PSA accuracy due to DRE?

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yana2100
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Date Joined Jul 2009
Total Posts : 12
   Posted 7/26/2009 3:36 PM (GMT -6)   

PSA:  0.98 (7/07), 2.12 (12/07, DRE-normal); 1.03 (3/09), 1.25 (6/09, DRE-nodule suspected, later found non-cancerous from Biopsy)

Biopsy (7/09)  Age 61 –

1 positive/16 cores, G6 (3+3), T1c, 2mm size or 3% (2mm/62mm from 7 samples-right lobe.  left lobe- 9 samples-normal)

 

From literatures: 

 

M. L. F. Klomp ; “The PSA levels showed a statistically significant rise of 20% immediately after DRE and TRUS”

Maria de F. : “ Mean PSA rises by 12% , 30min post-DRE”

S. Dutkiewicz, “Mean PSA rises from 8.5->9.4,1-24hr post-DRE”

 

Both blood samples for two PSA tests were taken <15min post-DRE.

 

  1. If PSA=2.12 (12//07, DRE) & PSA=1.25(6/09, DRE) are accurate –       PSADT=0.32Y (0.98>2.12, 7-12/07);   PSADT=1.05Y (1.03>1.25, 3-7/09)

2         If PSA = 2.12 & 1.25 could be ignored because of potential DRE interference –

PSADT = 22.3Y (0.98>1.03, 7/07 – 3/09)

Dr. disregarded PSA’s rise and down.   However, Interpretation of PSA data could affect the prognosis.  What could explain PSA’s rising and down from 1>2.12., then from 2.12>1 if no post-DRE effect? Appreciate for any comment and advice? 

Thanks


John T
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Date Joined Nov 2008
Total Posts : 4227
   Posted 7/26/2009 8:26 PM (GMT -6)   
A DRE will definately affect your PSA readings. I would disregard those psa readings. I would wait 3 months and get another psa without a DRE then you will have another point of reference.
You might want to read: "Prostate Cancer Basics" by Dr Stephen Strum; there is a lot of information on PSA kenetics and dirivatives in there. Also Strum has some papers on the PCRI website on how to use PSA kenetics in diagonosis.
Your Gleason and low psa numbers are indicative of indolant PC. PSA doubling time will give you a good indication so it's important that you get it right. Three months won't make a difference with your stats.
If you do choose Active Survelience, get a doctor that is experienced with it. I would be concerened with any doctor that takes a psa reading right after a DRE; it indicates that he is not well informed on how to use psa in diagostics.
A color doppler would also be very useful in helping you make a treatment decision and can be used a baseline if you choose AS.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT


zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 7/27/2009 5:23 AM (GMT -6)   

Hopefully you understand this clue, if your doc did DRE 1st and then psa test, is this the doc that should or could be treating you? Is this the doc that may be a qualified surgeon or future director of your drug therapies and care on PCa???? This is so basic that we lay person sheep understand it, but the expert doc doesn't? Consider it a clue, if he does not know that one, what makes you think he is an alround expert? Yes, I slam the mis-informed docs they should not even be practicing if they don't know the basics. It is their duty to stay current on what they do and to be in accord with the Hypocratic Oath (atleast in theory). 

There are good and bad out there in treatments and skills and knowledge levels and bias levels and open minded or closed minded, types. Try to find out more about what type of doc do you have and if they don't match up well with you, consider finding another in your best interests, it is very possible you could do better or enjoy better consultation, treatment, care, compassion and other intangibles that might even be priceless to you.  Even if this disease is a crap-shoot put all the pluses on your side if possible.


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4156
   Posted 7/27/2009 7:30 AM (GMT -6)   
Dear yana:
 
I cannot improve over JohnT's excellent post so I just want to reinforce it.
 
Beyond that, zufus is certainly correct that it is "basic" that a DRE affects PSA scores and a provider who doesn't know that is lacking...
 
Tudpock
Age 62, Gleason 4 +3 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 7/1/09.  6 month PSA now at 1.4 and my docs are "delighted"!

geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 7/27/2009 7:52 AM (GMT -6)   
I have tried to look a little closer at the articles mentioned: You can read the abstracts of the two I found by searching PubMed. Note that both of these studies are over thirteen years old. I could not find the third one with the information given

Br J Urol. 1994 Jan;73(1):71-4.
The effect of transrectal ultrasonography (TRUS) including digital rectal examination (DRE) of the prostate on the level of prostate specific antigen (PSA).
Klomp ML, Hendrikx AJ, Keyzer JJ.
Note: this study involved BOTH TRUS and DRE

Int Urol Nephrol. 1996;28(2):211-4.
Effect of digital rectal examination on plasma prostate-specific antigen (PSA).
Dutkiewicz S, Stepien' K, Witeska A.
Note: all the subjects (130) in this study had BPH – the greatest effect was for patients with the highest PSAs before DRE (PSA over 10.0)

I would not hang my hat on either of these as proof that DRE ordinarily raises PSA especially since there is literature to the contrary.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads


yana2100
New Member


Date Joined Jul 2009
Total Posts : 12
   Posted 7/27/2009 8:53 AM (GMT -6)   
Thanks for the all comments- 
PSA was ordered by family Dr. and was done right after annual physical and DRE.
It could be my own fault or family doctor's since no one told me to wait a little while.
Uro Dr. disregarded PSA and gave no explanation on PSA's  rise and fall upon request.
He most likely knew DRE effect but nothing was explained.
Uro Dr only recommendation was an immediate repeat biopsy.
 
My question now is that if PSA (post-DRE) is not reliable, then it appears my PSA
stays fairly stable and close to my baseline value until now.  Why an immmediate repaeat biopsy ?   I would agree with JohnT's recommendation that PSA in 3 months
is a more resonable approach.
Yet , most Uro guidelines suggest an immediate repeat biopsy within 2-4 weeks before engaging AS and also re-biopsy in one year.  Wouldn't it make sense to bring next year's biopsy to now and to give peace of mind now.  Thanks yana2100
 
 

geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 7/27/2009 9:20 AM (GMT -6)   
First, remember that we are not doctors. Probably the safest thing is to get a second opinion from another urologist -- perhaps one who is more communicative.

As far as a lay opinion, I see little danger in waiting 3 months for another PSA. Why? With one positive core out of 16 and that a Gleason 3+3 the chances are that your cancer is small and indolent. Current PSA of 1.25 is very much in the low range. Why not? Perhaps your positive DRE is still an issue. If we consider a three month change from 1.03 to 1.25 as true then you have a PSA doubling time well under one year -- not good.

By the way, while I am skeptical about the PSA - DRE link, there seems to be stronger evidence that sex before the PSA test or things like bicycle riding can increase the reading
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads


yana2100
New Member


Date Joined Jul 2009
Total Posts : 12
   Posted 7/27/2009 10:11 PM (GMT -6)   

Earlier, I agreed to Uro Dr's recommendation for a repeat Biopsy next week was due to the alarming PSADT=1.05Y from last two PSA tests.  Then I googled PSA and found DRE effect.  I pretty much rule out other factors except DRE which is why PSA test accuracy now plays such an important role in decision making for repeat biopsy.

1. DRE-positive nodule - non-cancerous.  4 samples - all negative.  A small PCa was found on another half lobe from 7 needles. 1 positive/7.

2.  If small PCa could be detected from 1st biopsy, there is an equal probability, albeit small, that PCa can be found from a repeat biopsy.  Yet, 2nd biopsy reveals no additional inf. except when PCa of higher grade or stage is found.  But this could be better judged from PSA and esp. PSADT instead of 2nd biopsy since most literatures have shown convincing evidences of PCa progression and mortality to PSA and PSADT.  2nd, assuming last two PSA tests were correct and bad PSADT is true and there is perhaps PCa with grade>6 exists, chance of hitting bad PCa from repeat biopsy is poor.  Immediate PSA test appears more urgent since it could un-mistakenly reveal high-grade PCa or PCa's progression.   Conclusion-  2nd biopsy is not warranted at this time, esp. when PSA is very low.

3. Some papers indicate that PCa with Gleason grade >6 could still be found at small PSA value.  (definition, small is PSA<4).  Also my PSADT at 1.05Y, if it is true, implies malignant PCa of high grade >6 exist.  For this case, 2nd biopsy offers a chance to uncover PCa of grade >6 if they do exist.

4. Dr was too busy to have time replying my prepared two full pages of questions (I simply followed the instruction from internet on “What to ask Dr”.)  I guess he is still a good one.  Without his extra effort (+12 more samples) , Pca could not be found in un-suspected areas.  This proves that "All old men have Pcs IF enough biopsies are done."

Thanks for OhioState’s good advice on being my own advocate.  Dr does nothing wrong by following “guideline”.  But guideline is usually too broad to be suitable for each individual's unique situation.   Mine is a good example.  Hopefully with your kind guidance and doing more reseach on DRE/PSA, there will be no regret later.

5. Post-biopsy PSA test – How long it takes for prostate to heal itself for next PSA?  

Thanks  Yana2100


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 7/28/2009 10:40 AM (GMT -6)   
Yana,
about 3 months after a biopsy psa should not be affected by the biopsy.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT


yana2100
New Member


Date Joined Jul 2009
Total Posts : 12
   Posted 12/17/2009 9:24 PM (GMT -6)   

PSA:  0.98 (7/07), 2.12 (12/07, DRE-normal); 1.03 (3/09), 1.25 (6/09, DRE-nodule suspected on left lobe, later found non-cancerous from Biopsy), new test 0.8(10/09)

Biopsy (7/09)  Age 61 –

1 positive/16 cores, G6 (3+3), T1c, 2mm size or 3% (2mm/62mm from 7 samples-right lobe.  left lobe- 9 samples-normal)

*****************************************

 

Back in 7/09, I refused Dr's recommendation of a quick 2nd biopsy before engaging WW.  Then I decided to join PASS, a clinical trial for WW cases, whose protocol includes PSA & DRE every 3 months, biopsy yealy for next two years, and followed by biopsy every 2 years.

 

My latest PSA (10/2009) is 0.8 which is significantly lower than previous test result of 1.25 (6/2009).  It proves that "lifestyle change" alone could yield good result.    *exercise more *cut down meat/milk *lost 8 pounds *drink green tea and soy milk.   Some more questions -

 

1. Interpretation of PSA's reduction?   PC tumor shrunk???

2. Is it still a good idea for me to go throug the PASS trial if PSA continues to be stable from next test scheduled on Jan/2010?

I do not mind of checking PSA/DRE every 3 months , however repeated biopsy is my concern.   Thanks   yana2100

   

  


yana2100
New Member


Date Joined Jul 2009
Total Posts : 12
   Posted 12/17/2009 9:26 PM (GMT -6)   

PSA:  0.98 (7/07), 2.12 (12/07, DRE-normal); 1.03 (3/09), 1.25 (6/09, DRE-nodule suspected on left lobe, later found non-cancerous from Biopsy), new test 0.8(10/09)

Biopsy (7/09)  Age 61 –

1 positive/16 cores, G6 (3+3), T1c, 2mm size or 3% (2mm/62mm from 7 samples-right lobe.  left lobe- 9 samples-normal)

*****************************************

 

Back in 7/09, I refused Dr's recommendation of a quick 2nd biopsy before engaging WW.  Then I decided to join PASS, a clinical trial for WW cases, whose protocol includes PSA & DRE every 3 months, biopsy yealy for next two years, and followed by biopsy every 2 years.

 

My latest PSA (10/2009) is 0.8 which is significantly lower than previous test result of 1.25 (6/2009).  It proves that "lifestyle change" alone could yield good result.    *exercise more *cut down meat/milk *lost 8 pounds *drink green tea and soy milk.   Some more questions -

 

1. Interpretation of PSA's reduction?   PC tumor shrunk???

2. Is it still a good idea for me to go throug the PASS trial if PSA continues to be stable from next test scheduled on Jan/2010?

I do not mind of checking PSA/DRE every 3 months , however repeated biopsy is my concern.   Thanks   yana2100

   

  


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/17/2009 9:38 PM (GMT -6)   
yana,

when i look at all your posted data thus far, really looks like WW or AS is still a very do-able and sensible plan. your dietary changes are good for your general health regardless of any help to PC, wish i could make that drastic a diet change.

part of the plan of course with WW is to have biopsies on some agreed upon schedule. the fact that you only had 1 positive core out of 16, and that being only 3 % gleason 6 is great at face value. would normaly be considered a real low grade case of pc.

there is however, the chance over time that the cancer grows, or the single biopsy you had, even though 16 core, missed more of the cancer. your low psa number however, adds another odd dimension to your case.

if i were you, just my opinion, would still do the psa every 3 months, and a new biopsy at the one year mark, just to be on the safe side.

david in sc
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 12/17/2009 11:43 PM (GMT -6)   
Yana,
Even though you have all the indications of an indolant cancer you should still get regular psa tests and a biopsy at least every two years or on any sign of psa increase above .75nlg. This is the prudent thing to do. psa is highly variable. If you look at YANA, Terrry Hurbert did an experiment and had his psa taken daily. The variation was amazing. A good diet could influence your psa.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT

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