PSA 4.2 and asymmetrical prostate 3 weeks ago... advice on criteria for next step?

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VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 3/4/2013 4:29 PM (GMT -6)   
I'm 50 years old, and after 5 years with a primary care doctor who never performed a DRE, I changed doctors. The new doctor did a DRE, and detected and asymmetrical Prostate. He advised I see a urologist within the next 6 months. I made an appointment with a uro right away.

When my blood results came back from my wellness physical, my PSAs were 4.2. I already had a urologist appointment, so I just called and moved it closer (today). As I researched (scared myself about) potential issues, I found that I had three things that shouldn't be done before a PSA test - ejaculated a few hours before the exam, rode my bicycle 1.5 hours the day before, and the doctor did the DRE before the blood draw.

In my urologist appointment today, he said my prostate is perfectly normal in size and shape. So either it was asymmetrical three weeks ago, and now isn't; or my primary care doctor can't feel symmetry, and it was actually symmetrical. My urologist said the PSAs only go up a small percentage from the three issues I brought up.

He then pulled more blood for a PSA. I should get the results on Thursday. He said if it's over 3, he'll recommend a biopsy. My logical mind thinks that the asymmetrical prostate and the high PSA were related, and that the normal prostate should mean a more normal PSA this week. Of course I need some wishful thinking...

What criteria would you use to determine if a biopsy is needed, based on the above? What criteria would you use to determine if you should get a second opinion?

My thought is that if the PSAs are higher than 4.2, I'm going for the biopsy. If they are falling, I will not do a biopsy, but wait 6-8 weeks and recheck the PSAs.

Thanks for reading this, and for your thoughtful responses.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 3/4/2013 4:32 PM (GMT -6)   
Most PCP's don't do PSA tests or DRE's before age 50, that is typical, unless there are other issues or a history of prostate cancer in the family. However, glad it was done, and seeing a uro with your psa of 4.1 is the right step to take. On what you said, and based on my own history, I would go for the biopsy, if nothing else, to give you some peace of mind.

Good luck, and hoping you don't need to join our club for real.

David in SC
Age: 60, 56 at PC dx, PSA 16.3
3rd Biopsy: 9/8 7 of 7 Positive, 40-90%, 4+3
open RP: 11/8, Catheter in 63 days
Path Rpt: 3+4, pT2c, 42g, 20% tumor, 1 pos margin
Incont & ED: None
Surgery Failed, recurrence within 9 months
Salvage Radiation 10/9-11/9, SRT failed within 9 months, PSA 4/12 = 37.x
Spent total of 1 ½ years on 21 catheters, Ileal Conduit Surgery 9/10,
7 other PC-related surgeries
Member of Prostate Cancer & Chronic Pain HW Communities since 10/2008
“I live in the weak and the wounded” – Session Nine (Movie)

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7203
   Posted 3/4/2013 4:40 PM (GMT -6)   
Velo:
I think your read and your plan is about right
 
Mel
PSA-- 11/09--4.19 .Biop.11/30/09.G 4+3.RP: 1/26/10. G 4+3. PNI,EPE, Margin, No SVI. Nodes clr.100% continent by 3/10. PSA: 3/10/10-0.01; 6/21/10--0.02. 9/21/10--0.06; 1/4/11-0.13,3/1/11--0.27. SRT May '11, PSA 7/11/11-0.60; 8/11/11-0.75; 11/1/11-1.38;12/22/11-1.97 ; 2/23/12--3.43;3/23/12-2.28; 4//25/12-2.44;5/29-2.52; 6/29-4.4; 7/30-3.52; 10/1-6,62;10/31-5.86;11/30-9.0;1/2/13-10.08

BOOGEE
Veteran Member


Date Joined Jan 2012
Total Posts : 726
   Posted 3/4/2013 4:41 PM (GMT -6)   
Velonut,

My husband was just about your age when DX.
Didyour Urologist recommend antibiotics first to be certain it isn't an infection.?

Our Urologist however did state the scale of normal PSA is 1-4, but at my husbands age the psa should be closer to less than 1. Wait to see what your blood test results are and perhaps they will be low enough your Dr. will put you on antibiotics.
Do keep us posted!

BOOGEE
Age 53
2010 PSA's 6.3, 4.7 5.6
RP open Oct -2011
Stage T1c
Gleason 4+3 left side Gleason 3+3 right side
11 lymp/ no mets.
Perineural invasion present
neg. marg.
Path staging (pt1): pT2c: bilateral disease
PSA Post -Op
1.2 11/2011
1.8 12/2011
3.5 1/2012
2-12Casodex Lupron PSA .03,
5/12 PSA <0.1, T-12
CT, BONE, MRI Neg. for Mets.
F-18/FDG showed 1 met.,spine T-11

VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 3/4/2013 4:54 PM (GMT -6)   
BOOGEE said...
Velonut,

My husband was just about your age when DX.
Didyour Urologist recommend antibiotics first to be certain it isn't an infection.?

Our Urologist however did state the scale of normal PSA is 1-4, but at my husbands age the psa should be closer to less than 1. Wait to see what your blood test results are and perhaps they will be low enough your Dr. will put you on antibiotics.
Do keep us posted!

BOOGEE


He didn't mention antibiotics, but maybe that's because the prostate is normal.

Thanks everyone, I am thankful you are here to help me along.

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4151
   Posted 3/4/2013 5:05 PM (GMT -6)   
Velo, welcome to HW and I hope you don't have to be here long.

I'm not a doctor but before you agree to a biopsy, I would recommend that you request four things:

1. A short treatment with antibiotics to see if you have an infection that may be causing the PSA level.

2. A PSA-free test that goes along with the PSA test.

3. An analysis from the urologist of PSA density to determine your "normal" PSA for your prostate size.

4. A PCA3 test.

Rushing off to a biopsy is not necessarily the right thing; learn about your situation first.

Good luck,

Jim
Age 62 (66 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, only minor discomfort. Everything continues to function normally as of 11/2/12. PSA: 6 mo: 1.4, 1 yr: 1.0, 2 yr: .8, 3 yr: .5. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1

Upstate Guy
Regular Member


Date Joined Mar 2012
Total Posts : 165
   Posted 3/4/2013 6:19 PM (GMT -6)   
You have time to investigate this in a structured and orderly fashion. Take your time and do some additional bloodwork before jumping to the biopsy. Having said that, if the bloodwork suggests a biopsy, do it. It's not a big deal and it is good to get a real look at a sample from the prostate.
Age: 57
Dx: 3rd biopsy 3/3/12; 6 of 7 Right, 70%, G 4+3; 1 of 7 Left, 20%, G 4+4. 2nd Opinion, G 5+4. Extensive perineural invasion on right.
RALP: 4/19/12; Right nerves taken. Left nerves spared; catheter 9 days;
Path rept: Neg Margins on surgical specimen; extraprostatic extension; neg SV; neg LN; Gleason downgraded to 4+3.
PSA: 12.01 pre-op; 7/26/12 <0.02; 11/4/12 <0.02; 2/28/13 <0.02

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5815
   Posted 3/4/2013 7:27 PM (GMT -6)   
Gp's are, arguably not the best at giving DRE. they do it as protocol. When a uro does one , you know you have had one. Your logic on the assymmtry and psa connection is faulty in this instance, which does not mean it doesn't connect in another scenario, not yours. Also because your Gp found it abnormal and your uro found it normal, does not mean that it magically gained symmetry between the 2 appointments. Your'e uro found it normal. We are talking fleshy organs here, define asymmetrical. The psa is related to an infection. BPH or PCA. The sex on a bicycle, while exercising, {can never resist that way of putting it] would push it up a little. Also just because a dre is normal, does not mean prostate is not infected, Just as a abnormal dre does not necessarily mean it is infected. Also prostate infections do not always cause noticeable infections, but will show a high psa. Anyhow velonut, stick with the uro if he says biopsy above 3 go with that. Logic is a great quality, but it must be melded with knowledge of the data points. Doctors have that knowledge. Alota, alota folks here at HW do also to a much lesser degree, more or less. Since you are on the road with us. Read books, Walshes is a good start, ask questions, so you also will have the knowledge and logic to better connect the data points. This last point is not a scold, just information so as not to drive yourself velnuts,worrying about stuff that is not there. Stay with us,welcome and let us know about progress. On a reread I see you took note of the symmetry issue yourself
Diagnosed 8/14/09 psa 8.1 66,now 69
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough ED penatration at 2 years with cialis/viaga. < .1 at 33 mod < 0.1 @ 39mos

Post Edited (logoslidat) : 3/4/2013 6:30:51 PM (GMT-7)


VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 3/5/2013 11:33 AM (GMT -6)   
Thanks everyone for the advice and support. I will post my PSA as soon as the doctor provides it.
March 2013 - normal prostate, waiting for PSA...
February 2013 - asymmetrical prostate, PSA = 4.2

overthepond
Veteran Member


Date Joined Apr 2011
Total Posts : 648
   Posted 3/6/2013 5:11 AM (GMT -6)   
Good luck VeloNut, I hope your stay with us is very brief indeed.
Let us know how you get on.
Susan
x
Husband's age 64, excellent health
First PSA test – 7. Two months later – 11
Biopsy results: Gleason 3+3 in two cores (right medial 30% and right apex 90%).
Feb 2011 – Brachytherapy – Iodine 125
Post Brachy PSA results:
3 months 3.83 - 6 months 3.18 - 9 months 1.78 - 12 months 2.77 - 17 months 2.31 - 24 months 3.73
SE's = zero!

Cajun Jeff
Veteran Member


Date Joined Mar 2009
Total Posts : 4106
   Posted 3/6/2013 7:12 AM (GMT -6)   
Good luck we will be waiting for the results of your blood work. Do keep us posted.

Cajun Jeff
9/08 PSA 5.4 referred to Urologist
9/08 Biopsy: GS 3+4=7 1 positive core in 12 1% cancer core
10/08 Nerve-Sparing open radicalSurgery Path Report Downgrade 3+3=6 GS Stage pT2c margins clea
r3 month: PSA <0.1
19th month: PSA <0.1
2 year PSA <0.1
Only issue at this time is ED but getting better

lapilot
Veteran Member


Date Joined Nov 2012
Total Posts : 856
   Posted 3/6/2013 5:23 PM (GMT -6)   
I just turned 60 and my PSA climbed from 4.2 to 5.0 over the course of a year with a free PSA value of 10 (very bad). My urologist (faculty at a medical school and believes in conservative approach to diagnosis) put me on doxycline and my PSA went down to 4.1 (not significant) but my free PSA went up to 20 (good). Six months later my PSA went back to 5.0 so the urologist did an ultrasound to measure the prostate. (He doesn't believe in jumping into biopsy since about 4% of the patients get infections, some of which can be severe.) Larger prostates put out more PSA so by dividing prostate volume by PSA you get PSA density. Well, my prostate was normal, but he found many prostate stones which he said would cause the PSA to be all over the place. He did mention that these stones are typically asymptomatic.

With that said I would first want to try antibiotics first. Several weeks of treatment and retest can possibility save you from an unneeded biopsy.

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5815
   Posted 3/6/2013 6:00 PM (GMT -6)   
Lapilot Sounds like you have a knowledgable Urologist and no cancer. A man doesn't get to far past 50 without prostate problems in some respects. I wonder if we have had a conversation before, I worked ATC in SFO , Bay tracon, SEatac OGG, HNL,ZOA ZSE among others. I remember a joke we used to have. In the event of a missed approach climb out on the 050 radial till 5 thousand feet and execute the pilot. Are you Private or commercial?
Diagnosed 8/14/09 psa 8.1 66,now 69
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough ED penatration at 2 years with cialis/viaga. < .1 at 33 mod < 0.1 @ 39mos

Post Edited (logoslidat) : 3/6/2013 5:05:54 PM (GMT-7)


HighlanderCFH
Veteran Member


Date Joined Dec 2012
Total Posts : 677
   Posted 3/7/2013 12:03 AM (GMT -6)   
Hi VeloNut,

Based on your initial post, it appears that your latest blood test was taken just AFTER the doctor performed the DRE? If this is so -- and if your PSA is still over 4 -- I would still not necessarily agree to a biopsy.

Instead, I would insist that you have ANOTHER PSA test in a couple weeks in which you are completely clear from having any sex, bike riding & DRE's for at least 48-72 hours before the blood is drawn.

Then you can feel more assured that you are getting a "true" PSA reading without any activities that put stress on the prostate. As the doctor said, those activities can cause a small boost in PSA readings -- but I've also heard urologists say it can sometimes cause more than a "small" boost.

Good luck to you!
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.

lapilot
Veteran Member


Date Joined Nov 2012
Total Posts : 856
   Posted 3/7/2013 5:56 PM (GMT -6)   
logoslidat,

I am a general aviation pilot in Louisiana and never been to California. I really do like my urologist, he is a retire Army doctor (lots of prostates!) now faculty at our medical school. I like his approach on being conservative, and he has said that in the vast many cases several weeks or months of prudent diagnostic investigation can possibly negate the risk of unnecessary biopsies and the risk of infections.

lapilot.

VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 3/7/2013 6:29 PM (GMT -6)   
I just got the results for my PSA, and it climbed to 5.4. The doctor recommends a biopsy. I asked about antibiotics, and he said I have no symptoms to make him think there's an infection. S I asked about the free PSA, and he said that the rate of rise from 4.2 to 5.4 in 3 weeks is significant, and based on that alone, I need a biopsy.

There are a few things causing alarms for me.
- Both times my blood was drawn, it was after the DRE. The urologist said PSAs don't raise much from a DRE, which I am cynical of.
- According to several reputable sources, a UTI is sometimes asymptomatic. My wife gets UTIs a lot, and I wonder if I we each react differently to them.
- The two DREs were 3 weeks apart, but the guidelines say that the tests should be 6-8 weeks apart.
- I don't have any symptoms of anything, and am very active. This morning I ran 3 miles in 22 minutes.
- I'm concerned that pushing a needle through my intestinal wall to pull samples to test for cancer, may I corporate sludge into the prostate that shouldn't be there.

I made an appointment for the biopsy for the 18th, but will call to cancel it tomorrow. I'll try to get a second opinion, preferably from Sloane.

Does this sound prudent? Thanks everyone, you are keeping me from getting too nervous about all this.
March 2013 - normal prostate, waiting for PSA...
February 2013 - asymmetrical prostate, PSA = 4.2

Buddy Blank
Veteran Member


Date Joined Jan 2013
Total Posts : 1406
   Posted 3/7/2013 6:35 PM (GMT -6)   
A person won't usually get any "sludge" from a standard biopsy but see if you can get a Stereotactic Transperineal Prostate Biopsy and alleviate your concerns that way.
PSAs: 4.76 (May 2012), 4.23/PSAF 12.29% (August 2012), 3.98/PSAF 13.32% (October 2012) 4.9 (February 2013)
Biopsy right prostate: Benign tissue
Biopsy left prostate: Prostatic adencarcinoma, Gleason score 7 (4+3), Tumor involves 2 of 10 cores and 5% of total tissue sampled, Positive for perineural invasion
TRUS measured prostate volume 19.36 cc
Stage T1c

Fauntleroy
Regular Member


Date Joined Dec 2012
Total Posts : 366
   Posted 3/7/2013 10:22 PM (GMT -6)   
Being that it is known that having a DRE prior to the PSA test can cause an increased PSA level, why not simply draw the blood first and then assault you with his index finger? New Uro time?

overthepond
Veteran Member


Date Joined Apr 2011
Total Posts : 648
   Posted 3/8/2013 9:29 AM (GMT -6)   
Yes I am with Fauntleroy, find yourself a new urologist and get a second opinion.
Good luck to you Velonut.
Susan
x
Husband's age 64, excellent health
First PSA test – 7. Two months later – 11
Biopsy results: Gleason 3+3 in two cores (right medial 30% and right apex 90%).
Feb 2011 – Brachytherapy – Iodine 125
Post Brachy PSA results:
3 months 3.83 - 6 months 3.18 - 9 months 1.78 - 12 months 2.77 - 17 months 2.31 - 24 months 3.73
SE's = zero!

VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 3/8/2013 9:48 AM (GMT -6)   
My father in law worked in medical education (as did I) for several years (pharma PhD). I found out last night when I called him to discuss my situation that he focused on prostate cancer. He said two PSA readings three weeks apart, and then a biopsy recommendation is way too fast. He also said there's quite a lot of disagreement on whether PSAs are a diagnostic tool, or if their real value is in monitoring after a cancer diagnosis to inform the doctor on treatment. There's also a lot of disagreement on the impact of the biopsy on the health of the prostate. Having multiple puncture wounds isn't low impact.

He recommended I look at Pub Med to locate any research related to DRE impacts on PSA, and I found this: http://www.ncbi.nlm.nih.gov/pubmed/10565747. This study shows the average total PSA increase after a DRE to be at 0.9 points for a pool of 91 men.

This morning I cancelled my biopsy, and had the urologist send his notes to Memorial Sloan-Kettering. They will review the numbers and call me back to schedule a consultation.

But for today, I watch the snow fall, hug my wife and speak positive, and be thankful for all I have. My perspective on life changed in a matter of days. Thanks again, I hope my stay with you is short.
Doctor recommends biopsy, I am getting a second opinion
March 2013 - normal prostate, PSA = 5.4
February 2013 - asymmetrical prostate, PSA = 4.2

overthepond
Veteran Member


Date Joined Apr 2011
Total Posts : 648
   Posted 3/8/2013 10:16 AM (GMT -6)   
Good for you and enjoy your weekend. Just keep that positive attitude and you’ll do just fine.
Susan
x
Husband's age 64, excellent health
First PSA test – 7. Two months later – 11
Biopsy results: Gleason 3+3 in two cores (right medial 30% and right apex 90%).
Feb 2011 – Brachytherapy – Iodine 125
Post Brachy PSA results:
3 months 3.83 - 6 months 3.18 - 9 months 1.78 - 12 months 2.77 - 17 months 2.31 - 24 months 3.73
SE's = zero!

Buddy Blank
Veteran Member


Date Joined Jan 2013
Total Posts : 1406
   Posted 3/8/2013 1:03 PM (GMT -6)   
Good luck.
PSAs: 4.76 (May 2012), 4.23/PSAF 12.29% (August 2012), 3.98/PSAF 13.32% (October 2012) 4.9 (February 2013)
Biopsy right prostate: Benign tissue
Biopsy left prostate: Prostatic adencarcinoma, Gleason score 7 (4+3), Tumor involves 2 of 10 cores and 5% of total tissue sampled, Positive for perineural invasion
TRUS measured prostate volume 19.36 cc
Stage T1c

VeloNut
New Member


Date Joined Mar 2013
Total Posts : 8
   Posted 4/8/2013 4:16 PM (GMT -6)   
Thanks so much everyone for your wisdom and advice. I did 10 days of doxicyclene, and then a sulfate. Last Friday I had more blood drawn by my regular family doctor. She said a first year med student knows not to do a DRE before a PSA test, and couldn't believe two doctors (one a urologist she knows) did just that. My PSAs are now 1.2. Had I listened to the first doctor, I'd have already had a biopsy done. Positive thoughts and gratitude are coming your way. I've never stressed over something so much in my life. Thank you, thank you, thank you.
March 8, 2013 - Contacted Memorial Sloan-Kettering for a second opinion...
Doctor recommends biopsy, I am getting a second opinion
March 4, 2013 - normal prostate, PSA = 5.4
February 14, 2013 - asymmetrical prostate, PSA = 4.2

sheepguy
Veteran Member


Date Joined Nov 2010
Total Posts : 763
   Posted 4/8/2013 7:53 PM (GMT -6)   
So, VeloNut, you are saying a PSA of 5.4 was caused by infection and DRE performed before the blood sample was taken ? Do you plan on another PSA test anytime soon? My brother had a PSA of 5.0 then in 6 months 1.8 and 6 months again 5.6. Anecdotes don't prove the point I know...but still.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 4/8/2013 8:05 PM (GMT -6)   
sounds like you may have bitten the bullet here, hope you do well in the future.

david
Age: 60, 56 at PC dx, PSA 16.3
3rd Biopsy: 9/8 7 of 7 Positive, 40-90%, 4+3
open RP: 11/8, Catheter in 63 days
Path Rpt: 3+4, pT2c, 42g, 20% tumor, 1 pos margin
Incont & ED: None
Surgery Failed, recurrence within 9 months
Salvage Radiation 10/9-11/9, SRT failed within 9 months, PSA 4/12 = 37.x
Spent total of 1 ½ years on 21 catheters, Ileal Conduit Surgery 9/10,
7 other PC-related surgeries
Member of Prostate Cancer & Chronic Pain HW Communities since 10/2008
“I live in the weak and the wounded” – Session Nine (Movie)
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