77%, not 90% as previously thought! That means that up to 23% of men scanned with via mpMRI with a NEG outcome may be positive for serious cancer. BUT there is a criteria that is provided for those men…PSA Density! If a man’s PSA density is more than 0.1 AND he has a NEG mpMRI he should proceed to a biopsy!
Take note and don’t make the same mistake that I did. PSA of 4.0 is not safe. A DRE wont find all cancer. A mpMRI can help and if its NEG and your PSA density is high, move to a biopsy. Find, treat and cure this disease while its inside your prostate. Once it gets out it’s a totally different condition, disease and prognosis.
Notes from ART;
1. Multiparametric MRI (mpMRI) of the prostate has a negative predictive value (NPV) of 77% for csPCa, defined as Grade Group 2 or higher cancer. Prior research suggested that mpMRI has an NPV approaching 90%.
2. The study included 857 patients across 26 urology practices who underwent 871 prostate biopsies within 1 year of a negative mpMRI. Of these biopsies, 439 were performed in the biopsy-naïve setting and 432 while on active surveillance (AS).
3. The patients had a mean age of 65 years and a median PSA level of 5.6 ng/dL.
4. On multivariable analysis, a PSA density of 0.1 or higher was significantly associated with 5.1-fold greater odds of finding csPCa following a negative mpMRI.
5. The investigators concluded that this PSA density threshold should be used for pursuing prostate biopsy following a negative mpMRI.
I had PSA 4.2 GP referred me to urology, consultant did DRE which was normal no symptoms he ummed and arred about MRI until I told him both father and brother had pc which was in my notes by the way, had MRI the rest is history.If my psa had been 3.9 my GP wouldn't have referred me as 4 is the threshold but would've still had cancer, c'est la vie
Hello RMontana, I’ve followed you for a while and always find your post interesting and packed with good info. If we listen to our MO’s and testosterone is the fuel that feeds the cancer then, we begin ADT. I’ve been on Lupron and Zytiga for about 19 months. I’m told I’ll never come off as long as it’s effective. Ever since Covid and vaccine mandates I’ve had a healthy distrust for our government and our health system. I’m being a good little boy right now but, considering an Orchiectomy to avoid years of Lupron. They tell me I’d still have to take Zytiga to cover T coming from the adrenal gland. I’d value opinion.
Your case is well advanced, so I am out of my depths here...read your bio. If I was in your shoes what would I do.
First, TET (testosterone) is made by other organs in the body but from what I read no where near the levels that would make the threat of PCa growth a risk. But you have your prostate still in place (did not get RP operation), so I dont know for you what 'baseline' levels of TET are appropriate for a remaining prostate, even though its been radiated. If it does not produce any TET then the remaining organs produce very, very little. I found one source that says, after an orchiectomy, your TET is reduced 90-95%.
So, would the remaining 5-10% make any difference? What I read is that the overall end result would not change; progression of the PCa at very low TET levels is 'not likely.' But that is a statistical term; for me in my PCa journey it seems I am always picked to populate the bell curve on the side of worst results, so as to allow the averages and mean to report overall sucess...seems I have been picked for that role. But statistically very low TET does not lead to PCa progression...even TET levels of 250 appear to not make a difference in PCa OS, BCRF or other factors. I have written about this a lot...see;
BUT, proceed with caution...I would do the following;
1. Test at the uPSA (ultra low) levels if your PSA is that low...get as much information about what is happening to your PSA as possible and as low as you can measure it.
2. PSADT doubling time matters...not that PSA is increasing but at what rate its increasing...see this ART;
Your could try intermittent HT if your PSA rise was slow enough...it would give you time to recover between ADT injections and allow TET to bounce back a little between shots. But your case is way advanced and what you cannot do is allow this beast any chance to advance...if you can delay castration and keep PSA under control, great. If not you are looking at lifelong ADT treatment with all is shi##y side effects...
Dont know what more I can say. Let me know what you decide. Rick
Another thought...have you taken or considered taking, Sulforaphane supplements? There is a lot of discussion on the site about this supplement; some think it does not work, OR really that it works by reducing the rate of growth for PSA by lowering TET (acts like a natural HT)! In fact, Sulforaphane has been shown in clinical, phase 3 studies with men, to reduce the increase of PSA by 80% plus! So, if it lowers PSA growth directly, or lowers it by reducing TET, for me this is a difference without a distinction.
If your TET is going to be low anyway (assuming you go back on ADT either continuously, or via intermittent treatment), then all the more effective Sulforaphane will be...you have two choices. Either buy supplements, or grow broccoli sprouts your self (its very easy). OR a third choice, which is what I do, BOTH supplements and daily smoothie of 100g of frozen sprouts daily (will turn off the firehose now).
Look at these posts if you have not done so; consider Sulforaphane. I am on a 10 year daily program; on my 2d year now...Rick
I had HDR brachytherapy for prostate cancer in 2018. Oncologists goal was to keep PSA under 1 which we were able to do for 6 years. Then PSA elevated from .86 to 1.49 in a 6 month period between 6/23 and 12/23. My urologist debated about doing an MRI now or waiting 3 months and checking PSA again. I told him I wanted the MRI now. I'm looking for advice on whether I did the right thing?
I see no harm in getting as many MRI’s you need as early as you can, in order to find any metastasis before it spreads. If only I had known that an multi parametric MRI existed I would’ve asked for it years before I stumbled upon it and recommended it to my doctor; it would’ve changed my life. Going forward jump on any doctor that recommends any testing or other exploratory procedure that allows you to find this beast as soon as you can before it gets out of control. So I would say get the MRI quick and see what’s going on. It also gives you a baseline to go on if you find nothing. Rick
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