Rising PSA - what to do?

I'm very sorry to hear about your father's passing.

*IF* your friend's MRI had been unremarkable, you could make the case that the increase in his prostate size from BPH (and perhaps the prostatitis) could account for the large PSA jump, supporting further close monitoring before deciding about a biopsy. A three-month wait to make a biopsy decision is probably not going to make a difference, however:

(1) The strong consensus in the studies I've seen is that PIRADS 3 (Intermediate or "gray-zone") lesions should be investigate by biopsy. IMO the chance of the lesion being malignant means you can benefit from early diagnosis should the cancer should turn out to be high-grade (a Gleason score of 8-10, which accounts for about 20-25% of prostate-cancer diagnoses). Early diagnosis and treatment has the biggest payoff in cases of high-grade cancer diagnosed when the cancer is still prostate-confined.

(2) BPH can mask the presence of prostate cancer, and a baseline biopsy is prudent in biopsy-naive men when cancer is suspected--even when an MRI has revealed nothing. Even though a biopsy can miss existing cancer; a negative biopsy does bring some peace of mind, especially with regard to a lesion seen on MRI.

(3) The PSA jump was rather large. I wouldn't want to wait only to find that the next reading is above 10 and have a biopsy confirm the presence of cancer. A PSA >10 is a statistic that increases the risk that the cancer--if present--is serious and/or has spread or progressed. (Men diagnosed with low-risk cancer who are in active surveillance programs are often advised to seek treatment if their PSA climbs over 10.)

(4) A targeted + systematic biopsy samples all prostate zones--not only the MRI-identified targets. Microscopic exam may find cancer lesions that were too small for the MRI to detect.

(5) When a uro is OK with either biopsying now or waiting one more testing interval, some men (like myself) are psychologically unsuited to waiting; other men dread the thought of their first biopsy and prefer to postpone if possible. This is why uros sometimes ask patients what they want to do: joint decision-making means the patient has a say.

(6) Before having a biopsy, I would suggest your friend discuss with his doc a repeat PSA test now to rule out lab error and increase the reliability of his current PSA value. AFAIK, it's fairly common when there's been a larger-than-expected PSA increase.

I had many biopsies over a 20-year period because of BPH and a fluctuating PSA--it's hard to judge exactly how much of any one PSA increase can be entirely attributable to the increase of healthy prostate tissue. Whenever I was given the choice of doing a biopsy "now" or waiting to see the next PSA result, I always said let's do it now. My biopsies always came back with no finding of cancer--until one didn't--and it revealed serious cancer, too. I always took solace from a good biopsy report and never felt it was a wasted effort.

Djin

Hi - No telling what the standard of care for PCa is in Germany but expect it would be good. Biopsies are not wonderful but neither is untreated PCa so a bit of a conflict exists.

Djin pretty much summed it up. Getting another PSA 30 days after the last one would be prudent and 30 days after that if inconclusive. In any case, his base PSA level is getting to the point that a biopsy would be recommended by most urologists in US and scheduling it now. PSA and scans are just indicating possible issues and only the biopsy can determine if there actually is a PCa problem. It is really about that simple and there is little justification for not doing a biopsy.

May the Lord hold your father close.

Other than the two PSA outliers in Jun 23 and July 24, the PSA levels and trend is not surprising for someone that age with known BPH enlargement and significant size of the prostate. What does the urologist say about these two readings? I agree that more investigation should be done. Given the crazy results of the 23 and 24 PSA, I would look at testing monthly for now.

My urologist is a well known prostate specialist with both BPH and PCa. He has shared with me that for years when treating men with BPH and suspect PSA the first thing he does is to start a 3-6 month course of Avodart. This will reduce the prostate size by 35-50% and subsequently the PSA expression. He monitors the PSA monthly and is better able to detect any increase trend that would be indicative of PCa. The reduction in prostate size will also make the DRE more reliable as it is difficult to detect small abnormalities in a significantly enlarged prostate. Since the advent of the MRI used for diagnosis, he has seen an improvement in readings when the prostate size is reduced.

If the biopsy is postponed, his doctor may advise waiting until after it is done to start Avodart or a similar drug. 5α-reductase inhibitors (finasteride and dutasteride) not only shrink the prostate to help relieve BPH symptoms, but also--over the span of roughly 5-6 months--have the effect of reducing one's PSA by about half. If a decision is made to hold off on the biopsy, I don't know if the downward effect could interfere with monitoring the amount/rate of climb of his PSA.

This reduction in PSA has no benefit that I know of, but subsequently has to be taken into account by a doubling rule: if a man's PSA drops from, say, 6.0 to a low of 3.2, all readings after this nadir are doubled (e.g. 3.2 to 6.4) when discussing/evaluating his PSA as long as he stays on the medication.

Djin