Biopsy Necessary?

[larrye]

I am a 51 y/o male with a history of prostatitis and prostatic stones but no family history of prostate cancer.

My PSA was .98 in 11/05, 1.6 in 12/06, and 1.8 in 11/07. My uro did a DRE today and only reported that the left lobe felt larger than the right. He did not report any nodules. He is ordering a biopsy. He insists that my PSA went up too much too quickly and that's what justifies the biopsy (he understands that my PSA is not even close to 4).

Any recommendations? I've heard a full range of experiences in terms of how easy/difficult the procedure is, but why go through it if it's unnecessary? Should I seek out another opinion before letting him do the biopsy?

[HeinrikMD]

I am an oncologist

[larrye]

Thank you. Are you an MD? Is urology your specialty?

[HeinrikMD]

Hi,

The part about having another data point and confusing things doesn’t make much sense to me either. Problem here, is that the utility of such monitoring is unclear for patients who are prostate cancer suspects only – its real utility as I have said in the previous post are for those patients who already have prostate cancer.

You are correct that prostate enlargement can account for an increase in PSA. Symmetry is not necessarily a sign of cancer. Hardness is one feature sought as well as nodularity.

At this point, there seems to be no compelling reason to biopsy beyond the rising PSA values. Hence, you may need to make a value judgment.

Stay positive.  

[larrye]

Thank you.

I asked the uro if he would consider taking another PSA and he claimed that it would confuse things to have yet another "data point". Does this make any sense to you?

I also have a hx of prostate enlargement (confirmed on CT and MRI), stones, and prostatitis ... couldn't this be responsible for the increase in PSA?

Also, would you consider "the left lobe being slightly larger than the right lobe" as an abnormal DRE?

[HeinrikMD]

Hi,
You are correct that the usual range in which a biopsy is recommended would be a PSA value higher than 4.

What you need to understand is that the test is not fool-proof. Even a PSA of 1 which is deemed normal, there would be some patients who would have cancer.

For patients with known prostate cancer (meaning confirmed by biopsy) the rate of change of the PSA can be used to estimate how aggressive the disease is. This is called the PSA doubling time. A doubling time of less than 3 years is deemed to be a marker of more aggressive disease. Bear in mind, that the established usefulness of such testing are for patients who are known to have prostate cancer, but who may choose not to undergo surgery or radiation (a watch and wait approach).

For your case, there is an observed increase in the PSA value for the first interval, and over the next interval the increase was not marked. If you try to calculate the doubling time, this would be less than 3 years. It is also probably apparent to you, that there is a problem with this methodology. It is of course, easier to double a value of 0.5 to 1 than it is to double the value of  2 to 4, but if we use such a criteria we would be saying that the patient with a PSA of 0.5 may end up with having a higher risk for cancer than the one with the PSA initially of 2. Hence, while there is some logic to use the calculation for patients suspected to have prostate cancer, there is no clear guide as to what value should the calculations start.

The decision to go through with the biopsy based on what values you have now, would of course be a value judgment. This is a personal decision, in which a person who is risk-seeking may go ahead with the biopsy (deeming the possibility of a complication from the biopsy a small price to pay for the certainty that the current status is not reflective of cancer), but the more risk averse person would probably have the PSA repeated about 6 months from the previous, and then reconsider his position.

If your doctor’s DRE was normal, this by itself is an indication for the biopsy regardless of the PSA values.

Discuss your options with the doctor and come up with a plan that is acceptable to you.