Posted 3/12/2007 5:37 PM (GMT -6)
Let me add my welcome to this site about this unwelcome situation. My experience is sort of a mix of the others, and maybe yours. You really owe it to yourself to read both the Walsh and Scardino books to get the full scoop on all of this.
PSA is a biochemical (antigen-usually a protein) that is produced when the prostate is "messed with." It goes up with prostatitis (an infection), just plain ejaculation (the work-out of the pumping action of the prostate), the manipulation of a digital rectal exam (some docs feel like they're leaving a bruise!), prostate enlargement of the benign type, or prostate cancer activity. The density that someone mentioned is the amount of PSA in relation to the size of the prostate, which if you have an enlarged prostate, is less than if there is cancer for any given amount of PSA.
There is also a prostate "velocity," which is the rate that the PSA is increasing. Since I had about seven or eight years of PSAs from community screenings and pcp visits, I could plot them, though I didn't do this 'til I was sitting at home after surgery (if I had before, I might have totally freaked out. I found that mine was increasing at an exponential rate-a pretty good sign of cancer, as per the studies of a doc named Carter at Johns Hopkins in Baltimore). Some think this velocity is the real telling indicator rather than the absolute amount of PSA. Sen. John Kerry had only 2.5 when he was diagnosed, but it had gone up from, I believe, under 1 in a short period of time.
There is, in addition, something called free PSA percent, which one wants more of rather than less. If the free PSA is under 15 (mine was 8), there is a greater likelihood that there is cancer.
You don't want to suppress PSA if there is cancer (like I thought I did, too). I had low testosterone for a few years before the cancer showed up. My pcp put me on hormone replacement because low testosterone makes you feel terrible, in addition to being related to heart disease and osteoporosis in men. But he told me to be sure and get frequent PSAs and DREs, because (some) prostate cancer cells live on testosterone. And I'll be darn if that isn't when my PSA started going up. He didn't know about PSA velocity concept, and was an adherent to the "over 4.0" rule for referral for a biopsy. Then, at a regular visit, I had 4.4. He told me to get to a urologist. Being naive and not having done any research like reading the books and visiting forums like this, I thought, well, I'll just stop the testosterone for a couple of months and see if the level drops below 4.4. Then, I'll be safe. Well, that's not how it works. After the two months, I found a great urologist (I already knew him as a colleague), and he repeated the PSA, as well as adding a free PSA percent, but scheduling the biopsy, notwithstanding. The PSA had gone up to 5.7 in two months without the testosterone, and the free, as I said above, was 8. The biopsy came back as described in my signature area.
My father-in-law tried to treat his prostate cancer only with some herbal stuff that was taken off the market, PC-SPES. It had Chinese herbs that actually worked like female hormones, but also all kinds of stuff in it that wasn't supposed to be there, like Xanax. It suppressed his PSA, all right, but then when he couldn't get any more, his PSA went up to 40.
My biopsy was done as an outpatient, and was no trip to the beach, but wasn't as excruciating as I expected. His nurse gave me a preparation kit ( strong antibiotics (Levaquin) to take a couple of days before and after, and a Fleet enema to use that morning). He numbed the area around the prostate with an injection of Xylocaine on either side, and then Zap times 12 to take the samples (guided by the transrectal ultra sound). There were six from each side, systematically spread from base to apex (top to bottom). Four of the 12 came back positive for cancer, but these four were only found on the right side. I left the office, and drove myself to work and worked a full day, with nothing but Extra-Strength Tylenol to address the sensations. The pre-procedure imaginings were much worse than the aftermath.
Now, prostate cancer is not "black and white," as said before, and that also refers to its presence in the gland. You can have tumors (collections of cancer cells that make a lump) that may or may not be felt by the doc, or may or may not show up on imaging (ultrasound, CT, or MRI). The cancer may also be microscopic, and throughout the gland and not feelable or imageable by the ultrasound. That is why they sort of sample all around the gland, rather than just where they see something. In my opinion, any less than 12 samples is not enough to rule out anything. In my case, nothing showed up in the biopsy samples from the left side, but after my prostate was taken out and the whole thing was examined microscopically, they found microscopic areas of cancer cells all over the left side. Now, many in this forum may criticize me for being closed-minded and biased toward surgery for the treatment of this, if it happens to turn up as suggested by biopsy. But, unless it is out and studied, one is not going to know right away what one is dealing with in terms of extent of cancer, except for post-treatment PSA levels.
I'm not an M.D. and in any event, of course, cannot say that you have or don't have this; only the biopsy will tell. But, if you do, you want to have the most up-to-date doc that you can find to take care of you, and one that you like and get along with. To me, one way to choose an up-to-date urologist is to look at the website that the robotic surgery company puts together, and see if there is one near you. This site is www.davinciprostatectomy.com/hospitals.html, and I saw that there is a guy there from Pittsburgh. Hopefully, this is not the guy you are seeing, bedside-manner wise. But, it looks like there are a lot of docs not too far from you, from Philadephia to Cleveland to Buffalo, who know how to help.
Sorry for the long wind, but just some thoughts. Please stay with us and keep us posted.
All the best,