To Biopsy or not to Biopsy?

Hey all

I've been researching your forum regarding prostate biopsies and I'm seeing some similarities in the reasons for and against. My situation seems a little different and I would like to get some opinions about it before I move forward.

My GP discovered a nodule via DRE then suggested I see a uro for clarification. His DRE showed the same, but he thought it might just be calcification. However, he noticed what I've seen described a lot on this forum which is a firmer right side and said it could be an infection, inflammation, or cancer. He suggested a biopsy to rule out cancer.

From what I've been researching, it seems to me that watchful waiting might be a better first step. Also, what about treating it as an infection or inflammation first then do another DRE? Why the rush?

A few things to note that make my situation different:

- My psa score is very low - approx 0.5 and has been there for as long as I'm aware
- I was on propecia for 15 years, then off for 2, and now back on it for 3 months
- I'm 52 years old
- In the last 5/6 years, I've been in extremely good physical condition - involved in high-level workout programs through Nike. However, that program stopped a year ago and my physical condition is still good, but nowhere near where it was. I've gained 15 pounds of fat weight. (6'3 200lbs now). So, not in bad shape, but a change occurred.
- My diet has also not been quite as good - more sugar intake, more fatty and carby foods - but no fast food, etc. - another change.

The uro is a younger doctor - probably mid/late 30's and wants to move forward. My main questions are:

- Should I get a second opinion about the biopsy?
- How likely is it to have a very low PSA and have cancer that should be treated (aggressive type)?
- Are the dangers of biopsies real or diminished these days?
- What about these other tests I'm reading about: new blood test and canine "sniffing" - are they for real?

Thank you for any thoughts you might have.

Paul

Post Edited (PaulTT) : 5/18/2017 10:55:59 AM (GMT-6)

Paul said...
My psa score is very low - approx 0.5 and has been there for as long as I'm aware

This is a very low PSA value. I would get a second DRE before having a biopsy.

George

I would expect that the second doctor will not detect anything with a DRE.

George

With a PSA that low, I don't think there are any other blood tests (e.g., PHI) that have been validated for this purpose.

You are right that it is extremely rare to have a PSA that low and have PC. Yes, there are rare types that never put out much PC, but I don't think many would cause a hard nodule either. On the other hand, calcifications are extremely common (I had a couple that showed up on US that were independent of my PC), as is non-symptomatic prostatitis.

Here's what NCCN says about getting a biopsy based on a positive DRE alone:

NCCN said...
However, in men with normal PSA, the positive predictive value (PPV) of DRE is poor (about 4%–11%).Therefore, an abnormal DRE result alone as an indication for biopsy would lead to a large number of unnecessary biopsies and the detection of many insignificant cancers in men with low PSA values. In fact, in an analysis of 166,104 men with prostate cancer diagnosed between 2004 and 2007 from the SEER database, only 685 (0.4%) had palpable, PSA-occult (PSA level of <2.5 ng/mL), Gleason score 8-10 prostate cancer.

Overall, the panel believes that the value of DRE as a stand-alone test for prostate detection is limited, even though DRE picks up some cases of advanced cancer that would otherwise be missed. Therefore, the panel believes that DRE should not be used as a stand-alone test without PSA testing. Instead, the panel recommends DRE as a complementary test that may be considered with serum PSA in asymptomatic men who had a risk/benefit discussion and decided to pursue screening for prostate cancer. Those with a very suspicious DRE should be considered for biopsy referral regardless of PSA results, because it may identify high-grade cancers in such situations. Furthermore, the panel believes that DRE should be performed in all men with an abnormal serum PSA to aid in decisions regarding biopsy

I don't know what "watchful waiting" buys you - waiting for what? If your PSA is not an indicator for a very rare cancer, then waiting will not help you - your very low PSA will just continue to be very low no matter what. Antibiotics normally don't work on prostatitis, and may only increase your antibiotic resistance. Antibiotic resistance (and sepsis) is a growing concern with biopsies - it occurs in about 7% of cases in the US lately.

So I guess I'm not really being very helpful. I can see merits in arguments for both sides. It depends on the risks (low risk of a very rare but lethal cancer vs. higher risk of sepsis) you are willing to live with and your assessment of the utility of an early diagnosis of something that is probably not there.

PaullTT,
I wanted to comment because recently I have gone thru the actions to do extra testing to try and convince
myself to avoid a Prostate Biopsy. My main concern about having a biopsy was risk of infection. I did have an
elevated PSA which is different from yours - you can see my condition in my signature.

My suggestions, if your insurance will pay for it or you can afford to pay for it is to get a 3T-MRI and a urine test
called PCa3. Both will provide you with more significant information about whether a Biopsy is needed
or not needed. If these testing indicated a Biopsy not needed you would then just need to monitor you DRE/PSA going into the future.

I would not take the Biopsy "lightly" regarding the possibility of infection. If you do move forward with a Biopsy
you can request a Rectum Swap test for Bacteria Test prior to the Biopsy. Most Doctors do not do the Rectum Swap test but some will if you request it - this will tell you if you have risk of antibiotic resistant bacteria. Mayo Hospital does this Bacteria Swap as a Standard Practice is what I have read.

Best of luck going forward.

I'll tell you the same thing I was told...Get the biopsy.

Based on what I'm reading here, discovering from friends who have some experience, and other research including the NIH website, it sounds like the smartest thing to do next is get a second opinion DRE from a uro who specializes in prostate treatment. I'm not exactly sure how to find that doctor, but since I'm in LA I suspect there are many to choose from.

I will also look into the PCa3 test and 3T-MRI test. I have a very high deductible so it'll be out of pocket most likely...

How would I find a uro with a high % rate of positive PCa biopsies. Do most docs keep track of their % in that way? Is that something that is commonly asked when getting a referral?

This has all made me a bit nervous and anxious, but the research seems to help cope... Perhaps it's nothing, or perhaps I have PCa. Either way I'm learning a lot of valuable information that will benefit me now and in the future.

I've been looking into the PCa3 and Free PSA tests. Is there any reason why my urologist wouldn't have ordered those tests prior to a biopsy, esp in my case?

I'm also in the process of getting a rx from my GP for those tests and looking into a 2nd opinion.

Gleason 6 is a favorable result. It gives you options. Watchful waiting, active surveillance should both be on the table. You also have the gift of time to get another opinion on the pathology and research your choices.
Aside from having cancer cells in your prostate, they are not aggressive. You should be encouraged. Good luck.

No issues with getting a second opinion, but I were you I would get the PSA. There is a good chance that it is not cancer, but I do not tank it is worth the risk. Perhaps my story may help you make up your mind.

While rare, there are cancers that do not raise your PSA. I waited for about six years after I was diagnosed with an enlarged prostate with no nodes. I was 52 years old. As my PSA was always below the threshold of 4.0 I decided to wait. That changed when I turned 58 and it hit 4.7. Unfortunately by that time it was advanced cancer. The doctors all said if I had a biopsy years earlier than when I did they may of been able to catch it when it was still curable. Some other points:
1) My PSA was 4.7 when I decided to get a biopsy. After getting two digital exams in less than two weeks they retested my PSA. It jumped to over 11. Sometimes the cancer "hides" in the prostate. The only reason it increased was it was squeezed out like juice from a lemon.

2) Being under 60 and physically active do not rule out cancer. While they found my cancer at 58, I may of had it for over six years. Up to the time of surgery I was active, doing week long bike tours, backpacking, SCUBA and other sports. (Still do them but on a smaller scale.)

Wishing you the best.