While waiting for my biopsy results, I did scare myself by doing a bit of research on treatments. Many alternatives exist. The most proven one is an open radical prostatectomy or RP. In the hands of a very experienced surgeon, this method has the best long term cure rates and among the best success rates for long term incontinence and impotence, too. A handful of experienced surgeons across the country have done thousands of these surgeries, including the nerve-sparing procedure for those with early stage cancer.
This isn’t to say open RP is the best treatment for everyone. There’s a robotic procedure (RRP or DaVinci) that is gaining popularity. It’s too new for long term results, but it looks to be similar to that of the open procedure if you can find a very experienced surgeon. Again, from my research, the choice of an experienced surgeon appears to be at least as important as the choice of which surgery to have. A surgeon that has done hundreds, if not thousands, of the same procedure is ideal. Even better is one who has published results or at least one who will share detailed statistics on their results with you. Another thing to ask is for referrals to patients who have had a “trifecta”. That’s the term for a long term cure of prostate cancer with no long term urinary or sexual issues (be careful on how a surgeon defines incontinence and impotence). If you’d ask for referrals on home contractors, you should absolutely do the same for someone about to cut you open! Continue reading Prostate Cancer Treatments: The Major Options
It’s now three weeks since my biopsy and I’m pretty much back to normal. All of the annoying side effects are finally gone. I am really not looking forward to ever having another biopsy. It wasn’t horrible, but definitely not something I wish to repeat. In other recent news:
From the New York Times–
The PSA blood test, used to screen for prostate cancer, saves few lives and leads to risky and unnecessary treatments for large numbers of men, two large studies have found.
The findings, the first based on rigorous, randomized studies, confirm some longstanding concerns about the wisdom of widespread prostate cancer screening. Although the studies are continuing, results so far are considered significant and the most definitive to date.
Dr. Peter B. Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center, says one way to think of the data is to suppose he has a PSA test today. It leads to a biopsy that reveals he has prostate cancer, and he is treated for it. There is a one in 50 chance that, in 2019 or later, he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.
Prostate cancer treatment can result in impotence and incontinence when surgery is used to destroy the prostate, and, at times, painful defecation or chronic diarrhea when the treatment is radiation.
I think it’s clear we need more accurate diagnostics, especially ones that are less invasive than a biopsy. There is an obvious need to know how large and aggressive a cancer is before deciding if radical treatment is necessary.
Update: The New York Times added this article today
A biopsy can’t rule out prostate cancer. Some men have 2, 3 or even more biopsies before they finally detect cancer. Sometimes, they just miss it, because the major flaw inherent in using a biopsy to search for cancer is that it only samples a very small percentage of the prostate tissue. It’s also possible that there was no cancer originally and it developed after the first biopsy. In fact, some studies indicate that prostatitis, BPH or atypia may increase your risk of future cancer, so being diagnosed with these means you need to keep a close check. There are also apparently some areas of the prostate that are difficult to sample during a typical transrectal ultrasound (TRUS) biopsy.
Fortunately, there are newer techniques for prostate biopsies other than the random 6 or 12 sample method done in in a typical urologist’s office. Like the targeted MRI/TRUS fusion biopsy I had, there are also saturation and “mapping” biopsies that use more samples or some type of specialized imaging to improve the coverage and reduce the chance of a false negative. Some of these are transperineal, meaning they are done through the skin, rather than through the rectum. A biopsy like these might be considered by higher risk patients who have had a negative biopsy in the past. Continue reading Negative Biopsy but High PSA: What Happens Next?
Great news! My biopsy was negative for cancer. I’m also very glad it only took a little over a week, as I was told it could take 2-3 weeks. The waiting is not fun; it’s on your mind very frequently. Now, I get to put it out of my head for at least 6 months until my next checkup!
I temper my relief a little bit, because I know that there are a lot of false negatives with prostate biopsies. This was one of my main concerns about having a biopsy in the first place. While a biopsy can confirm the presence of cancer, it cannot rule it out completely. In fact, a single, standard biopsy may not be all that much better than a PCA3 test or a 3T MRI for ruling out small, less aggressive tumors of the prostate. Also tempering my great relief was a finding of an “atypical gland” in 2 of the 16 core samples. This is basically a warning to keep close check on my PSA and have a regular DRE. I’ve had a handful of suspicious moles removed in the past. While none have turned out to be cancer, a couple did come back as “atypical”. So, I also have a dermatologist check my skin at least once a year, too.
I am still very relieved. Combined with my PCA 3 test and my 3T MRI results, the negative biopsy hopefully means I do not have prostate cancer at all and almost certainly means I don’t have any large or aggressive tumors. Amen.
After I got home from my trip to the NIH, I faxed in the form needed to get a copy of my MRI results. Three business days later, I received a packet in the mail with a paper copy of my MRI report, X-ray report, blood tests, urine tests and other lab results (the biopsy pathology report can take 2-3 weeks).
The best part? A custom labeled DVD with almost 1400 images from my MRI exam, complete with an included viewer. This is what I expected from my $950 ultrasound, but ended up with 5 still photos that almost completely failed to document the “3D/4D” ultrasound I was supposedly given.
I can’t interpret the MRI images any more than I could interpret the ultrasound images, but at least I have them for reference if I ever need them. As I expected, the limited ultrasound images were not very helpful to the urologist or radiologist at the NIH. So, for anyone considering any type of prostate ultrasound (colorflow, color doppler, power doppler, 3D, 4D etc) or MRI (MRSI, MRIS, spectroscopy, diffusion weighted, contrast enhanced, T2-weighted, 3T, etc), be absolutely sure to ask what types of images you will receive. If you aren’t happy with the response, you should probably look for another physician, especially if you are paying for the service up front.
Anyay, for as much flak most government agencies get in regards to efficiency and customer service, I am pretty impressed with the NIH.
The prostate MRI like the one I had is not unique. I mentioned in an earlier blog that a urologist in Florida does 3T MRI screenings for a fee, some of which is paid by insurance. This is also an area with clinical research, such as the study I entered at the NIH. I was told that I was somewhere around the 75th patient in this particular trial. I believe this is the link for the trial I entered, but it may be a related trial and not the exact one where I participated:
Other major centers are doing similar research, notably, the MD Anderson Cancer Center in Houston, Beth Israel Deaconess Medical Center at Harvard and Memorial Sloan Kettering Cancer Center in New York. These are all among the top research institutions for prostate cancer. You can search for such trials at www.clinicaltrials.gov. Here’s a few I found that might be similar:
These are just a few active studies I found that appear to be recruiting participants. These may vary from the study I entered in important ways, so you would need to read about the details and contact the researchers to make sure the study applies to you. For example, some may have age limits or require that patients have a positive biopsy result for prostate cancer. There may also be other studies I didn’t find in a quick search, or those that are still open but not actively recruiting. It doesn’t hurt to email a researcher if you find one like this. Clinical trials aren’t for everyone. They may or may not help in a diagnosis or treatment. You have to do a lot of your own research to determine if one is right for you. Remember that not only might a clinical trial help you in the short term, but they will help others in the long term by advancing the technology for detection and treatment of prostate cancer.
My TRUS/MRI fusion biopsy is now over and the joy of waiting 2-3 weeks for the pathology results begins. The good news is that Dr. Pinto thought it was very unlikely there would be any findings, given all my results so far. In addition, he said they were unable to reproduce the dark (hypoechoic) region that was a concern to Dr. Bard on his ultrasound. He said that one very low risk area they did target may have been in the same general area, but I inferred that there just wasn’t enough information to correlate them from the limited 2D ultrasound images I received from Dr. Bard in New York. From what I’ve gathered, ultrasounds of all types are not always consistent and can even be manipulated to some degree, thus one of the reasons they aren’t widely accepted for prostate cancer detection.
I also got the results of my PSA blood test measured at the NIH. It was 2.7, the same result I had at my urologist in late 2008 and essentially the same result as the first reading of 2.5 I had almost one and a half years ago. This is also a bit of good news, as a rapidly rising PSA level can also be an indicator of prostate cancer. One study of PSA velocity indicated that a change of 0.75 in one year is a concern, while a change of 2.0 in one year suggests a higher risk of aggressive prostate cancer. My level is essentially unchanged or a very slight change, as I understand that day-to-day variations can easily account for a few tenths of a point. So, if my level was to go up to 3.5 or so a year from now, that would probably be a concern, while a smaller increase may be more indicative of prostatitis or BPH.
Anyway, I was discharged from the NIH this morning and am waiting at Reagan National Airport for my flight home. I haven’t had a fever since yesterday morning. I do need to continue my course of prophylactic antibiotics (Cipro) for 2 more days. Otherwise, I’m feeling pretty good. No issues with blood in urine since the first few hours after the procedure. I do have a slight bloody nose this morning, though. I gather it was probably pretty dry in the hospital, especially considering the cold wave that hit while I was there. It was about 15 degrees outside.
My room mate was in fair condition. Recovery from a radical robotic prostatectomy isn’t easy and I’d guess his was pretty typical for the first day. Fortunately, it didn’t sound as if there were any serious complications and I wished him a speedy recovery.
From the beginning, the pretense of my blog has been that many biopsies are probably unnecessary, given the sheer number that are done (about a million a year) and the large percentage that turn up negative. I didn’t have any “smoking gun” that indicated I was at risk, other than a PSA level that was somewhat high for my age. In fact, my DRE and PCA3 tests did not indicate suspicion of cancer and my ultrasound and MRI results only had minor areas of suspicion. Had they been completely normal, I probably would have opted not to have a biopsy at this time. In that the MRI identified at least one suspicious area deemed very low risk, the biopsy seemed necessary.
(There’s a little TMI in this long blog entry, so don’t read on if that kind of detail makes you queasy or whatever)
I was nervous about it, having postponed mine for two months now. Reading all the internet horror stories didn’t help, either. It didn’t help much knowing that the odds of being one of those horror stories are very long. After all, my experience with urologists includes a failed vasectomy.
Continue reading My Dreaded Prostate Biopsy
I have a summary of results from my 3 Tesla high resolution MRI, given to me by one of Dr. Pinto’s associates. I am told this included a T2-weighted (T2W) 3T MRI scan. If I understood correctly, they also took scans with spectroscopy (MRIS) and then with diffusion weighting (DWI) as well and finished with contrast enhanced (CE) images that I assume related to the injection I was given. I was told the report indicated that there were no suspicious lesions whatsoever(!). The only finding was a pattern consistent with prostatitis (non-malignant infection or inflammation of the prostate). Very good news, but again it’s an experimental trial so it can’t rule out prostate cancer. I was also told that the radiologist, Dr. Choyke ,consulted with the urologist I saw yesterday, Dr. Pinto. Having been advised of the ultrasound findings I gave them, I have the impression that the radiologists took a second look at the area in question. They apparently decided that there may be one area of interest, but deemed it very low risk. So, I will proceed with biopsy tomorrow, including a “fusion” biopsy targeting the one suspicious area.
I am hopeful the biopsy will be negative and that all I have is indeed prostatitis. Of course, even a negative biopsy report is not enough to rule out cancer and this has been the basis of my blog. On the other hand, I’m at the point where the only other alternative available to me is “watchful waiting”. So, I decided to have the biopsy and pray it will help to put my mind at ease. After all, I’m already admitted to the NIH, it will be done in an OR and under mild sedation. Plus, it’s free. Combined with the targeted fusion system, it’s a more comprehensive alternative compared to a typical outpatient prostate biopsy procedure. Assuming the biopsy is negative, I would then still continue with routine PSA/DRE at my checkups to make sure nothing changes, but I will do so knowing that no available test could confirm the presence of cancer.