Annual Surveillance

I had my first followup with my new urologist last week.  The good news is that my PSA has dropped for the first time, to 5.85 from 6.45.  This puts it back on the trajectory it has been on in the last few years.  The free PSA level remained about the same, 16% up from 15%. His advice is to test again and see him in a year.

A stark contrast to the urology office at Duly Medical that freaked out about almost certain cancer last fall, wanting to do an immediate biopsy for a suspicious lesion on the MRI that had not changed from the previous MRI.  All due to a slightly higher PSA than expected.  Not to mention that the MRI they wanted to schedule had no targeting whatsoever to make sure to sample the suspicious lesion.

I know docs are busy between insurance and large medical group management.  Even so, there are some things that should not be left completely to assistants.  At least not if you care about keeping patients.

Do you have  a PIRADS 4 or 5 result from an MRI but had a negative biopsy?  Stay in touch with your urologist!

New Urologist

I’ve been a patient of the same urologist at the nearby DuPage/Duly clinic since my vasectomy about 15 years ago.  I like my physician, but the office and staff have become increasingly unresponsive in recent years.   This time, it took literally a month to hear back from an assistant when I inquired multiple times about having routine testing prior to my appointment.  It got worse from there, as it became clear that my only point of communication was not even familiar with relevant diagnostic technology.  For example, I tried to confirm that they used the standard for prostate imaging, a multiparametric 3T MRI that would be comparable to the one used for my last MRI in 2019.  She apparently had not heard of it and could only refer me to the MRI department for information.

Ultimately, I was never able to discuss my concerns with the urologist or with his colleague to whom his assistant referred me for a biopsy.  Messages on MyChart and those left with the office were routinely ignored.  My last interaction with the office was a call when the urologist’s assistant alarmingly indicated that a biopsy was urgent because the MRI showed that I still had a PIRADS 4 lesion that is “almost certainly cancer.”  (It’s not.  The correlation is not well established, at worst possibly 50-50)  Even though the same lesion was targeted in two negative biopsy samples in 2019, she enthusiastically indicated how essential it is to biopsy it again to confirm the cancer and start a treatment plan.

Weeks later, I finally heard back from the colleague’s office (again from an assistant and not the physician). After pressing for information, I was able to find out that the scheduled biopsy was not targeted or guided in any way.  They were simply going to use the old-school method and randomly skewer the area of the single lesion and cross their fingers that they didn’t miss.  Well, at least that’s what the assistant said, perhaps being able to talk to the physician would have been helpful!

Given my increasing frustrations with the local clinic, I decided to get a second opinion shortly after the local urologist’s assistant referred me for a biopsy.   I first contacted the great team at the NIH. The imaging experts there were happy to review my new MRI results.   It took under a week to get a copy of the images, send them to the NIH team and get a new MRI report that now had a comparison to the MRI from 2019.  All this while waiting to hear back once from the local urology office!

The new report was reassuring, “We don’t see a change in the single lesion you have.”  In fact, all the indicators listed in the report were essentially identical to those in 2019.  Phew.  The only change was that my prostate had grown in size.  Even so, the increase was consistent with the PSA increase.  My “PSA density” has actually decreased slightly.  I offered to send this new comparison information to the local urology clinic, but never heard back, of course.  The urologist at the NIH was willing to have me travel there for another evaluation, MRI and possibly another biopsy.  After the last trip in 2019, I was not looking forward to another trip.

Ultimately, I scheduled a second appointment with a urologist at the University of Chicago who was referred to me by the NIH urologist back in 2019.  I saw him again a couple weeks ago.  Armed with all my test results since 2019, I gave his resident physician a full background of my saga.  She spent more time in one visit listening to my concerns than I have been able to spend with my local urologist over the last 5 years.  After she consulted with the staff urologist, he recommended that there was no need for a biopsy at this time.  Instead, I will repeat labs in 6 months and consult with him again at that time.

Suffice to say, I have a new urologist moving forward.  It’s an hour longer to drive there in Chicago traffic, but well worth it.  Plus, if I ever do need another biopsy, I confirmed they are performing transperineal MRI fusion-guided biopsies, essentially the same as the NIH.

When you can’t get a response from a physician over the course of 3 months to discuss your concerns with them, it’s time to move on.  I appreciate that physician’s assistants can do a wide variety of work for the physician, especially if it’s for a flu or less serious illness. On the other hand, there is no substitute for even one discussion with your physician when a biopsy and cancer are on the table.

Here We Go Again

It is now almost 14 years since my prostate journey began.  My PSA continues to rise.  It could be a sign of an ever-increasing prostate size, consistent with Benign Prostate Hyperplasia.  It could be a sign of cancer.  The rate of increase had slowed down a little for a couple years but is now back on the original trajectory.  My latest PSA was over 6.5, up from 5.5 a year ago.

My local urologist’s assistant referred me for a 3T MRI.  The same type used in the NIH study I joined in 2009 and then for a follow-up three years ago.  In that most recent 2019 MRI, a single lesion was found.  This month, the new MRI confirmed the same lesion is still present.  Both radiology reports classified it as a PIRADS 4 lesion and my interpretation of the report is that the size is similar, about 0.5 cm.

There is still mixed information on correlation of a PIRADS 4 lesion to cancer, but probably less than 50%, depending on the study you find.  These lesions can also be present in Benign Prostate Hyperplasia.   No other significant findings appear to be present in either report.

My local urologist’s assistant has now referred me to a surgeon for transperineal biopsy.  I have been somewhat annoyed that it has been impossible to discuss this directly with either physician.  So, I  sent the images to the great team at NIH who quickly got back to me and said they would take a look and provide another opinion.  Depending on their feedback and whether or not one of the local doctors ever responds to me, I may be back to the NIH, University of Chicago or elsewhere for a biopsy.

Anyway, the latest PSA and MRI results could have been worse, so I am thankful.  On the other hand, I’m not looking forward to another biopsy and the waiting for those results.  I’m also not looking forward to having to travel to get the most optimal type of biopsy from a physician who is willing to provide basic information on the procedure they use.

4KScore Blood Test for Prostate Cancer Risk

I have now had two negative prostate biopsy results.  My urologist is still concerned that my PSA is steadily increasing.  The percentage increase has been fairly constant each year over the last decade, roughly doubling in the first 10 years since this blog started.  Even so, he advised me to take the 4KScore blood test.  It uses various factors, including  various PSA and bio markers in the blood, plus your clinical history including biopsy and DRE results.

My score came back with an Elevated Risk of 13% to find a high grade cancer if I had another biopsy.  In looking over my results, I noticed it indicated I had no previous biopsy.  I called my physician’s office and they said it did not make any difference to the test results.  I had previously read in some papers on the topic that a previous negative biopsy was a major factor in these results.  So, I contacted Genpath Laboratories (of BioReference/OPKO Health) and they agreed to contact my physician and recalculate the result.

The revised 4KScore indicated a Low Risk of 2%.  So, it is always a good idea to carefully examine your test reports since this test will be a basis for future 4KScore results that in theory may allow me to avoid or at least postpone another biopsy.

I also note that as of late 2021 my PSA was measured at 5.53, up from 5.15 in 2018.  The rate of increase has slowed somewhat from over 7% each year through 2018 to about 3% a year since then.  I am due for another test soon and still expect it to be under 6.

Good News for Men on Certain Cholesterol Drugs

Some statins like Lescol (Fluvastatin), Mevacor (Lovastatin), Zocor (simvastatin) and Lipitor (Atorvastatin) can significantly reduce the risk of high grade prostate cancer when taken over long periods at relatively high dosage.

“A history of treatment with statins was associated with a 15% reduction in the relative risk of low-grade prostate cancer and a 46% lower risk of developing high-grade disease. However, the association was limited to men who took statins for 11 months or longer and those who took a relatively high dose (a defined daily dose [DDD] ≥121, based on a reference dose of 20-mg simvastatin).”

Prostate Cancer Discussion Forums

If you’ve come here for discussion forums, I apologize but the ProstateBiopsyBlog forums were broken a few years ago with some WordPress and server updates.

There are hundreds of comments about prostate biopsy side effects and complications and you can participate with comments here: What To Expect After Your Prostate Biopsy

There are also many good forums on the internet for discussion of Prostate Health and Prostate cancer.  Here are a few-

American Cancer Society Cancer Survivors Network for Prostate Cancer

Us TOO Prostate Cancer Online Support & Community Discussion

Cancer Compass Prostate Cancer Discussions

The Cancer Forums Prostate Cancer Forum

Facebook Prostate Cancer Support Group

Risk of Cancer after Negative Prostate Biopsy

I’ve written many times about the false negative rate involved with using a biopsy not only to confirm cancer, but to search for it in the first place.  It’s an invasive procedure that can easily miss cancer, resulting in concerns that you may have undetected cancer that can spread in the years following.  Here’s a recent article with some statistics:

Following a negative initial biopsy, 23.7% of men are still diagnosed with and 1.8% die of prostate cancer within 20 years.

One Month Later

It’s been a month since my second trans-rectal prostate biopsy.  Suffice to say, it is not a pleasant procedure.  The side effects can be shocking, and in rare cases, even fatal.  And that’s not even considering the worry about a biopsy result positive for prostate cancer.  I wrote about the risks here- .

I am glad to say that I did not get an infection and that no cancer was found.  The blood in my stool lasted only a day or two and even the traces of blood in my urine were gone in a few days.  I did have blood in my semen for almost a month, declining from solid blood red color at first to a trace of pink after a few weeks.  The worry about the results lasted a very long three weeks until I received “the call”.

One thing I do know, I have a small benign tumor or lesion in my prostate based on my 3T MRI.  So, I will not be waiting another 10 years until I seek another MRI or one of the newer blood/urine tests for prostate cancer.  Even though no cancer was detected, I consider myself on active surveillance.  The team that did my MRI and biopsy at the NIH/NCI is advancing the technology. I’m hoping that within a few years there will be even better non-invasive tests and treatments, if necessary!

Unnecessary Prostate Biopsy?

This blog started over 10 years ago out of concern over unnecessary prostate biopsies.  These procedures are so common now that they are done as routine outpatient procedures.  They generate a lot of money for urologists and hospitals.  They also have a relatively high risk of complications and false negative rate.  Though blood, urine and MRI technology are improving, for many men, the necessity of a random 12+ core biopsy to search for cancerous cells is a page out of a 1960s medicine book.  Improvements in the procedure have been made, but the basic theory is still using one needle to find another proverbial needle in the haystack.  The problem is this particular needle costs over $1000 and can cause major complications, like sepsis.

In 2009, I had my first prostate biopsy.  I had hoped to avoid it if at all possible, but multiple physicians deemed it necessary.  At least I was able to do so in a free study designed to improve MRI imaging of the prostate that might some day reduce the need for biopsies.  As it turned out, my first biopsy was probably unnecessary, other than any value to the research study.  I didn’t have any major risk factors for prostate cancer, other than a relatively high PSA caused by an enlarged prostate.  My MRI didn’t show any lesions and was determined to be low risk (PI-RADS score of 1).  The biopsy was negative.

By 2019, newer technology is starting to help with protocols to reduce unnecessary biopsies.  From advanced biomarker blood and urine tests to high resolution MRI, the hope is that some combination can help many men avoid an unnecessary prostate biopsy.  Sadly, it didn’t help me avoid another one.  My second MRI showed a moderately high risk lesion in my prostate (PI-RADS 4).  Fortunately, the biopsy (12 sextant cores plus 2 targeted cores) was negative in my case.

I am so thankful that I have twice avoided a biopsy positive for cancer.  I have also avoided serious infection and other major side effects of a trans-rectal prostate biopsy.  I now have some personal experience with both necessary and unnecessary prostate biopsy.  I am still of the opinion that a trans-rectal biopsy is probably performed far too often.  The problem is that there is little consensus of what combination of less invasive tests and metrics might reduce unnecessary prostate biopsies.


A Negative Prostate Biopsy but Concerning MRI?

I’ve had two prostate biopsies.  Both were negative.  Both were targeted MRI/fusion biopsies.  The first MRI had no lesion or tumor to target, but the second one did.  I had a PI-RADS 4 lesion about 0.5 cm in size.  The team at the National Institutes of Health believe they successfully sampled it with two targeted biopsy cores.  Neither one showed cancer, but clearly, something has become abnormal in that area of my prostate over the last 10 years.

Prostate biopsies can miss cancer.  The inherent flaw in a biopsy to search for cancer is a relatively high false negative rate because the biopsies can only sample a very small percentage of the prostate volume.  Even a targeted MRI/Ultrasound fusion biopsy can miss cancerous cells.  My prognosis is to keep with regular PSA and exams with my urologist and followup if there are any changes.  Clearly, I have BPH, and possibly a benign tumor as well.  With a PSA level around 5 at age 51, I have a few risk factors for future prostate cancer.

One thing I am considering is the ConfirmMDx test.  This test uses the tissue samples obtained during your prostate biopsy.  It checks them for certain biomarkers that are indicative of prostate cancer that might be lurking just outside the sampled cores of biopsy tissue.  I’m not sure if I will proceed or if my tissues samples are even eligible for this additional testing, but I am investigating it.  The results may affect how long I wait until I decide to get another MRI or biopsy.  Other blood and urine tests for genomic indicators and biomarkers of prostate cancer may also be indicated for high-risk patients with negative biopsies.