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.

https://www.medpagetoday.org/hematologyoncology/prostatecancer/82726?vpass=1

“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:

https://www.urotoday.com/conference-highlights/aua-2018/aua-2018-prostate-cancer/104293-aua-2018-population-based-outcomes-of-men-with-a-single-negative-prostate-biopsy-importance-of-continued-follow-up-among-older-patients.html

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- https://www.prostatebiopsyblog.com/prostate-biopsy-recovery-side-effects-complications .

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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6043739/

 

MRI and Biopsy Results: PI-RADS, Gleason and PCa

The waiting is brutal.  Three weeks ago, I was shown my prostate TRUS MRI fusion results.  I was given a PI-RADS score of 4 on a scale of 5, with a 5 being most likely for cancer.  For reference, ten years ago, my MRI report score was a  PI-RADS 1, or “highly unlikely” to have clinically significant cancer.  A score of 4 means that, “Clinically significant cancer is likely to be present.”  The modified scale used by the NIH was only slightly better, “Moderately likely for prostate cancer.”

As you can imagine, it considerably freaked me out to learn this in the hours of worrying while I waited to be taken for my biopsy procedure.  On the plus side, it also told me that I was doing the right thing.  A half-centimeter size lesion was shown on the MRI, and a random biopsy might miss that small of a lesion altogether.  Armed with the MRI results, they were able to precisely target this tumor with two separate biopsy samples from different angles, along with 12 other random cores to see if cancer was present or had spread elsewhere in the prostate.  Ten years ago, I did not have any cancer, nor was any type of lesion or tumor indicated on the MRI.   Things were not  nearly as promising on this one:

Making lemonade out of lemons, the fact that only a single lesion was present was relatively good news.  Plus, there was no indication it had spread beyond the prostate or into any other tissues within the prostate.  These might all be positive considerations for less invasive focal treatments.  There are a number of studies out there showing the correlation of PI-RADS to biopsy results for cancer.   Thankfully, it seems that a PI-RADS score of 4 isn’t nearly as bad as a score of 5, but on a scale of 1-5, even a 4 feels pretty bad to a patient.   The correlations for a score of 4 just aren’t as well established yet, and that’s why these studies continue.  On the other hand, a PI-RADS score of 5 is usually bad news and has a much higher correlation to cancer.

Suffice to say that while a score of 4 does not usually indicate the presence of the most aggressive cancers (Gleason score of 8 or more), it often shows concerning cancers with a Gleason score of 7.  PI-RADS 4 lesions also can be benign or less aggressive cancer with a Gleason score of 6 or less.  In plain English, based on the MRI results and on various studies I have read over the three longest weeks in my life, I figured I had about a 50-50 chance of having a clinically significant cancer that required some sort of treatment in the near future.  For the optimist, maybe only a 40% chance or even a bit lower, depending on which study you read and whether or not the physician recommends treatment for Gleason grade 7 cancers.

Yes, I intentionally put off discussing my biopsy results to the end of this article.  This was to give anyone reading only a tiny fraction of how it feels to wait THREE WEEKS after seeing a PI-RADS score of 4 on my MRI.   Some days it has been almost paralyzing to wonder why it was taking so long, when I was originally told 5-8 business days.  Were the results so bad that a second opinion on the biopsy cores was needed?  Did they have to develop a treatment plan before contacting me?  Was a radical prostatectomy and all its risks, side effects and quality-of-life issues now a given for me in the near future?  Yeah, that stuff and worse goes through your mind every night at 3am, and even during the day.

I am both blessed and greatly relieved to say that I dodged a second bullet, both in terms of infection and biopsy results.  My phone call came an hour ago and NO cancer was indicated in the results.  Presumably, the targeted lesion is simply a benign tumor or other abnormality, one to be monitored for changes in the future.

Of course, prostate biopsies have a significant false negative rate.  Even with MRI/Ultrasound targeting guidance, they can miss cancerous cells that exist elsewhere in the prostate.  Sadly, no better diagnostic exists today, which is why I participate in this NIH study.  Trans-rectal prostate biopsies are not at all pleasant, and if you get a resistant infection, they can even be fatal in rare cases.  Improving non-invasive diagnostics like MRI, blood and urine tests is critical to reducing the need for random rectal biopsies that seem like a holdover from 1960s medicine.

Suffice to say I am very thankful to God, the universe and to the NIH/NCI Urology team, not only that no cancer was found and that I have no major side effects of the biopsy, but also that I hopefully don’t have to see them again for many years!

 

 

Is Active Surveillance a Good Choice?

Given the risks of prostate biopsy and the major potential side effects of a radical prostatectomy, many men are choosing to monitor their prostate symptoms, rather than seek invasive treatments.  The decision to pursue Active Surveillance (AS) varies based upon a number of factors and should be carefully discussed with physicians.

https://www.sciencedaily.com/releases/2019/02/190211182853.htm

https://www.renalandurologynews.com/prostate-cancer/prostate-cancer-active-surveillance-is-a-viable-option-for-men-younger-than-60/article/829682/

“AS is a safe and effective approach which spares any properly selected men younger than 60 years with low risk prostate cancer from intervention, provides adequate time for intervention if required, and shows durable disease specific survival.”