Some psa & Pca related guidelines paraphrased data of Dr. Strum~leading onco-doc

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zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 2/28/2009 5:11 AM (GMT -7)   
Clinical practice guidelines: every man should have an annual psa and dre starting at age 40 and lowered to age 35 for men at risk via family history (including mother, sisters with breast cancers) and African-American men.
 
A psa of 2.0 and over at any age should be investigated. A first step in investigating elevated:
 
psa 2.0 and above should be a fPsa (free) percentage test. (fpsa=unbound antigen test)
fPsa over 25% is associated with lower risk of PCa
fPsa test of under 15% is associated with higher risk of PCa
 
A benign cause of elevated psa and a low fPsa-% could be prostatitis (4-6 weeks of Cipro or similar antibiotic can be used )
BPH (normal aging enlargement of gland) does not cause a low fPsa-% It may cause an elevated psa level and as men age *this could be the reason they see psa rise over longer time spans. (bph with urinary flow restrictions can be treated with-avodart or proscar drugs)
 
Sampling for psa tests normally done at least 3 months apart and by using same lab that uses same proceedure are necessary to establish psa velocity (psav) and psa doubling time (psadt). The validty of such is increased if such testing involves at least 18 month span of time. But, progressive and serial increase in psa values should raise flags or concern that PCa is present and therefore greater degree of vigilance is mandatory.
 
PSAV that exceeds .75 ng/ml/yr is associated with a higher probability of PCa
PSADT of less than 12 years is associated with a high probability of PCA
 (*PSADT- in less than 6 months or within 1 yr.-considered to be red flag-investigate such)
 
Psa's that bounce up and down are more indicative of benign processes than malignant.
Psa's that show continued rise over time, particularly 3 consecutive rises, 3 months apart are suspicious for PCa regardless of the level of psa. *recommending vigilance
 
Gland volume in cc mulitpled by  .066 yeilds the amount of psa produced by a normal, non-malignant gland  (cc volume can be measured by your doc), any amount of psa in excess of this should be considered by a malignant process, until proven otherwise. *E.G. prostate gland found to be  40cc you can calculate the normal psa level 40 x .066=normal psa level, anything higher than that number could be malignant PCa.
 
If these guidelines were used by all men it would eliminate advanced presentations of PCa, annual screening in this manner would present an opportunity to detect localized PCa in over 95% of men, such stats offer outstanding chance for curative approach to the disease.
 
The extremes in indolent vs. aggressive PCa's (kittens vs. tigers):
 
Kittens (generally) have low psa values (under 10) and long doubling times and low velocity. *Patients found 'indolent' versions of PCa (like defined by John Hopkins-Brady Urology) can be canidates for w.w.-watchful waiting (monitoring etc.) Patients whom chose such need to monitor their status vigilantly and be aware that "if" manifestations of disease progression become evident, then reevaluate their situation and consider local forms of treatment, before the window of opportunity for success could be come lost. 
 
Tigers (generally) have high psa's (over 10) or very low psa's assocaite with very aggressive, high Gleason scores like: (4,3), (4,4), (4,5), (5,4), (5,5) cancers. These are dangerous because they could escape investigation for long periods of time since the psa's appear to be normal. High Gleason scores often have reverted to such a primitive state that they no longer secrete psa into the blood.   * Thus the need for screenings with dre, possible blood marker tests and other tests like PAP, Pyrilinks etc. Perhaps the newer PCA3 urine detection method, also perhaps using the fpsa test and patient mentioning any potential symptoms to his doctor.
 
Some of this I paraphrased or with the * added my own comments to Dr. Strum's
*This should be considered generalized guidelines and information, since there are some unique rarer forms of PCa, these guidelines might not be fully applicable every variant (rare) type, thus maybe exceptions to some degree.
 
 


 

Post Edited (zufus) : 2/28/2009 5:48:39 AM (GMT-7)


Purgatory
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Date Joined Oct 2008
Total Posts : 25353
   Posted 2/28/2009 8:15 AM (GMT -7)   
Some good points here, Bob.

My GP, whom I love dearly after almost 15 years, went by old school standards of PSA first time at 50 and anything over 4.0 requiring a biopsy. Very standard for a white male, with no history of PC in the family.

So at age 50, faithful as a good watch, I had my first one done at my yearly exam, and I remember clearly, my PSA came back at 2.8. Since it was well under 4.0 standard, nothing was done or suggested (if I only knew then, what I know now - because a 2.8 is well high for a base PSA for a 50 year old male).

So, I kept going back every year, watching that PSA creep up each year. Nothing was suggested until the summer of 2007, when it went over the 4.0 mark for the first time. Then the GP sent me to the Urologist, who did the first prostate biopsy. Came back "clean" - whatever that really means. To mean, it just means that the 12 needles missed the raisins in the raisin bread. I was 54 at that time.

A year later, PSA 12.3, two more biopsies, and the rest is history.

My point, I feel my PSA was too high at age 50, my PC might have been caught 6 years earlier, possibly, when it was much smaller and less agressive. I dont blame my GP, because he was following the standards of that time, and even what the American Cancer Society suggested.

If I had only known the danger I was facing then, I would have been pro active and began other testing a year or two earlier.

Now I have to pray and hope, like many here, that my post surgiacal pathology report is correct, and that my PC really was contained and my great surgeon really got it all. To me personally, and its not that I am not thankful for where I am now, but it will be a long nervous path to year 1, 5, and 10 for me.

Early and more sopshisticated testing is needed.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Right nerves saved, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05
 
 


John T
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Date Joined Nov 2008
Total Posts : 4168
   Posted 2/28/2009 10:16 AM (GMT -7)   
Bob,
Thanks for the very good summary. I, like David, had all the indications of PC early on but urologists kept diagnosing me as BPH because biopsies came up negative. The cancer was discovered only when I visited an oncologist who understood the real meaning of the PSA markers. If it looks like a duck and quacks like a duck then it is probably a duck.

David, with 9 of 8 cores positive I can't believe that the 1st 2 biopsies missed it, Where was the tumor located?
JohnT

I had a psa of 4.4 in 1999 and steadily increasing psa every 3-6 months before reaching 40 in 5-08.Free psa ranged from 16 to 10%

I had biopsies every year, 13 total in all. I saw 5 different doctors, all urologists or urological oncologists at Long Beach, UCLA, UCSF and UCI and had an MRIS at UCSF in 2007. All tests were negative and I was told that because of all the biopsies I most likely didn't have PC, but to keep getting biopsies every year.

in Oct 08 my 13th biopsy of 25 cores indicated 2 positive cores, gleason 3+3 less that 5% in 2 cores. Doc recommended surgery.

2nd opinion from a prostate oncologist, referred by my wife's oncologists said cancer found wis indolant and statistacally insignificant, but PSA histor was a major concern and ordered a few more tests.

Color Doppler ultrasound with targeted biopsy found a transition zone tumor 18mmX16mm, gleason 3+4 and 4+3. CT and bone scans clear, but Doc thinks that there may be lymph node involvement (30% chance) because of my high PSA, and referred me for a Combidex MRI in Holland, currently scheduled for Feb 14.

Changed diet and takiing supplements while I wait. The location of the tumor plus the high psa make surgery an unlikely option. I'm still evaluatiing all treatment options and will make a decision once I get the results of the Combidex scan.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25353
   Posted 2/28/2009 10:30 AM (GMT -7)   
John,

The first one was a 12 core shot in random, and came up empty handed. I was never dx with any prostate problem prior to the pca dx. My dr. said my prostate didn't even appear slightly enlarged, espec. for my age, and I had no urinary or bladder problems. Just a fastly increasing PSA.

The second biopsy, about 15 months later, came back "clean" of cancer, but lots of high grade pin in the samples, and my dr. said he saw 4 "suspicious areas".

The 3rd one, about 6 weeks later ,perhaps a bit more, was targeted to the left side of the gland, where he saw the suspicious areas, and it a 7 core job. All 7 came up positive, the lowest was 40% cancer, and the bulk of the others were in the 70-90% range. Original gleasons were shown as both 3+4 in one area and 4+3 in others. With that much cancer present in the cores, really amazed the gleasons weren't higher. After surgery, they called the gleason 3+4, which is the better of the "7" gleasons, but still serious.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Right nerves saved, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05
 
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25353
   Posted 2/28/2009 10:36 AM (GMT -7)   
PS to John, my urologist was very experienced and has an excellent reputation state wide here, I think like you said, he knew there was a duck inside me, and no, I don't feel he was hard up to find another surgery patient, his practice is overwhelmed on a bad day. After the 2nd biopsy came up no cancer, I told him I wanted to forget the whole thing for at least another year, he said, not so fast, and he gave me reasons to do the 3rd. I am thankful he was dilligent in his search, and I am thankful I was compliant enough to listen to him. He knew that my rapidly rising PSA without the prescence of BPH or other non-cancerous prostate problems was more likely to be cancer.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Right nerves saved, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05
 
 


zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 2/28/2009 10:58 AM (GMT -7)   
Thanks fellow brothers fighting in PCa, in the past the parameter of psa level around 4.0 or less would have been considered normal or acceptable like you mentioned David and that was the generalized thinking by the docs. Not much was known as to the value of smaller velocity and smaller psa doubling times that could lead up to that psa level, which hindsight is important to monitor and define.

Docs like Strum, Labrie (let me include Walsh too)and others have made huge impact in the world of PCa and helping patients to gain knowledge, wisdom and learning the multitude of variables within PCa. Sure lite a fire under my posterior as to battling this disease, of course never met him (Strum) but have his book and because I endorsed it early on, so co-author Donna contacted me and asked if I would like to be within it, so got to be one of the patients pictures w/blurb about the book, inside cover for me ('this book trumps them all'). Thus I get to be a poster child for PCa, so trying to make a difference if that is possible.

:-)
 


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 694
   Posted 3/1/2009 10:19 AM (GMT -7)   
The content of Zufus' post was authored by Strum and Pogliano.

http://www.yananow.net/DonnasDoctor.html
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com


mspt98
Regular Member


Date Joined Dec 2008
Total Posts : 369
   Posted 3/1/2009 11:05 AM (GMT -7)   
It is sad but true that how fast we find our cancers is often a combination of luck and standards of medical practice in our community. In my case it was after seventeen years of monitoring by urologist, when I was 52, that my PSA  jumped from 1.9 to 2.85 in a year. I was basically "ordered" by my urologist to get a biopsy. I knew I was in the safe range of PSA of less than 4.0 and didn't want the biopsy but went along with MD's advice anyway. First biopsy showed signs of cellular atypia, "suggestive of ca but not diagnostic." I was told to have biopsy repeated in 3 months. I didn't like that idea either due to pain of biopsy. I even contacted other urologists through the blogs to see if having a second biopsy so soon was an extreme move. I wanted to wait 6 months or a year. The other urologists said the second biopsy was a reasonable thing to do.  So I had the second biopsy and found the cancer and the rest is history. Although I had to end my relationship with my urologist because he didn't do robotic surgery I will always be grateful to this guy for being so aggressive with his testing, and also glad that he found the cancer on the second biopsy........ 
my age=52 when all this happened,
DRE=negative
PSA went from 1.9 to 2.85 in one year, urologist ordered biopsy,
First biopsy on 03/08, "suspicious for cancer but not diagnostic"
Second biopsy on 08/14/08, 2/12 cores positive for Prostate Cancer on R side, 1 core=5% Ca, other core = 25% Ca, Gleason Score= 3+3=6 both cores,
Clinical Stage T1C
 
Bilateral nerve sparing Robotic Surgery on 09/11/08, pathological stage T2A at surgery,
No signs of spread, organ contained,
First post-op PSA=.01 on 10/15/08,
Second post-op PSA <.01 on 01/15/09,
Incontinence gone in early December '08,
ED remains, using daily Viagra and 2x/wk bimix/trimix injections for penile rehab


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25353
   Posted 3/1/2009 11:26 AM (GMT -7)   
mspt: this proves there are good doctors out there, that know what they are doing, despite what their patients may be thinking or feeling. Both my long term GP and my Urologist were right on target with me, and fortunately, from a lifetime of medical woes, I am a very compliant patient, so the two things worked together well for me.

David
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Right nerves saved, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05
 
 


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/1/2009 11:32 AM (GMT -7)   
Thanks Galileo I tried to weblink it herein but for some reason when I clicked on it, it would not be found, so I assumed it would not work for others so, I paraphrased which I mentioned in my topic line and then added a coupld comments with the * thing so others would know it was not per Dr. Strums words. Dr. Strums piece there should be a PCa almost bill of rights or guide map to getting it most correct on PCa and Psa data.

Mspt98- Luckily you did have a persistent uro-doc and on your case to see what is what. I have heard of and talked to patients whom had the opposite experiences and that is why I am vocal on alot of things, it is not all wonderful out there and alot of new patients are perhaps not fully informed as to choices, testings, options, list of all possible side effects, cure rates or even trends, considerations for watchful waiting or taking casodex or another drug while you wait and analyze your own situation or second opinions before jumping into the 'rush' mode, which is usually not needed to push for the rush.
 


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 3/1/2009 11:50 AM (GMT -7)   

Hi everyone.  If I could just add one comment here - we have to be proactive sometimes in making sure our doc's do what they are supposed to do.  When I was having my annual physical at age 55 we were getting down to the end and I could tell my doc was not going to do a DRE.  I told her I know you don't know me very well and I don't know you but I need a good physical.  She looked right at me and said I know exactly what you are talking about and yes I was going to skip it but we'll do it.  So she called her nurse in and I had a young (she looks about 18 but I'm sure shes older) woman to do it and another woman to watch. 

As she was wrapping up she said something I will be eternally grateful for - Do you know a urologist?  She was not afraid to say that she was very inexperienced with DRE's and she thought she felt something and she thought I would be better off if I had it examined by an experienced Urologist.  The rest is history - he examined me, did biopsies and 6 weeks later I had surgery. 

I've told her several times that I appreciate her willingness to admit she didn't know something - so many doc's want to seem infallible and none of us are.  So the moral of the story is it is up to us to make sure we get the tests we need when we need them.  David


Age 55
Diagnosed Dec 2007 during annual routine physical
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 positive with 2 marginal
Gleason 3 + 3 = 6
RRP 4 Feb 08
Both nerves spared
Good pathology - no margins - all encapsulated - Gleason 4 + 3 = 7
Catheter out Feb 13 - wore pad for couple of days - pad free Feb 16
Great wife and family who take very good care of me


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/1/2009 12:49 PM (GMT -7)   
CPA that is an interesting scenario on atleast 2 or 3 fronts, we can look at it from the male/female and untrained fickle finger of fate award for her to atleast try it and say hey is does not feel normal and she was wise enough to tell you see a decent urologists (experienced one) whom probably knows what an abnormal DRE feels like. I will skip the other 2 fronts on the gals doing a DRE, humor and such optional-(LOL). I also had DRE's multiple times(including ladies), especially with 8 opinions, it was like do I drop my drawers after the hand shake or what????? Really harlious when they asked my wife to leave the room, couple people being embarrassed by such?

In case others did not know what does a normal gland feel like: the front of the bridge of your nose is how it should feel, smooth, firm, and basically how your own nose feels to you as you slide your index finger over it North & South.....how do I know... this has been explained by other docs as to how it feels, comparitively. So if there is a hard spot, unevenness, maybe like an edge or such....red flag for something abnormal.
 
Good your was found in the early detection scenario.


 

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