Prostate Cancer

[ktown7]

Is it unusual for the PSA to be normal, around .52 and prostate cancer to be present with a Gleason scale reading of 3+3 = 6? The biopsy was done as a precautionary measure due to a slight tenderness felt during the DRE while having an annual physical, no symtoms other than the tenderness. If this happens then why? If so, many men are being deceived thinking that a normal PSA reading means cancer-free. Please respond if you have any knowledge of this as I am considering treatment in the near future but am a bit unsure about the biopsy results.
Thank you,

[UroDoc]

PSA is not a diagnostic test, some men with very high PSA will have no cancer and some men with a normal PSA will have cancer, That is why the digital rectal exam is still done. PSA is about screening the chance of having cancer with a normal PSA is low, but still possible and the higher it is the more likely you are to have cancer but not necessarily, good luck

[kdunbar]

Tests (like medication) often only cover the 'average man', which is about 80% of the population. The problem being the 10% either end, particularly the bottom 10%. Consider yourself lucky the tenderness indicated a biopsy, and a gleason 6 is as good as it gets. Consider all treatments and any resulting post treatment side effects. Surgery is still the gold standard.
Good luck,
KD

[Fred1945]

I was diagnosed with prostate cancer in Oct 07 following a digital exam in which my doctor found a lump. I had a biopsy immediately (the VA can be quite efficient) and showed 5% neoplasm (cancer), Gleason 3+3. My PSA was 1.0. A second biopsy in Apr 08 showed 20% neoplasm, a 400% increase but PSA was still 1.0, Gleason 3+4, perineural invasion identified. My PSA over the past ten years has not varied at all (0.9 to 1.2 attributable to test variation). My VA urologist recommended immediate treatment since I appeared to be in the "bad" 20% with such aggressive growth. I started hormone (anti-androgen Zolpadex) treatment that day, started IMRT treatment in six weeks, have had 31 "zaps", 12 more to go.

Obviously, for me, follow-up tests will have to be frequent but I am concerned that VA medical personnel will lump me into the top 80% (inapplicable in my case) and merely monitor me by watching my PSA from time to time (e.g., every six months to a year). It is my understanding that PSA is very slow to respond to latent prostate cancer or even aggressive cancers and that I could be dead before any test shows a PSA increase. There seems to be some controversy among urologists about the value of PSA tests in prostate cancer, e.g., a high PSA may indicate only that one has had prostate tests for years. What follow-up tests should I insist upon to detect radiation/hormone failure and/or metastasis in my aggressive cancer? I am going to insist upon post-treatment monitoring tests at least once every three months. Are PT, MRI, bone, and/or CT scans the only reliable means to detect post-treatment prostate cancer spread?

Thanks!
Fred

[UroDoc]

Given your low normal PSA while having Gleason 7 prostate cancer it will be difficult to tell if you have a recurrence utilizing PSA. The fact that you have Perineural invasion will put you at increased risk for recurrence. There is some data to suggest that continuing anti-androgen therapy for 2 years after radiation may decrease recurrence, it certainly wouldn't hurt. PSA may be of some value in monitoring if it decreases to basically zero after your therapy. If one of my patients had the findings you describe( a special circumstance) I would do 3 month PSA's (which is my standard) and consider PET scans on perhaps an annual basis depending on changes in your PSA. You did not mention your age which would also factor in decision making, additionally I wonder why you were not treated after the initial biopsy in Oct 07. Good luck

[Fred1945]

UroDoc, I'm "only" 62 but this is my second cancer in two years (i.e., two summers in a row spent under-going radiation treatment), both apparently Agent Orange induced (I also have AO diabetes Type II attributable to AO, controlled through diet at this time). There is no cancer nor diabetes history in my family. Agent Orange cancers don't necessarily follow the rules so I'm trying to stay on top of this latest and most potentially lethal of my various maladies. I am quite concerned about prostate cancer recurrence which appears likely given my relatively young age; hence, my inquiries about early recurrence detection modes. And I certainly appreciate your response: dealing with the VA, it is difficult to obtain professional opinions since most personnel with whom I communicate are non-medical administrative types or, at best technicians.

Without asking my urologist (I see him tomorrow for a second Zolpadex capsule insertion) why he did not recommend immediate attention last October, I can only surmise that he based his judgement for watchful waiting on the low PSA and 3+3 Gleason with only 5% neoplasm in the original biopsy that it was the slow growing type. A second biopsy three months later would have, I am certain shown that my cancer was a lot more aggressive. VA budget contraints prevent more frequent visits unless I yell, kick, scream, and threaten but I didn't have the knowledge then that I have now (I'm a wildlife biologist, so research and medical papers' terminology provide no barrier). Hindsight being 20-20, I would have gone with immediate radiation and hormone treatment starting last October. I DID secure a second PSA in Jan 08 with no change (1.2, variance attributed to test and methodology variation).

I appreciate the reinforcement of my feeling that PET scans on a frequent basis might be the best means for detecting recurrence. They're expensive and the VA balks but again, yelling, screaming, etc often works.

[UroDoc]

You're welcome. I wish you well.

[Mark R.]

I am a healthy 52 year old guy who in early 2007 had a PSA of 2.5- In January of 2008 a new PSA score was 3.8 and a 10 sample biopsy was performed. The biopsy showed two areas of HG PIN but no cancer was detected. Immediately I started taking Centrum Silver vitamins. In May 2008, my PSA went down to 2.1(not sure if the vitamins were a factor) but another biopsy (14 sample) was performed with two samples taken from each area where the HG PIN was found the first time. The results of the second biopsy showed no cancer or HG PIN at all but showed one area of average severity ASAP. (I had been assured by my doctor that if I was cancer free at the second biopsy I should be ok for awhile) My questions are:

1. Is there a particular PSA score where a biopsy is called for in the first place and what is that score?

2. Should I have even had the second biopsy noting that my PSA had dropped from 3.8 to 2.1 in five months?

3. Is it normal to have HG PIN in one biopsy but have it not found in the follow-up biopsy?

4. If a saturation biopsy is recommended to me at my next appt. next week should I do that or are these biopsys somewhat unreliable in their findings?

ANY INPUT WOULD BE GREATLY APPRECIATED. THANKS FOR READING MY STORY.....Mark

[Mark R.]

[quote="Mark R."]I am a healthy 52 year old guy who in early 2007 had a PSA of 2.5- In January of 2008 a new PSA score was 3.8 and a 10 sample biopsy was performed. The biopsy showed two areas of HG PIN but no cancer was detected. Immediately I started taking Centrum Silver vitamins. In May 2008, my PSA went down to 2.1(not sure if the vitamins were a factor) but another biopsy (14 sample) was performed with two samples taken from each area where the HG PIN was found the first time. The results of the second biopsy showed no cancer or HG PIN at all but showed one area of average severity ASAP. (I had been assured by my doctor that if I was cancer free at the second biopsy I should be ok for awhile) My questions are:

1. Is there a particular PSA score where a biopsy is called for in the first place and what is that score?

2. Should I have even had the second biopsy noting that my PSA had dropped from 3.8 to 2.1 in five months?

3. Is it normal to have HG PIN in one biopsy but have it not found in the follow-up biopsy?

4. If a saturation biopsy is recommended to me at my next appt. next week should I do that or are these biopsys somewhat unreliable in their findings?

ANY INPUT WOULD BE GREATLY APPRECIATED. THANKS FOR READING MY STORY.....Mark[/quote]


....I should add that all digital/rectal exams and both ultrasounds were normal and BPH Vol. 25 (7 years on Flomax, can go most nights without having to get up to urinate)...

[UroDoc]

1. Is there a particular PSA score where a biopsy is called for in the first place and what is that score?

There is not a a particular PSa score that would prompt a biopsy. Rate of rise, age of the patient, and family history of prostate cancer are other factors that are taken into consideration

2. Should I have even had the second biopsy noting that my PSA had dropped from 3.8 to 2.1 in five months?

I believe your physician was concerned about the presence of high grade PIN and not necessarily the PSA value. Since biopsies only sample the prostate small areas of cancer can be missed. The presence of high grade PIN puts you at high risk for prostate cancer

3. Is it normal to have HG PIN in one biopsy but have it not found in the follow-up biopsy?

This can happen for the reason stated above , i.e. small sampling of a larger area

4. If a saturation biopsy is recommended to me at my next appt. next week should I do that or are these biopsys somewhat unreliable in their findings?

The biopsy itself is not unreliable i.e. the pathology result but it is somewhat of a random sampling so you can get different results depending on the area biopsied. The decision to go ahead with another biopsy would be up to you and your urologist to discuss. You might ask about being put on daily Proscar since there is some information that it may decrease the chance of developing prostate cancer in high risk individuals, it certainly won't do any harm. Good luck