Arnon is Arnon Krongrad, M.D. and he’s been treating patients with early stage prostate cancer for 25 years. So he knows his stuff!
Dr. Krongrad is a highly experienced surgeon and researcher with interests in prostate cancer surgery and chronic prostatitis treatment. He practices in Aventura, Florida, and specializes in minimally invasive prostate surgery.
Dr. Krongrad will answer questions when he is able to do so, but he cannot guarantee to answer every question that is posted.
Dr. Krongrad is not your doctor and he cannot give you medical advice unless you become his patient. You should always talk to your doctor about your condition and what you should do.
You may post your question for Dr. Krongrad using the comments/reply box below. Questions and answers are retained on this page for approximately 60-90 days from the time they are originally posted.
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Hi there, You have done a fantastic job. I’ll definitely digg it and in my view recommend to my friends. I’m confident they will be benefited from this web site.
I am a 67-year-old, Gleason 9 prostate cancer patient who is otherwise in excellent health. I had a radical prostatectomy in May 2011 but in 7 months my PSA rose from 0.2 to 0.7. In January through March 2012 I had 39 days of radiation therapy and my post-radiation PSA was 1.0. A bone scan and CT scan were negative. My PSA has since risen consistently to 2.1 as of November 2012. Because I stated an aversion to hormone therapy, my radiation oncologist suggested a 1/1/13 PSA test and, if still rising, I would then take Proscar and monitor my results. My urologist, on the other hand, feels strongly that I should go to hormone therapy immediately (Lupron) and that Proscar will be of no real value. I’m confused. Can you help?
*****Answer*****
Dear Richard,
Two questions: (1) When to treat, and (2) How to treat?
Given that you are asymptomatic and have no radiological evidence of anything, it’s a bit of a judgment call as to when to start treatment. Nobody really knows how long you might go with no evidence of anything other than biochemically (PSA). So, in this indefinite window, you could go without treatment and obviously without the possible side effects of treatment. Absolute criteria for initiating treatment would be such things as spread to cervical spine, as evidenced by radiological testing, whose progression could be very serious.
The preferred treatment is leuprolide acetate (or another LHRH agonist), possibly with antiandrogen (Casodex) pretreatment, especially if there is bone spread.
Arnon
Dear Doctor,
I had a robot-assisted radical prostatectomy on November 10, 2011 at age 66 years. My PSA before surgery was 7.19, Gleason score of 7 (3 + 4).
Posterior left mid (0.1 cm) and posterior left base (0.1 cm.) were positive for carcinoma; perineural invasion is present; lymph node invasion is not identified; no malignancy is identified in the lymph nodes; pathologic stage III
My PSA 3 months after my surgery (on December 13, 2011 was 0.1 ng/ml and stayed the same when tested every 3 month through my last PSA result on October 13, 2012.
My urologist referred me to a radiation oncologist after my surgery for adjuvant radiation, but when I met with the radiation oncologist he scheduled me to see him again on November 19.
My question is, since my PSA is stable at 0.1 to the present, do I really need to have radiation therapy now or should I wait until my PSA rises (which I hope and pray it will not do)?
I would appreciate very much if you could respond before my appoitnment on Monday, Nov. 19, 2012.
Thank you.
Linmer
*****Answer*****
Hi Linmer,
There seems to be an inconsistency. Why is this stage III (pT3)? Was there tumor outside the prostate? And what about the surgical margins: positive or negative?
The analysis of risk depends partly upon the stage and partly upon the PSA follow-up. So far, the data provided do not show that you have currently and/or will have later a recurrence. So this has to be taken into account, after the stage is precisely clarified. Then one has to place all this into context of your overall health (obesity, diabetes, smoking, …) to try to determine if, even if it materializes, any recurrence would pose a real relative risk. These are all things your doctor(s) can help you do.
Arnon
Dear Dr. Krongrad,
My oncologist recommended to me the following:
‘Intermittent androgen suppression for rising PSA level after radiotherapy’, New England Journal of Medicine 367 (10), Sept. 6, 2012. The principal finding seems to be non-inferiority of intermittent treatment. Also of interest to me was that PSA level in the non-treatment interval was allowed to rise to 10 ng/ml. Generally, the article seems to me to warrant response as e.g. on this website, and I would be very interested.
Thanks for website and your work here.
Response from Sitemaster:
Dear Grover:
The original presentation of the data published in the article in the New England Journal of Medicine (which occurred at the Gentitourinary Cancer meeting in 2011) has already been extensively discussed on this web site, along with other relevant (and conflicting) data from other studies. Please see the following links:
– IADT: the still unanswered questions and choices that must be made
– IAD vs CAD in men with hormone-sensitive, metastatic prostate cancer
– Interpreting the data from the S9346/INT-0162 trial in hormone-sensitive mCRPC
– IAD vs CAD all over again: are you confused yet?
The relative potential and value of IAD and CAD in the treatment of advanced prostate cancer remains a moving traget.
Dr Krongrad,
My PSA was 17.4 and my biopsy showed a Gleason 9 (with 6 positive cores out of 12 sites, all on one side). An MRI showed some escape from capsule; a bone scan showed no lymph node or seminal vesicle involvement, but numerous bone metastases (iliac and lumbar). I have been on Casodex since 1 August and on Lupron injection since 24 August. My PSA was 0.44, my testosterone was 34, and my DHT 12 on 16 October. These levels seem still too high to me and should be lower. Should I push to get prescribed dutasteride too? Should I be seeking separate treatment for the bone metastases? Any other advice?
I am also still confused by the long-term prognosis. It seems that all I can find is that I could suffer PSA rebound anywhere from 6 months to 20 years, with alternate LHRH treatments good for 3-6 months, followed by the inevitable, with no guidance otherwise.
*****Answer*****
Dear Arcy,
Without knowing the pre-biopsy PSA and testosterone, it’s impossible to put the current levels into perspective. However, it’s possible they’ll continue to drop on the current regimen. Either way, the objective is to improve the clinical situation and, in this light, it’s not clear that adding dutasteride has merit, i.e., I am aware of no data to that effect.
Depending upon their location and severity, bone metastases could represent risk of fracture, such that if they don’t respond to hormone treatment this may require separate treatment, e.g., with radiation. This risk analysis is something your doctors can help you make after reviewing the x-rays and your clinical response and course with currently instituted treatment.
Arnon
Dr. Krongrad,
Thanks much for the reply which listed several items on this website where the research I asked about had been discussed. I don’t know how I missed the September comment, after the time I was reading regularly, but I am glad to be able to read it now.
What really caught my attention (given my own current situation) was that aspect of the Canadian study (Sept. 6, New England Journal of Medicine) concerning when subjects ended their off interval: PSA 10 ng/ml (p. 897). It seemed my oncologist had previously thought 4 ng/ml was high enough. Of course it does also seem that maximizing the off interval might be important to preserve effectiveness of the treatment. But 10 ng/ml? On the strength of this study my oncologist is now letting my off interval extend to 10 ng/ml, which at my rate of doubling will be reached next month. For quality of life this number suits me — but intuitively 10 ng/ml seems maybe a bit too much. My intuition is worthless of course. Would you have any thoughts on this?
Thanks again for the previous reply and thanks again to The New Prostate Cancer InfoLink.
Grover
*****Answer*****
Hi Grover,
I suppose ultimately we all have intuitive senses about what we learn, but it’s the data that count. :-)
And you’re welcome.
Arnon
I am a healthy, 65-year-old black male with a PSA score of 6.2 and a free PSA score of 4.2. My doctor wants to perform a biopsy ASAP because he felt a small mass during my rectal exam. The question is “Is this the only method to detect cancer and should I wait until the PSA levels are higher”?
Dear Ron:
You appear to have at least three significant risk factors for a diagnosis of prostate cancer (your PSA level, your free PSA level, and the possible mass felt by the doctor). I would suggest that you would be wise to follow your physician’s advice and get a prostate biopsy very soon. Your do not want to wait until your PSA is any higher than it already is. No other test can actually be used to prove whether you do or do not have prostate cancer. However. you could ask the urologist who does the biopsy about whether a prostae-specific MRI might also be a good idea to see whether there is any risk that the cancer has already extended outside the prostate.
Once you know the results of your biopsy, you can make decisions about what may (or may not) be necessary as a form of treatment, but the first important thing to do is to get a very clear idea of what you are dealing with.
Dear Dr Krongrad,
Love your site — No BS, succinct, cogent responses to questions we all have, which sits well with me: 71, great health but … Gleason 8 in 4 of 6 positive samples on a biopsy just 10 days ago. Had a CT scan and a bone scan on Tuesday, results benign. Have had “the talk” with hotshot young urologist here in Washington, DC (Jason Engel).
Something I have not seen on your otherwise excellent site is any sort of independent “rating” means — anywhere. Other than Dr Engel’s fairly glowing description of his skills, where do I go for independent opinions (other than support groups, who, incidentally, support his self-evaluation!)?
Another thing I see reading between the lines is that there is a fair amount of commercialism to the whole thing and that there is more than a little competition in the prostate cancer “industry”, with concomittant “advertising” (sometimes in the form of slanging other treatments or treatment centers). This automatically causes a knee-jerk reaction, at least in my mind, as to who/what can you trust?
Thanks for the hard work on the site — wish I has seen it before all this. Best regards, Bob Shipley
*****Answer*****
Hi Bob,
Yes, there is commercialism at play. And no, there is no independent, comprehensive, and valid source of opinions of which I know. Perhaps the best source of opinions about some of the aspects of surgical care comes from OR nurses; it would be hard for most people to get a systematic survey of OR nurses.
Arnon
Dear Dr Krongrad
Re the baking soda and molasses protocol
I’ve read about this alternative treatment to raise the body’s pH level to kill the cancer cells. This treatment calls for blackstrap molasses or maple syrup class B and baking soda. I can’t find these exact items here in the Philippines so I am wondering if this will work with regular maple syrup or regular molasses? What is your opinion on this protocol?
Thanks for your time.
Jim
*****Answer*****
Jim,
This is all news to me. No idea why anyone believes that pH can be adjusted so simply and no idea what the basis might be that pH modification matters in this context. Also no knowledge of any data to support that dietary modification of any kind, including with baking soda and molasses, can kill cancer cells but not healthy cells.
Arnon
Doctor,
I am 59, had a 12-core TRUS biopsy 18 months ago with negative results but one core positive for HG-PIN. My latest PSA level over 3 years is 3.9 ng/ml, with a free PSA of 17%, and a PCA3 of 60; no nodules or growths have been detected on DRE.
My current urologist wants to do another 12-core Doppler TRUS biopsy based on the above blood test data. I have read and heard from other urologists that the MRI spectral guided biopsy is more efficient, with fewer cores needed, but also that the Doppler TRUS process sees more of the organ. I am leaning toward the MRI-guided biopsy regardless of insurance as I want better care than the current, so-called standard of care (the TRUS biopsy). Am I making the prudent choice?
Thanks.
*****ANSWER*****
GM,
Biopsy is very operator dependent, so the answer lies in this question: Who is doing the biopsy? And how much experience does he have in the two techniques? Focus on these questions and ask them to see if you can get a level of confidence about a choice.
Arnon
August 2010, PSA on PE 5.4, asymptomatic. October 2012, PSA on PE 7.5, asymptomatic. Family Hx, my mom had breast cancer.
Prostate biopsy on 11/12/12, 5 of 6 cores adenocarcinoma, Gleason score 3 + 3 = 6 in all five cores. Prostate size 37 cc. DRE negative. On all of the risk analysis assessments I seem to be between low and intermediate risk. First urologist referred me for a chest x-ray, a bone scan, and an abdominal CT scan. Second urologist recommended surgery. It seems my cancer has possibly spread outside the prostate due to the number of cores with cancer. However, the cells are moderately slow growing. I am 63 years old, work full time, and am going to massage therapy school.
I am scheduled for robotic prostatectomy on 12/12/12. However, with all of the previous entries about post-prostatectomy complications and having to end up doing radiation and/or hormone therapy, maybe surgery is not the best first choice. I am wondering if you could offer feedback on how to decide between surgery and radiation as treatment.
Thank you so much,
Chris
*****Answer*****
Dear Chris,
There is no scientific basis upon which to build an rational answer to your most rational question. For what it’s worth, the sequence of surgery followed by salvage radiation (if needed) presents less surgical risk than radiation followed by salvage surgery (if needed). Other than that, the decision is about personal assessments of the risks and inconveniences of each option.
Arnon
Doc,
Thank you.
GM
I have neuropathy in my feet. It started about a week after I had a radical prostatectomy (not a RALP). My VA doctor is telling me the surgery could not have caused this neuropathy. Could I please have your opinion on this?
*****Answer*****
Hi Harrel,
While foot pain (if this is what you mean by “neuropathy”) can be seen with prostatitis, it’s hard to link it to RP. A neurologist may be able to shed some light.
Arnon
Is it normal to see HG-PIN in the biopsy along with adenocarcinoma? I have a recent prostate cancer diagnosis, still being staged, etc. … Due to my history of sarcoidosis, I’m researching any possible complications this might pose with respect to diagnosis and treatment. As I’m sure you know, there are several cases of sarcoidosis mimicking various cancers.
So, when I read that HG-PIN is considered to possibly be precancerous, I wondered if it is usual for the biopsy to show a high Gleason score of 8, but zero HG-PIN.
Is this usual? Unusual? Or of no significance?
Thanks for any insights you care to share.
*****Answer*****
Hi Grant,
Probably of no meaning to see or not see PIN coincident with Gleason 8 prostate cancer. What would seem to matter is the cancer. If there is any question at all, the concurrent sarcoidosis should be reported to the diagnosing pathologist with the question: does this influence your assessment?
Arnon
I’m 75. I have had a testosterone deficiency many years and until recently received monthly shots of 350-450 mg? My serum T level has been monitored during therapy, with me generally feeling tired when I tried off the shots, so I would like to go back on.
I just have had PSA of 24 and a diagnosis of prostate cancer with biopsy Gleason scores of 6 and 7, all on one side of prostate. Treatment options are being evaluated. My testosterone therapy was stopped after October and thru fatigue I think my body is telling me I’m missing the testosterone. My doctors oppose my taking testosterone, and have offered no alternative to improve how I feel missing it.
I have a copy of Dr. Abraham Morganthaler’s paper “Testosterone replacement … therapy and prostate risks: where”s the beef?” (not dated), which advocates that there is no problem taking testosterone with prostate cancer. Do you agree? What is the latest and most compelling research available on the subject? Do you know of anything else with the same theme I could show my doctors?
Many, many thanks.
Bill Allman
*****ANSWER*****
Dear Bill,
The relationship between serum testosterone and the clinical behavior of prostate cancer is demonstrably strong in some ways. For example, testosterone depletion (Lupron; orchiectomy) can result in immediate and dramatic reversal of neurological symptoms due to spinal cord involvement of metastatic prostate cancer. What you are asking is the converse of this example: what happens if you add, not subtract, testosterone? Here the data are not so easily available, such that the hesitation you’re describing originates more in inference than from data. There are no data of which I am aware that would permit one to make a quantitative projection of any potential ill effect of adding exogenous testosterone in a setting such as the one you describe. How fast, how much, how badly would testosterone supplements affect the clinical behavior of the prostate cancer?
One approach you can discuss with your doctor(s) is if removing the prostate cancer (and seeing the pathology report and ensuing PSAs) would mitigate some of their theoretically rational caution.
Arnon
Dear Dr. Krongrad,
I was diagnosed with prostate cancer on May 25, 2012. My urologist suspect some abnormalities in my prostate during the digital exam. A 12-core biopsy came out with two positive readings at the prostate base, both with a Gleason score 6, and 5% tumor tissue (1 mm) in each positive core.
A second, 18-core biopsy was carried out at UCSF Cancer Center in the last week of November. The digital exam at that time reveal no abnormalities but slightly increased prostate size. Both biopsies found cancer in the same zone with Gleason score 6. However, the second biopsy shows 13% and 10% of tissue involved by tumor (4 mm) verses 5% of cancer tissue that was found in both cores in the first biopsy. Three cores were positive on the second biopsy.
May PSA scores have remained stable over 2012 but have increased from a 2011 reading as follows: 02/2011, 1.0 ng/ml; 02/2012, 1.55 ng/ml; 06/2012, 1.6 ng/ml; 09/06/2012, 1.56 ng/ml.
I’m a 64-year-old family man. They say that the next biopsy will be done only in 2 years time.
Should I rush into the surgery since the volume of tumor practically doubled over last 7-months?
Conflicting inferences are apparent in research publications in this area. Most of them suggest that beginning prostate cancer with a Gleason score 6 should not be treated aggressively since patients with such characteristics will probably pass away from a different cause. At the same time, there is a recent study suggesting that robot-assisted surgery can increase survival rates for prostate cancer patients by 35%. While these studies do not contradict each other, I’m under the impression that at least some of them can be flawed by data mining or curve fitting problems. However, there no other studies to my knowledge that are trying to mitigate these obstacles.
The stats for post-surgery side effects are also misleading. They correlate highly with surgeon experience. Some of the best surgeons claim that complete urinary continence at 12-month period is attained in 85% of their patients, and that normal erectile function without medication is attained in 70% of the their patients in a 12- to 24-month period. However, a general study published in 2011 provides drastically lower averages for these data.
There are papers which show that PSA velocity is not a very useful assessment tool as well.
The most important issue for me is how to estimate the risk of waiting while testing the PSA every 3-months during next 2 years?
Thank you so much in advance,
*****ANSWER*****
Hi Eric,
You have correctly identified a few of the uncertainties and ambiguities in the management of early stage prostate cancer. In this light, you may want to go back to your doctor(s) and ask them to put all this into the context of your overall health. If, for example, you are in poor health (diabetic, obese, heart disease), then perhaps all this is moot. Conversely, if you are in excellent health, all this may also be moot, but because you should obviously have treatment. And in the middle … back to the uncertainties as described. In other words, don’t skip this critical assessment in the context of overall health.
Arnon
My PSA has gone from 6.1 to 7 in 3 months. It has been over 4 ng/ml for the last 2 years but I have not got a biopsy and now want to. The problem is I am scheduled for a hip replacement on 12/21/12. I know biopsy can cause serious infection and with a metal hip it goes right to the joint replaced and can cause a real problem. I left a a message for my surgeon about how long I should wait after surgery to get the biopsy but will not have an answer until Monday 12/17. In your opinion, should I cancel the surgery until I get the biopsy or chance infection after the surgery?
What percent of biopsies get infected, and is there anything out of the ordinary my doctor can do to prevent infection other than the antibotic
given?
The reason I never got a biopsy earlier was I just read too much on the internet about the cons of getting one. With this jump in my PSA over 3 months, I am ready, but would like to get the hip done first. I am going to get a PCA3 test on Monday, but that result will not be back right away. What do you think of the PCA3 test? It looks like a lot of doctors are doing it now; mine just started doing it. I am almost 68 years old and I do have BPH and have had it for years. My free PSA is 23.91%
Please, looking for all the help, ideas you feel you can give me.
*****ANSWER*****
Art,
The issue is too nuanced to be handled online this way. Too many details are missing, so please review all this with your doctors. Keep in mind that the issue is not the biopsy getting infected so much as a hip prosthesis becoming infected. Your orthopedic surgeon may have something to say about all this.
Arnon
I am age 70, in excellent health with a family history of life expectancy in the high 90s.
A first biopsy was Gleason 6 but I got a second opinion from John Hopkins that downgraded it to PIN.
My PSA started 5 years ago at 0.25 and worked its way up to 2.5 ng/ml 2 years ago. Six months ago it was 3.5. That triggered the first biopsy. Now, in the past 3 months, my PSA is at 4.2 ng/ml, and a second biopsy is being recommended. The question is, do I schedule it or wait for more PSA information. Also, other markers like multiparametric MRI or PCA3 have not been discussed.
*****ANSWER*****
Hi Dennis,
Excellent health, rising PSA, mixed opinions on the first biopsy … what might be the argument to sweep a potentially serious situation under the rug? Why not biopsy?
Arnon
Dr. Arnon,
I am a 51-year-old who has been on testosterone therapy for 8 years. Over the last 8 months my PSA has increased from 3.1 to 4.9 ng/ml. My prostate is of normal size with no other symptoms. Would this call for a biopsy?
*****ANSWER*****
Hi Greg,
Is there risk of a positive biopsy? Yes. The decision whether to pursue a biopsy or not would depend upon many other factors, including physical exam, family history, overall health … all of which can be assessed with your doctor(s).
Arnon
Dr. Arnon:
I’m a 64-year-old with a family history of prostate cancer. Several years back, after a steadily rising PSA (it eventually got to 17 ng/ml) and several biopsies, a small amount (1/2 a core) of Gleason 3 + 3 cancer was discovered in one core of a 24-core biopsy. To complicate matters, an iliac aneurism was discovered on the ensuing CT scan (bone scan was negative for metastasis but fortunately for me it was misread and I was sent for the CT scan). My urologist initiated Lupron therapy to retard the cancer and the aneurism was successfully repaired with a stent a year and a half ago, and it has remained stable. Lupron eventually dropped my PSA to 0.1 ng/ml and I remained cancer free, but it was discontinued in December of 2011 because I was at the 2-year efficacy limit.
Beginning in June of 2012, my PSA started to rise again, and rather quickly got up to 8 ng/ml (1 month ago). I will see my urologist soon and I have a strong hunch I’m looking at another biopsy and more definitive treatment. I’m in reasonably good health but I’m a cigarette smoker and I suspect surgery will be ruled out. (It would, however, be my first choice based on everything I now know about the disease.) That will leave me with EBRT or, perhaps, cryosurgery. Both concern me a bit because of the aneurysm’s proximity to my prostate — about 4 cm. Also, one branch of the artery is “coiled.”
The thought of going back on Lupron is distasteful because I was extremely lethargic when it finally began to work efficiently (this took about a year), and I’m under the impression that I’ve already hit the average limit of treatment, 2 years. I’ve thought about trying to locate a urologist who would perform a retroperineal prostatectomy with regional anesthesia only, but don’t know quite where to begin looking.
Can you offer any advice, or correct any misconceptions? Thank you!
Rob
*****ANSWER*****
Hi Rob,
It’s understandable that you want to understand and control events to come. At the same time, you may be getting ahead of yourself. Depending upon many factors, including specific anatomic factors and your overall health, it may well be that you would be a candidate for prostatectomy, i.e. it may be that neither the smoking nor the aneurysm is a barrier. You may want to consider taking one step at a time and letting the doctor(s) who know your specific case best guide you through this.
Thank you.
Arnon
Dr. Krongrad,
There is a urologist’s opinion that in a year or two a cancer with Gleason 6 will develop to Gleason 7. Dr. Walsh’s book A Guide to Surviving Prostate Cancer, 2nd ed., p. 206, states that 25%-50% of monitored men with prostate cancer will develop progression of the disease in 3 or 5 years. What is your opinion on this matter? If this is, indeed, the case, how does this go along with the multiple population studies that suggest that most men have not died from prostate cancer during the 15 or 25 years after they were diagnosed?
How often you would suggest to repeat the biopsy for a patient with a Gleason score of 6 and 10%-15% tumor in three out of 18 cores?
Thank you very much.
*****ANSWER*****
Hi Eric,
One has to be careful not to conflate terms and concepts. Upgrading from 6 to 7 may be considered but one form of “progression,” which can imply upgrading, upstaging, rising PSA. Not sure we’re comparing “apples” and “apples.” And yes, most men do not die of prostate cancer. Of course, most men are treated, too, but not sure how any of this relates to the question about progression as asked here.
The frequency of biopsy really is driven by many factors, including overall health and the like. It’s best decided in consultation with the treating doctor(s).
Arnon
Dr. Arnon,
Has any researcher been able to demonstrate a relationship between cortisol production and testosterone level in high stress occupations? I was a professional firefighter and, like many of my chums, became an adrenalin “junkie.” Though I’ve been retired nearly 15 years, I frequently seem to have adrenalin highs without any particular cause. Is it possible that my body became conditioned to produce extra stress hormones and has remained more or less in “high gear” ever since, and perhaps now producing excess testosterone to compensate?
Thank you, Rob
*****ANSWER*****
Hi Rob,
Are you describing a cause and effect? Coincidence? Things that go together in response to a third, unidentified factor with which you were born or which you acquired prior to choosing your profession and that is still at play? This is one long and complicated Gordian knot of chickens and eggs that is way above my pay grade to untie.
Merry (calming) Christmas.
Arnon
Dr. Arnon,
I am a 61-year-old with prostate cancer — Gleason score 6, PSA of 8.9 ng/ml. I went to Memorial Sloan-Kettering for a second opinion. They would like me to have an MRI with coil. My regular urology doctor said its unnecessary. What is your opinion?
I am leaning towards surgery and otherwise in good health.
Thanks
*****ANSWER*****
Hi Rich,
Your surgeon should be guiding (and explaining) any would-be staging actions. Likewise, anybody who is recommending a staging action should be prepared to explain how — in your case specifically — the action makes any difference, the point being that differences in action are driven by many variables ranging from the subtleties of the physical exam, the clues in the biopsy, your risk tolerance and desire for nerve preservation, the surgeon’s technical capabilities and assessment of your specific prostate and abdominal anatomy, and the like.
Arnon
I am a 65-year-old Caucasian living in Oklahoma. My Veterans Administration urologist wants to perform a biopsy due to having a 3-year long UTI (Enterococcus faecalis). I believe this infection was caused by a previous biopsy. I have taken many antibiotics to combat this UTI with little improvement.
I had a CT scan (with contrast) which revealed many kidney stones and cysts in both my liver and my kidneys. No prostate exceptions were noted on the report. My most recent PSA was 2.35 (steady for 2+ years) and no DRE was performed.
I also have chronic systemic sarcoidosis and have about 54% lung function, based on the most recent PFT. I had a pneumothorax about 2 years ago. The sarcoidosis is getting progressively worse and my quality of life is quite low. I am unable to do most anything requiring exertion or straining,.
My question is “Is this trip really necessary?”
I would probably refuse treatment if cancer was found. Why be sicker (from treatment) than I am now?
Did I just answer my own question?
*****ANSWER*****
Hi Jim,
To decide to take a step, one must define how its conclusions will affect management. If it will have no effect, then why take the action? This is something your doctor can help to better outline.
It would appear that you have implied your own answer.
Arnon
Dear Doctor,
I have written before and I really appreciate your answers. In short, I had an RP exactly 1 year ago (Gleason score, 3 + 4; one positive surgical margin and no evidence of spread; pre-surgical PSA, 5.8). My post-surgery PSA levels, taken every 3 months, have all been zero, and with the exception of heavy blood in my urine 6 months ago (all tests, cystoscopy and scans, were negative).
My question is how often my PSA must be measured passed this point if it stays negative? My urologist suggests every 6 months up to 5 years and my primary care physician insists on every 3 months for another year and every 4 months thereafter.
Best, Abbas
*****ANSWER*****
Hi Abbas,
Recurrence can happen many years after initial treatment. Given that PSA is such an easy test (it can be combined with periodic cholesterol checks), there is a reason to check it essentially forever.
Arnon
*****COMMENT FROM SITEMASTER*****
Abbas:
At the end of the day this is your decision. If the specialist who treated you thinks once every 6 months is enough for the next 5 years, you may want to ask your primary care doctor why he believes more frequent PSAs would be required. However, Dr. Arnon is correct when he says that even after 5 years you are probably going to want a PSA test once a year for life … even if it is still effectively zero after 10 years.
I have decided not to have a biopsy due to other health issues.
How many patients decide not to treat prostate cancer? The friends that I have watched go through the treatments have told me they would not do it again. Is this a “common” response?
jbs
*****ANSWER*****
Hi Jim,
I do not know the number.
Arnon
*****COMMENT FROM SITEMASTER*****
Jim:
While there are no data that I know of regarding the numbers of patients who decide not to have a biopsy when thought to be at risk for prostate cancer, or those who decide not to have treatment after a biopsy and a diagnosis, we do know that this is by no means unusual. The reasonableness of your decision obviously depends on things like your age, the severity of the “other health issues” that you mention, whether you have any symptoms suggestive of prostate cancer, etc.
I had biopsy and my Gleason score was 7 (3 + 4). … I also had a CT scan and the cancer appears to be confined to the prostate. Now decisions need to be made … treatment vs active surveillance …. surgery vs radiation … robotic vs open. … How is a person supposed to decide? Any advice would be appreciated. …
*****COMMENT FROM SITEMASTER*****
Ron:
If you join our social network, it is set up to offer you exactly that sort of assistance in making these decisions.
Hi,
I was diagnosed with prostate cancer back in 2006. My PSA was 7.3, Gleason score 3 + 3, and stage T2b/c. I had seed implants followed with radiation.
In October 2012, my PSA was 3.4 and November 2012 it was 4.3. I had a CT scan, a bone scan, and two biopsies: everything came up clear. I also had an MRI that showed “no definite evidence of metastatic disease.” I just hav a rising PSA.
My doctor wants to put me on hormone therapy. … What do you think?
According to a doctor that I went for a second option the MRI shows that my pelvic lymph nodes are kind of bigger then normal (even though the other doctors didn’t say anything and, as I stated above that radiologist wrote that there was no evidence of metastatic disease. Do you think I should of have a lymph node biopsy? Can the lymph nodes be removed or can I have radiation to the lympho nodes? Based on my history (PSA, Gleason score, disease stage) how long do you think the hormone would work work before I would need to start chemotherapy? Is there anything new in between hormone therapy and chemotherapy?
Thank you
*****ANSWER*****
Hi Jim,
There is no absolute right cut-point for initiating androgen deprivation in the absence of a clear and imminent problem from a metastasis, e.g., if the spine was involved. So given all the uncertainties you identified — Is it really a metastasis? Are the nodes even really involved? — the indication to initiate androgen deprivation is soft and associated with the risks of all kinds of side effects: hot flashes, weakness, bone loss …
All this has to be put into the context of your overall health, too, which your doctor(s) can help you do. If you have osteoporosis and/or diabetes, for example, what would hormones do to your risk profiles? etc.
Arnon
Thank you for your reply but can you answer these questions:
– Does only a rising PSA (e.g., June 2012, 2.5; October 2012, 3.4; last PSA, 4.3) mean metastasis?
– Do you think I should have/have had a lymph node biopsy?
– Can the lymph nodes be removed or can I have radiation to the lymph nodes?
– Based on my history (I was diagnosed with prostate cancer back in 2006; my PSA was 7.3, Gleason score 3 + 3, and stage T2b/c; treated with seed implants followed with radiation), how long do you think hormone therapy would work before I would need to start chemotherapy?
– Is there anything new in between hormone therapy and chemotherapy?
– How are the survival years after chemotherapy which is the last treatment?
Thank you
*****COMMENT FROM SITEMASTER*****
Dear Jimmy:
You are asking a series of very complex questions, and we don’t have all of the relevant information that would allow us to help you think about how to proceed. It would be a great deal easier for all concerned if you were to join our social network, which is specifically set up to assist patients think through their options over time.
Hi:
I have a conundrum.
I am 55. Normal DRE, except prostate minimally enlarged
PSA levels:
– 12/2008: 2.1
– 11/2009: 2.8
– 05/2011: 3.4
– 06/2011: 2.5
– 09/2011: 3.2 (and PCA3 20)
– 03/2012: 3.8
– 06/2012: PCA3 10
In 06/2012 I had a PCA3 of 10 and a 12-core, TRUS-guided biopsy (all cores negative for cancer; one core positive for HG-PIN).
On 01/10/2013 my PSA was 17.
What the heck?
No prostatitis symptoms. Do have decreased ejaculate volume and is watery since biopsy.
Next step? Repeat PSA (and if so, when)? Another TRUS-guided biopsy? Saturation biopsy? MRI?
*****ANSWER*****
Dear Starr,
The indication for another biopsy of any kind depends upon the context, especially overall health, competing illness, and the like. So if you’re otherwise sick, it may not make as much sense to re-biopsy as if you’re very healthy. This judgment can be made in consultation with a doctor who can put it into this broad context.
Arnon
Dear Dr. Arnon,
I have a rare situation. In 1999 I had colostomy for colon cancer. Three years later I had a sarcoma removed from my upper left hip. One year later I had sarcoma removed from right lung; one year after that I needed another sarcoma removed from the same lung; and 6 months later again I needed a sarcoma removed from the C4 vertabra in my neck.
I was cancer-free until last September, when prostate cancer detected. I had a needle biopsy and a CT scan. Twelve cores were removed on biopsy and cancer was found in two cores: 10% and 15% with Gleason scores of 6. My PSA was 14 before biopsy. I have had 50 radiations in that area from previous cancers, so I can’t have anymore. Tissues in the area are like leather.
We are waiting till March to see if it has progressed much. My current doctors say it will require a very specialized surgeon to remove my prostate as I don’t have a rectum. I may try the shots if my PSA goes up. Could you tell me your thoughts on this? Have you ever removed the prostate from someone without a rectum?
Thanks,
Terry
*****ANSWER*****
Hi Terry,
I have not done a prostatectomy for someone without a rectum, but have done it after pelvic radiation, cryotherapy, abscess, colostomy, aorta replacement, pancreas resection … a laundry list of other such things. Depending upon the specifics, it may be possible to do the prostatectomy, albeit at higher risk of injury and incontinence than in a “virgin” case.
The decision to do or not do a prostatectomy and/or treat with other modalities is what’s at issue now. This decision must be taken in context of many other variables, most critically overall health: smoking, obesity, illnesses (diabetes), and the like.
Arnon
Hi Arnon.
My dad, age 72, has just been diagnosed with prostate adenocarcinoma following a needle biopsy. We have his after-biopsy consultation with his urologist in a few days and I was hoping if I gave you the info we know you could possibly supply us with some questions that need to be addressed during that time. What we do know: his PSA before the biopsy was 4.8 (up from 1.2 from his physical a year ago). His combined Gleason scores on two cores were 6 and on two other cores were 8. There is PNI detected. The tumor has been given a clinical stage of T2. On initial examination, we were told that there was hardening of the prostate palable and a dark spot did show on the ultrasound. That is all we know for now. Thank you for your time.
Jodi
*****ANSWER*****
Hi Jodi,
It seems as though you understand the concepts of grade and stage, and this is a good start. Now put this into the context of overall health: obesity, smoking, illnesses (diabetes, hypertension), and the like. Ask a sequence of questions: (1) In this context, should the cancer be treated? (2) If yes, by which method? (3) What is the relative merit of this method? (4) What is the relative risk of this method? (5) Who should carry out the treatment if any? (6) Can we speak with other patients who have had this treatment with this doctor?
Arnon
Dear Dr. Arnon,
I am 62 years old. My PSA values ranged from 9 to 12 ng/ml between 2006 and 2011. I was diagnosed with prostate cancer with Gleason scores of 5 and 6 in both lobes, clinical stage T1c-T2a, and a prostate volume of approx. 61 mm, after a third biopsy in Taiwan.
I was treated with a combination of HDR brachytherapy between July 25 and August 8, 2011, followed by 6 weeks of tomotherapy. However, my PSA values are still around 3 to 6 ng/ml, and have most recently risen to 7 ng/ml. HMy bone scan is negative and there is no evidence of cancer on MRI. Supposedly, any prostate cancer cells are still within the prostate.
My doctor told me recently that I need to take Androcur (three tablets daily for 2 months) to decrease the PSA values. My questions are:
(1) Why are my PSA values not going down to 1, or even lower?
(2) Should I take the Androcour? My PSA value will not represent a “true” value after I take such tablet.
(3) Is it possible that I am too busy and hardworking, as well as too tired from working, that my PSA value is not decreasing?
(4) Is it still possible to let my prostate be operated on, and taken out?
(5) Would surgery still be reasonable and more effective, compared to taking hormones, like Androcur, or even more effective than hormones?
Thank you very much!
*****ANSWER*****
Hi Victor,
(1) Unless there is a hidden metastatic site, it appears that the cancer is radiation resistant. A biopsy of the prostate might be revealing.
(2) Androcur is not curative. If you are otherwise in good health and there is a chance to still cure (e.g., salvage prostatectomy), then Androcur could for now be a distraction.
(3) It’s not been shown that fatigue elevates PSA.
(4) Yes. This is called a salvage prostatectomy.
(5) Depends upon lots of factors: is there cancer in the prostate (requires a biopsy), how healthy are you otherwise, can you tolerate the risks, etc.?
Arnon
I was recently diagnosed with T1c, 3 + 3 = 6; my PSA has gone from 2.6 to 4.6 in the last 2 years. They found only one sample with 35% malignancy. I’m a very healthy, fit, 65-year-old with both parents alive in their mid-90s. I’ve read Dr. Walsh’s book, and while I’m in the low-risk group, I feel inclined to have the radical prostatectomy.
1. Do you agree?
2. Am I a candidate for robot-assisted laparoscopic surgery? I don’t know the size of my prostate. The book says 100 mg is the maximum.
3. How do I find out how big mine is?
4. I also read something about PSA density. How do I find this out?
5. And most importantly, how do I select the best surgeon in my area?
Phoenix area, or Seattle area? It seems that each rating organization picks different doctors as “top.” My promary care physician said a fellow doctor used a Dr. Ferrigni at the Mayo Clinic in Scottsdale, Arizona, with good results. Should that be good enough for me?
Thanks for any guidance.
*****ANSWER*****
Dear Lewis,
(1) I’d need more information.
(2) I’d need more information. 100 grams is not the maximum. I’ve taken out 200 gram prostates.
(3) Ask for the volume measurement from the ultrasound.
(4) Ask your urologist.
(5) Best surgeon in your area? Don’t focus on the area. Focus on the surgeon.
Arnon
I received my prostate biopsy report yesterday and it showed cancer in 3 of 12 cores: a 3 + 3 (<10%), a 3 + 4 (10%), and a 4 + 4 (<10%). My urologist said that my Gleason score was 8 and used that number along with my clinical stage and PSA to make predictions from the Partin tables.
When I read the report more fully at home, I noted that after listing the result for each core, it provided the following summary: “Histologic grade, Primary pattern 3, Secondary pattern 4, and Total Gleason Score 7.” Which Gleason score would give the better indication of various risks according to the Partin tables, the score of the worst core or the total score?
*****ANSWER*****
Hi Ray,
Please understand that the Partin nomograms are probability tables, meaning that they carry an inherent imprecision, i.e. they are not a “crystal ball.” In this light, then, it’s not clear that trying to figure out which is the “better” indication is useful, in that any choice carries the same inherent imprecision. In any event, I am not aware of any study that specifically looks at the question you pose, to see which of the options you seem to have in mind might give more precise estimates of probability.
Arnon
Dear Doctor:
My husband is 59; PSA 26; Gleason 4 + 5 = 9; MRI negative; bone scan negative; lymph nodes removed but due to seminal vessel for 39 fractions of radiotherapy. My husband looks 49 and is very fit. He was diagnosed on August 23, 2012 and has just finished radiotherapy; he is also on Casodex.
Doctor, I can’t seem to understand as they say they are aiming to cure him, but what does having a Gleason 9 actually mean for the future? I can’t seem to get a straight answer. I know that it’s aggressive but can it be cured or how does this work or can it just be kept at bay?
Kind regards,
MN
*****ANSWER*****
Hi Moira,
To some extent, there is no real difference between “cure” and “kept at bay,” in that if the cancer can be kept from any more biological progression for long enough then this is as good as a cure. In other words, if the cancer can be kept clinically dormant for 50 years, even if by some definition it’s not cured, is this not adequate?
In an otherwise healthy 59-year-old, a Gleason 9 certainly should be treated. Yes, there is a chance of recurrence, but there is also a chance that there will be no recurrence. Maybe this is what they are trying to say to you. Don’t be afraid to return for clarifications.
Arnon
Hi, dear Dr. Arnon!
I am very appreciative of your replies to my prior question.
To my last question (5), I have some follow-up questions:
(5.1) Must I be biopsied, to see whether my cancer cells are still kept within my prostate?
(5.2) I am feeling, I am still in very good health. What kinds of risks are there? Is it possible that cancer cells may be flowed or spread outside of the prostate during the salvage prostatectomy?
(5.3) Is it possible that the radiated prostate has been strongly stuck to other internal tissues or to the bladder? Whatever makes salvage prostatectomy riskful?
(5.4) Would the operation take rather long, so my health might not be supported?
Thank you very much!
Victor
*****ANSWER*****
Victor,
You really should review all this with the urologist who’s examined your prostate. But in principle, yes, it would make sense to know there is a disease before it is treated. And yes, a salvage prostatectomy carries risk.
Arnon
Recently had unprotected sex with a female. This was 3 days ago. Since then I have been having a buzzing sensation that starts and stops in the area of my prostate. What could be causing this problem?
*****ANSWER*****
Hi Don,
“Buzzing” is not a term one hears too often in this context, although certain patients have complained of a sensation of “ants in the urethra” associated with a condition known as prostatitis. Perhaps this is what you mean?
Arnon
Dr. Krongrad:
I had my prostate removed 4 years ago (PSA = 5.0) when I was 57, with a biopsy-based Gleason score of 3 + 3 = 6, and clinical stage T1c at diagnosis. After surgery (RALP, nerve sparing) the histology was Gleason 3 + 4 = 7, pT2 (no lymph node or seminal vesicle invasion). My PSA rose steadily from a 0.00 (1 month after surgery) to 0.01 (1 year), 0.02 (2 years), 0.03 (3 years), 0.05 (4 years, now). My dilemma is, should I undergo immediate salvage radiation therapy (as suggested my radiotherapist) or not (according to my urologist)? I would be very happy to have your qualified opinion.
Thanks
John
*****ANSWER*****
John,
There are many instances of a pattern just like this that stabilizes for many years, without any additional treatment. Assuming negative margins, your report is prognostically favorable and the question is asked: what is the rush? And: are there data to show that early treatment improves survival? And all this must be put into the context of your overall health.
Arnon
Hi John.
I had my prostate removed back in 2003, no radiation after surgery as it was confined to one side of the gland internally. My PSA was just as yours, 0.00 then a slow creep upward.
It is now almost 10 years since my surgery; my PSA is at 1.6. Last year I had a bone scan and an MRI as well as an x-ray done at the request of the urologist as a baseline and to see if anything was detected. There was nothing.
It is nearly impossible for every single tiny prostate cell to be removed, therefore any prostate cells remaining can leak PSA through the cell walls (as they age/weaken) into the bloodstream and hence you have a reading of PSA. As Dr Arnon stated, “What is the rush”? Mine has been rising at the rate of about 0.2 ng/ml/year. At that rate, I will be 120 before I have something to worry about.
I am 67 years old. In December 2011, my PSA level was 3.5. In December 2012, it was 6.5. I went to a urologist 2 weeks later and my PSA was 5.3. Should I have a biopsy performed?
*****ANSWER*****
Hi Joe,
Overall, PSAs in this range are associated with a risk of positive biopsy of approximately 25%. The decision about a biopsy in this context depends upon many factors, e.g., overall health, which you can discuss with your doctor(s).
Arnon
Can you recommend a doctor(s) in the San Francisco, California, area who will perform the PCA3 procedure and requisition lab urine analysis even if you have not had a biopsy?
*****ANSWER*****
Dear Fred:
The “New” Prostate Cancer InfoLink does not make recommendations to specific physicians. As Arthur has already advised you, almost any good, independent urologist in the San Francisco area can probably arrange for you to have a PCA3 test (even though you have not had a biopsy) if you really want one. The question is going to be whether your insurance will cover the cost or whether you are willing to pay for this out of pocket.
The value of having a PCA3 test in your situation, however, is not well characterized, and the PCA3 test was approved exclusively on the basis of data from men who had a rising PSA despite having a negative biopsy result.
The Sitemaster
Dear Doctor:
I am a 57-year-old male. I had a da Vinci prostectomy about 5.5 years ago. My Gleason score was 3 + 2 = 5; my PSA was 7.5.
I have had consistent readings of 0.000 or 0.001 since then on my PSAs. However, I am running low on the testosterone scale (from 253 to 325) and suffer from some fatigue. It has been suggested that I try some testosterone therapy to up my levels a bit. I am willing, but concerned that I might inflame any cancer that could be left, although my scores have been good for the last 5 years. Your thoughts on the risks involved?
*****ANSWER*****
Jeff,
Fatigue is a very non-specific symptom and may or may not have anything to do with testosterone levels, especially when those levels are on the low side but usually adequate. This is really a discussion about fatigue, it would seem, which means a broad exploration of possible contributors is in order. Among the contributors to discuss with your doctor(s) are sleep habits, obesity, exercise and aerobic condition, other illnesses (e.g., anemia), mood (e.g., depression), and on and on.
Arnon
Sir,
What are the symptoms of prostate enlargement, and also the foods that can’t be eaten by persons who have problems like this?
*****ANSWER*****
Adam,
Prostate enlargement is often asymptomatic and can actually cause kidney shutdown even in this asymptomatic state. Other times, it manifests in all sorts of mayhem, ranging from frequency to urgency to sensation of incomplete void, to slow stream and on and on. These symptoms can be exacerbated by foods that promote diuresis, such as beer.
Arnon
Dear Dr. Arnon,
My boyfriend is on finasteride and is also taking NOW Prostate Support. This has been going on for 6 months. When should he be able to stop these pills? His PSA was 6 and now 3. His last blood work was great and his next annual check up will be in August. I have heard positive and negative things about finasteride but nothing about NOW Prostate Support.
Sincerely,
Sandi and partner, Dennis
*****ANSWER*****
Hi Sandi,
The indications to start and stop any treatment, including finasteride, depend upon the clinical scenario and overall circumstances, including diagnosis (cancer, enlargement, prostatitis), stage, grade, other treatment(s), other illnesses, side effects, and on and on. The answer to your question is thus directly dependent upon an assessment of all these, which his doctor(s) can help to formulate.
Arnon
Dear Amon,
Hi. My husband is 51 and has an elevated PSA of 9.3. We waited several weeks and retested and still 9.3. (His free PSA is 7 which I know is not good). We saw a urologist yesterday and he didn’t give us much reason to believe there was a good chance something other than cancer was causing the elevated PSA levels. The digital exam had nothing abnormal; his prostate is not enlarged; he is not a cyclis; he doesn’t have any symptoms of infection (i.e., no urination and ejaculation problems). We don’t know if that was just the doctors “clinical” personality or what but he wasn’t encouraging … super-nice and competent but not encouraging.
My husband’s general practitioner (who doesn’t seem all that competent to me) said he sees this all the time and it turns put to be nothing. Am I correct in assuming that since he’s not having urinary symptoms he does not have an infection (which is what we were hoping it would be)? And am I also correct that if it is cancer it’s still in the early stages, since he doesn’t have urinary symptoms? Could it be a fluke of some kind on the PSA test? Do PSA levels ever go up for unknown reasons and then go down again? His biopsy is next week and results a week after that and we just need some hope to get through these next two weeks.
Thanks for any help.
Andrea
*****ANSWER*****
Hi Andrea,
I understand your desire for hope and certainly there are grounds for hope in this case. Yes, this may be not cancer as the internist is implying. And yes, if it is cancer it may be in an early stage and thus more treatable. You probably appreciate that without more detail I cannot give you more quantitative assessments and advice about would-be treatments, if at all necessary. But it seems clear that the hope you want is based on solid overall grounds. Take a deep breath. Exhale. It’s clear you care about your husband and that, come what may, you two will get through it.
Arnon
Dr Arnon:
I am a 62-year-old male, diagnosed digitally 1 year ago when my PSA was 4.1, followed with a biopsy, a CT scan, and a bone scan. These showed Gleason scores of 3 + 3 = 5 in five lobes (one lobe with 80% cancer); the CT and bone scans were negative/normal.
I have opted to change my diet to lots of greens and reduced sugars and carbohydrates. I exercise 3 to 4 days a week. I’m 5’10″ tall and weigh 174 lbs.
Since being diagnosed I have had two additional PSA tests. The first was 3 months after diagnosis at 4.2 ng/ml; the next one was 4 months later at 3.7 ng/ml.
I also had blood drawn for another PSA test just today and am awaiting the results.
Is it safe to assume that if my PSA scores continue to moderate that the cancer is slow growing? What does PSA tell us once a confirmed diagnoses exists?
*****ANSWER*****
Gary,
PSA responds to many factors, among them cancer, infection, trauma, hormones, and surely many unidentified factors, perhaps dietary. So no, one cannot assume that a minor fluctuation represents a change in cancer. And remember that PSA is a marker of disease, not a disease, so “sweeping it under the rug” is not the same as effecting a cure for the disease it has helped to mark.
Arnon
I’m 74, in great health, an avid golfer. Had cryotherapy in January 2011 when PSA was at 17.26. PSA count went to 4.63 in January 2012. It was at 4.60 in June 2012. But it has risen gradually — to 9.40 in November 2012, to 9.79 in December 2012, then jumped again, to 10.24 in January 2013. My urologist advised me there may be some residual cancer cells present.
As a result of this pattern, he recommended a CT scan and a bone scan (done on January 9 and January 11). The results were negative. He then wanted to do biopsies and ultrasound, performed on February 7, 2913. No prostate cancer is evident, he said.
I meet with him on February 21 to discuss where to go from here. I’m interested in your reaction to my situation thus far, as well as options you think need to be considered going forward — that is, if you have enough info for suggesting guidance.
Thanks.
*****ANSWER*****
Hi Bob,
On the one hand you are healthy and functional and thus would want to rid yourself of cancer if the opportunity presented. On the other, the negative biopsy implies that there is no point in a “salvage” prostatectomy. On the other other hand, a negative biopsy may or may not truly mean that there is no cancer in the prostate (a positive biopsy is definite). There is no clear choice here, although clearly at minimum surveillance with even periodic scans is needed. One might reach for a repeat biopsy, depending upon the adequacy of the first, about which the urologist can advise.
Arnon
I have been diagnosed with prostate cancer and given two treatment options by two different doctors. Both agree the cancer is on the surface of the prostate.
Dr. A wants to robotically remove the prostate after external beam treatment. Dr. B says due to the chance of invasion of adjacent tissues I should have external beam radiation followed by barchytherapy.
Who is right?
*****ANSWER*****
Hi Fred,
Are you sure Dr. A wants to do “salvage” surgery after radiation as a planned course? That’s unusual.
Overall, to make an assessment, one really needs the details: PSA, Gleason score, volume on biopsy, DRE results … Without these it’s impossible to infer a pathological stage, which is what you are referring to. And without this, a course of action is hard to choose. You may want to ask your doctors to review the details, assess pathological stage possibilities, and, in this light, explain why a given (stage-specific) treatment is more likely to work for you (in context of your overall health).
Arnon
I just got the results of my PCA3 test — a very high 179. My PSA is 6.5 ng/ml.
I am scheduled for a 12-core biopsy on March 7. Should I am be worried because of the high PCA3?
*****ANSWER*****
Kenny,
The decision to be worried or not is personal. Will it help? How will it help? Perhaps more to the point, it sounds like you’re worried and so the question is how to cope with that. Are there people you can talk with who are close with you and you can share this with?
Arnon
Hi Arnon.
I am aware that Xtandi (MDV3100/enzalutamide) was approved by the FDA for post-chemotherapy mCRPC on August 31st, 2012. Do you have any insight as to if and when this drug might be approved in Canada? (As a comparison, in 2011 Canada approved post-chemotherapy Zytiga about 4 months after it was FDA approved in the US). The approval process seems quite non-transparent to the public.
Thanks,
Andrei
*****RESPONSE FROM SITEMASTER On BEHALF OF DR. KRONGRAD*****
Dear Andrei:
Unfortunately neither Dr. Krongrad nor I have any information about when enzalutamide might be approved by the Canadian regulatory authorities (although we would assume that it would happen relatively soon). We also have no idea which Canadian regional authorities will be willing to cover the costs of treatment with this agent.
I just had lab tests for PSA and testosterone levels as a follow-up 2 years post-treatment with radiation for prostate cancer. My PSA level is 0.1 ng/ml; my testosterone was > 800 Should I be concerned? What could this mean? I’m 74 years old.
*****ANSWER*****
Jesse,
It will help to know the details of your case (e.g., Gleason score; PSA levels). That said, it’s nice to see a PSA this low in the face of such a healthy, high level of testosterone. That said, the question is also one of trajectory. Find out what your previous PSAs have been and if your results represent a rise or a fall (or a non-change).
Arnon
I placed a question on here about my prostate problem. It has not been answered. Am I doing something wrong?
*****RESPONSE FROM SITEMASTER*****
Dear Martin:
I am sure Dr. Krongrad will address your question as soon as he can manage. He could have been traveling, or there may be several other possible reasons why he has not been able to get to your question as yet. You are not doing anything wrong.
Dr. K:
I am a 64-year-old white male. My last 10 PSAs (from 2005 to date) were 1.2, 1.2, 1.8, 2.1, 2.1, 2.8, 2.3, 3.4 (had sex right before the blood draw), retook 2 months later 2.7, and 2.5 this last month.
My urologist, upon doing the digital exam at my last visit, stated that the perimeter of one side of the prostate was not as clear and pronounced as the other side. Should I request a PCA3 test and maybe even an MRI before having a biopsy? If the PSA has been fairly constant, do I need to do something ASAP or should I look at all options? I am trying to look at the least invasive way to get a handle on this.
Lastly, if the prostate is flush up against the rectal wall, etc., what is the risk for/incidence of metastasis?
Thx,
ML
*****ANSWER*****
Hi ML,
The risk of high-stage and/or metastatic disease is a function of PSA, grade (determined by the biopsy), physical exam (clinical stage), and various features on the biopsy (volume of tumor). It is not a function of whether or not the prostate is “flush up” against the rectal wall, as it is in all cases.
An apparent steadiness of PSA levels across time points is no protection against missing a potential window of opportunity for meaningful action. Until a biopsy result is known, including tumor grade as would be assigned, it is very hard to be sure that surveillance is safe.
Arnon
Dear Dr. Arnon:
My Dad’s PSA went from 5 to 49 in less than 6 months. He was having difficulty urinating, urgency, and only urinating small amounts at a time.
Last week he had a cystoscopic examination and a biopsy. The results show a very aggressive andenocarcinoma. His Gleason score is 9. He has also had a bone scan and a CT of the brain. He has metstases to the bone and to lymph nodes, but his liver and brain are clean at this point.
Our physician has suggested hormone therapy to slow the progression of this disease. It makes sense to decrease the testosterone level. This will slow the growth of the cancer. He also talked about trying to get him approved for a newer type of chemotherapy — not the traditional one. He said that there were three different protocols that we could apply for. All these drugs are FDA approved but very costly. He did not want to name the drugs until Dad is approved for one of them. Then he would discuss the side effects of the drugs.
Although I am a RN, this is not my area of expertise. I know that this type of prostate cancer is one of the worst to have and that a Gleason score of 9 is not good either. Are you familar with the treatment that this MD is proposing? I couldn’t get the MD to give us a prognosis of time. I personally think he has less than a year, but I am not a MD. Help! Any info would be appreciated.
Sincerely,
Deb
*****ANSWER (by the Sitemaster on behalf of Dr. Krongrad)*****
Dear Deb:
The new drugs approved in the past few years for the treatment of this type of advanced prostate cancer are: sipuleucel-T (Provenge), which is an immunotherapeutic vaccine; abiraterone acetate (Zytiga), and oral form of androgen suppressor (that must be taken in combination with prednisone or a similar agent); and enzalutamide (Xtandi), a different form of oral androgen suppressor. Any one of these drugs, or perhaps a combination of two of them, may be able to help your Dad. And there are other drugs in the pipeline as well. However, the first thing to see is going to be how he responds to the first-line androgen deprivation therapy (ADT or “hormone” therapy). Some men do respond extremely well (but there is a great deal of individual variation). You should be aware that the manufacturers of all three of these new drugs have programs in place to help patients to deal with the costs of these agents.
With respect to your Dad’s potential long-term survival … If he responds well to the first-line ADT, you could be looking at a lot longer than a year, with good quality of life, but exactly how individual patients will do is extremely difficult to predict, and other factors (his age and other medical history; the precise extent of his metastases to bone) are very important, not just his Gleason score.
Dr. Arnon,
I am a 67-year-old prostate cancer survivor, having had a radical nerve-sparing prostatectomy a little over 5 months ago. I am in excellent health, a vegan, lean, and very fit. I have no cardiovascular issues, no diabetes, and take no other medications. In all the amount of cancer was small — equaling 2% of the specimen — with negative margins and contained within the prostate with no perineural invasion. PSA both 2 and 5 months post-surgery was non-detectable.
My surgeon, a veteran of 3,000 or more procedures at City of Hope told me my nerves were spared and that I had an excellent chance of regaining my erections. I was continent after 3 months.
I started on 50 mg of Viagra each night before bedtime about 6 days after surgery. I have also used a vacuum device sporadically.
My question is: Do you agree or disagree that if I am not able to get an erection after an injection from my urologist that I will never be able to get one because the muscle has been damaged?
Thank you for your time and attention.
Ron Paul
*****ANSWER*****
Hi Ron,
I know of no data to quantify any possible negative prognostic value of a single injection. Especially not in this context.
You are in your late 60s. It would be surprising if your erections were normal so early after surgery.
Arnon
Dr. Arnon,
My 52-year-old husband was recently diagnosed with prostate cancer. His PSA levels had been constantly rising and now are at about 8 ng/ml. He had a biopsy in April of 2012 that showed no cancer. Another biopsy in March of 2013 shows a small amount of cancer in the left quadrant with a Gleason score of 3 + 3 = 6.
We would like to know where we should start from here? We have made an appointment with his GP to get some advice and a referral to a specialist. We don’t have any confidence in the urologist that performed the biopsy. All kinds of cancer run in his family and my concern is that it spreading outside of the prostate.
Thank you for your time.
Cindy
*****ANSWER*****
Hi Cindy,
Your next step is to get fully informed about treatment options. The specialists most suited to this task are urologists, radiation oncologists, and medical oncologists. You can ask the GP to make recommendations.
Arnon
Ron Paul again …
My urologist gave me an injection this morning and although my member swelled to a very large size it did not become rigid or hard.
My doctor believes that it is most likely damaged muscle tissue that is the cause and that continuing to use Viagra will not be productive.
What do you think, as it is hard to accept that my chances of recovering my ability to get the same excellent erections I had prior to surgery is over and done with.
*****ANSWER*****
Ron,
It’s hard to say. You may want to consider adding a ring, the kind used often with the vacuum erection devices.
Arnon
Dr Krongrad,
I had a first biopsy in September 2011 showing atypical cells (kind of pre-cancer cells), and a second, 1 year later, in October 2012, showing one needle at 20% (Gleason grade 3) and another needle at 5% (also Gleason grade 3), for a Gleason score of 6 and clinical stage T2. So, I am considered at low risk. My father died at 92 by accident and my 5 brothers, from 60 to 72 years old, don’t have any sign of prostate cancer, so far. My mother died at 95 years old. I am 66 years old, in good health, with no disease and jogging regularly.
My understanding is that active surveillance is highly recommended according to the new approach trend being adopted by urologists in situations like mine. Also, avoiding any treatment now may lead to a situation in which, during the course of the active surveillance, it might become too late for prostatectomy if the Gleason score reaches 7 or 8 with a clinical stage T3. The inconvenience and the side effects of the appropriate treatment then might be much worse than the application of the alternative treatment, now.
So, I am seriously considering doing something about it, now. My conclusion so far, on the most appropriate treatment applicable to my situation now (if I don’t want to live with active surveillance), is either radical prostatectomy or radioactive seed implantation (approach with better probability to save the erectile nerves). My specific questions are on the radioactive seed implant:
(1) Will the prostate still be operational after the radioactivity will have stopped from the seed implant or will the seed implants destroy the whole of the prostate and no more sperm will be produce?
(2) Could the seeds be implanted to only the part of the prostate most likely to contain the cancer cells, leaving the rest of the prostate operational and limiting more the side effects of this approach, leaving the option of implanting more seeds if the PSA rises again or proceeding with a prostatectomy then?
Claude
*****ANSWER (by the Sitemaster on behalf of Dr. Krongrad)*****
Dear Claude:
Your questions are easy to answer and so I have given the responses below on behalf of Dr. Krongrad:
(1) If you have well-implemented, whole-gland radioactive seed implantation (“brachytherapy”) either now or later then all the cells in your prostate will be killed if it is properly carried out and so yes this will affect your ejaculatory function.
(2) In theory it is possible to carry out so-called “focal” brachtherapy, in which radioactive seeds are implanted into only selected areas of the prostate, as you describe. However, we know of no long-term data on the effectiveness of this technique, nor do we know of very many physicians who have significant experience of trying to implement this technique. A report on a consensus meeting on the possibility of focal brachytherapy was published in 2012; the full text of a report on several different types of focal therapy is also available on line.
My husband had radiation treatment for prostate cancer in December 2011 and January 2012. He had clinical stage T1c found in three of four quadrants (a few percent of each core, low Gleason scores). In February 2013 we went back and his PSA is 2.4 ng/ml, which is the same as when we first found out about the cancer. His doctor said he was not worried; however, we are. Should we be? We go back again in a few months.
*****ANSWER*****
Dear Leigh,
Ordinarily, radiation is associated with a reduction of PSA to lower than before treatment and commonly to levels approximating 0.1 ng/ml. This is not what you describing. A second opinion is usually the next step in a situation that is unclear as this.
Arnon
Hello Dr. Konrad.
My husband (60 years old) had a radical prostatectomy a year ago, then was put on hormone therapy (Lupron) as cancer had spread to lymph nodes throughout his body. Weeks later a scan showed that the cancer had continued to spread to his lungs and liver. He then underwent chemotherapy (docetaxel) for 7 of 10 treatments which were stopped when a scan showed that although chemo had worked for the lungs, the cancer was still growing in his liver.
Now he is taking Zytiga (1000 mg daily) plus prednisone but is no longer on the hormone therapy … should he be given the Lupron shot as well?
I ask this because the information on the Zytiga site says: “Patients receiving GnRH agonists should be informed that they need to maintain this treatment during the course of treatment with ZYTIGA and prednisone.”
We have had a couple of scenarios that have quite rattled us and reduced our confidence in care that is being given so that is why I would like your opinion.
I really appreciate having this opportunity to ask questions. And I do have more but won’t tax you with them right now! Thanks very much.
Sincerely,
Margie and John
*****ANSWER*****
Hi Margie,
Thank you. It’s not known to me why the Lupron was stopped, but it’s a fair question, one you can rightfully and reasonably pose to his doctor(s) and/or any second opinion(s). Perhaps there is a reason and you should know it.
Arnon
Dr. Krongrad,
Hi. Thanks for your response on February 23, 2013.
To my knowledge my PSA levels have never been above 4 ng/ml. As I mentioned to you, my testosterone level was 1,200 at my last lab test and my PSA was 0.1. My Gleason scores at the time of biopsy were 7 and 8. I went to a urologist 2 weeks ago, as suggested by my primary physician, and he didn’t seem concerned. He repeated my T level and added another hormone test. I’m to go for a return appointment on Monday April 8th.
If my T level continues to be elevated, should I get another opinion, as I understand from everything I have read that this elevation could be a contributor to a return of the cancer. Also, how can I get my T level lower? Is there any medication or dietary therapy for that?
Thank you
Jesse
Jesse,
Let’s put the “horse” before the “cart.” The objective is to keep prostate cancer from being a bother to you, not to manipulate hormone levels. To the extent that the latter is useful for the former, then sure, it’s a real goal. On other words, it’s important to first ask which clinical maneuver will achieve the only real goal: hormone manipulation, radiation … etc. This is almost surely the question that should be posed to your doctors first as you review matters with them.
Arnon
I had a biopsy done on January 23 this year. My age is 62 years; my PSA is 0.75; my Gleason score was 6.
Is it necessary to have radical prostate surgery as soon as possible, or should I wait a while to see?
*****ANSWER*****
Hi Alex,
The decision and the timing have to reflect a large number of variables: findings on physical (DRE), extent of involvement of the tumor, overall health, obesity, previous surgery. … It’s about much more than just the Gleason score and the age. Your doctor(s) can help with this assessment.
Arnon
What effect would the radiation for prostate cancer have on a woman if the man doesn’t use a condom during intercourse?
*****ANSWER (by the sitemaster on behalf of Dr. Krongrad)*****
Dear Carol:
The standard types of external beam radiation therapy given to treat prostate cancer do not make a man’s organs or semen radioactive. It is completely safe for the female partner for a couple to have intercourse while the male is being treated with external beam radiation, and a condom is not necessary because of the radiation therapy. HOWEVER, …
If the man is treated with permanently implanted radioactive pellets (so-called “brachytherapy”), then he absolutely should use a condom for a significant period of time (months) after seed implantation. The precise time period depends on the type of pellet being used. In this case, it is possible (if unusual) for pellets to become dislodged from the prostate and then ejaculated during intercourse. If such a radioactive pellet were to remain in the woman’s vagina after intercourse, this would be problematic. It is standard practice for men treated with this type of brachtherapy to be told of the necessity to either abstain from intercourse or use a condom for the appropriate period of time after implantation of the pellets.
Dr. Krongrad:
I’m a 60-year-old and had a RP in 2002. Gleason was 7 with negative margins. My PSA has been on a very slow rise for over 10 yrs: 0.01 usually every 6 months or down. It has reached 0.37 and I have seen different oncologists who recommend salvage radiation or keep waiting. My doubling time was 5 years now 4 years. They say only 50% chance cancer is in the prostate bed. Not sure to wait or do the salvage RT. Some say you could wait till PSA reaches 0.5. Need to make a decision soon, not looking forward to side effects. Any advice would be appreciated.
Terry
***** ANSWER *****
Hi Terry,
They’re right that it’s impossible to say with any certainty if a recurrence is in the region of the prostate. So radiation may be for no benefit. Among the other considerations is a re-staging. Even with a “low” PSA, it’s possible that there is a discrete metastasis, including possibly in the spine. You may want to discuss a bone scan with your doctor(s), just to be sure you’re not missing something of potential importance. Another consideration is that the rise of PSA has been slow. Put this into context of your overall health. If you’re not very healthy otherwise, what is the putative benefit of any treatment? This, too, is something that can be discussed with your doctor(s).
Arnon
I was diagnosed with prostate cancer in 2004: Gleason score 9; PSA 35; no metastases at that stage. My treatments have been radical prostatectomy, radiation, chemotherapy (mitozantrone + cyclophosmamide) followed by years of hormone blockade — Casodex, Zoladex, Andracur, Avodart, ketoconozole. I have injected Leukine and taken ketoconazole. Finally, they all failed.
A 2012 PET scan showed a tumour on the left kidney and biopsy showed this to be prostate cancer. I had 10 sessions of docetaxel chemotherapy, finishing in October 2012; my PSA fell to 4.2 from 12.8. In March 2013 PSA my started to rise again from 4.2 in November 2012 to 7.8 in March 2013. I started Zytiga with amazing results. PSA fell to 3.5 in a month!
My question is, have you heard about genistein polysaccarides in combination with AHCC and whether it would help taking them with Zytiga? I would really value your opinion as my oncologist just says it is up to me and given the cost of Zytiga (not covered by any insurance, public or private in Australia ) I would not want to prejudice my treatment. I am 65 years of age, exercise every day, and have a good diet.
Ellis
*****ANSWER*****
Hi Ellis,
Thank you for writing. Your question is a good one, but not one with which I have any experience at all. If you can find a medical oncologist specializing in prostate cancer to give a second opinion, that is probably the next best step.
Arnon
Here is my concern. … I am considering CyberKnife therapy, but wonder why more facilities do not offer it if the results are substantially better than surgery or other radiation for many people.
Also, I see very little about sexual function immediately after and for a 3+ year period following. Any thoughts?
*****ANSWER*****
Hi JD:
Have a look here.
Arnon
*****ADDITIONAL COMMENT (from Sitemaster)*****
JD:
Since you don’t mention anything in your question about your personal risk level (low-, intermediate-, or high-risk, based on your PSA level, your clinical stage, and your Gleason score), you might also like to look at these additional links:
– Data from a 300+ patient series treated with CyberKnife
– CyberKnife radiation: is it being over-advertised?
At this time there are no data that I am aware of that offer any type of accurate comparison of outcomes between CyberKnife radiation and other forms of treatment. Another key issue is whether many of the men with low-risk disease being treated with CyberKnife radiation actually need to be treated at all or could be effectively managed on an active monitoring (“active surveillance”) protocol of some type.
What is the real, honest risk of needle tracking spreading cancer cells during a needle biopsy? I’ve had doctor’s responses to this question from “I don’t know” to “Absolutely no risk”. Has this topic ever been studied?
Dear Alan:
It is extremely important to distinguish between the physical tracking of cells as a biopsy needle moves through tissue (which does indeed happen and this has been studied) and the ability of the “tracked” cancer cells to survive and grow in their new biological environment.
I am aware of no case whatsoever in which tracking of cells has been shown to lead to new tumor growth within (let alone outside) the prostate as a consequence of a prostate biopsy. Can I make you some sort of absolute promise that this never, ever occurs, even in rare situations? No I can’t. However, what I can tell you is that it is extrardinarily difficult to move cells from their initial growth environment to any new environment by any means (let alone by this sort of abrupt, physical, “brute force”) and then to get them to start growing again in that new environment. Biology is complicated; even the smallest changes in the microenvironment of individual cells tends to lead to the death of those cells.
Given the vast increase in the number of prostate biopsies over the past 30-odd years since the initiation of prostate cancer screening with the PSA test, if this was a clinically significant problem it would have become highly apparent to pathologists by now!
I was recently diagnosed with prostate cancer (Gleason 6, PSA 6.1, with one core positive at 5%). I have just finished bone scan, CT scan, and x-ray tests. Can you suggest one or more comprehensive oncology centers that speciaize in prostate cancer in the north-east. I live in Connecticut.
Thank you
*****ANSWER*****
Hi Mickey,
So many to choose from: Memorial Sloan-Kettering (in New York), Columbia Presbyterian (also in New York), Dana Farber (in Boston). … But do you want a center to take care of you or a doctor to take care of you?
Dear Doctor:
I was recently diagnosed with a Gleason score 4 + 3 prostate cancer, a PSA of 7.9, and a prostate volume of 71. DRE: “maybe something there”. The biopsy was positive for 6/6 cores on the right and negative for 6/6 cores on the left.
Is brachytherapy a treatment option??
Bradford
*****ANSWER*****
Hi Bradford,
Brachytherapy is an option. There are pros and cons.
Keep in mind that who does the brachytherapy is very important.
Arnon
I had robot-assisted removal of my prostate in 11/09 after diagnosis with Gleason 7 disease. A PSA test in June 2011 was 0.19 ng/ml; with subsequent monthly testing, the PSA was undetectable by 11/11. Now (as of April 30, 2013) my PSA is 0.16 ng/ml. What should I do?
*****ANSWER*****
Jerry,
The first step might be to review the pathology findings with your surgeon, to help put some perspective on this oscillating PSA. A trend is not clear, obviously, so maybe this will help to judge if there is a high risk of recurrence or this is just a “funny” pattern.
Arnon
Doctor:
My PSA was 4.0 when I visited my GP and he referred me to a urologist; a month later my PSA had gone to 17 ng/ml. I have an enlarged prostate and experience some frequent urination urges. The urologist recommended a biopsy, which showed no cancerous cells. Should I be concerned?
Kevin
*****ANSWER*****
Kevin,
Dramatic jumps like you’ve described are generally not caused by cancer, but by trauma, inflammation, infection, and the like. With one negative biopsy, while your overall risk is not zero, it would suggest that the risk is low. All this should be put into context of family history, physical findings, and your age, overall health, and the like as any decision to re-biopsy is made. In the meantime, repeating the PSA in the coming weeks/months under the supervision of your urologist may really help to clarify what’s going on. You may want to talk with him about PSA follow-up.
Arnon
Hello Dr. Arnon:
My husband has prostate cancer with metastases to his bones and has been treated with Lupron for a year. After his doctor stopped the therapy last August, his PSA started going up again and he put him back on it. We would like to try something else and we were wandering if low doses of naltrexone would be a good option?
*****ANSWER*****
Hi Nidia,
The question is if Naltrexone has been shown to prolong the duration of period without any clinical effects and/or prolong survival. If such data have been presented — and this is very different from data on just lowering PSA, i.e., sweeping the information under the rug — then it’s something to discuss with his doctors. I am not aware of any such data.
Arnon
Hello. Can bacterial prostatitis be transmitted sexually to a non-infected partner?
*****ANSWER*****
Hi L,
That’s a very interesting question, particularly because it’s not always clear which is the offending bacterium, if any. It becomes all the more vexing in that sexual organs are already colonized with bacteria on both the transmitting and receiving ends, such that proving that a particular bacterium caused or did not cause symptoms becomes even more complicated. In any event, it is possible that any organism, including specific symptom-causing bacteria, can be transmitted through sexual contact.
Arnon
What are the possible side effects is someone should drink the gold markers??
*****ANSWER*****
Good question. I’ve never heard of anyone drinking gold markers.
How about Staphyloccus epidemidis, confirmed on prostate culture?
*****ANSWER*****
This is the most common bacterium on human skin. We all carry it and few of us are symptomatic. This bacterium is often isolated as a contaminant, including in urine and urethral swabs. It would be hard to implicate it as a cause of symptoms merely based upon isolation from a specimen with origins on skin and/or around the urethra.
Hello Dr Arnon.
I have a blood test once a year for various reasons as requested by my doctor, one of them being a PSA test. The first time was in 2009 and the reading was 2.0; the most recent was in March 2013 and was 2.19. My doctor thought that because it had increased over the 4 years he should consult a urologist who suggested I should have a biopsy. The reason being that my brother had prostate cancer 3 years ago and even though the PSA increase was small my doctor felt he needed advice.
I am 61 years of age and asked my doctor what a normal reading was for a man of that age and he said 4.0, so I said with my reading of 2.19 surely I did not need a biopsy and he said it was for the urologist to make that decision.
I have an appointment to see the urologist who will carry out a number of tests to determine whether or not he still feels I need a biopsy. What I don’t understand is, why he was willing to recommend a biopsy without examining me based on the 2.19 PSA and the fact my brother had prostate cancer.
I have no symptoms as such and have a reasonable sex life for a man of my age. I do however drip a little after peeing and manage to get through most nights without needing to go until morning. I also have mild back, hip, and thigh pain but assumed this was due to a bad golf swing.
I have heard many reports about infections and problems caused by having a biopsy and my gut feeling is they are just being over-cautious.
I look forward to your reply.
John Brooker
John,
The Positive Predictive Value of a PSA of 2.19 ng/ml is approximately 15-20%. Your brother’s history bumps that up, probably to the 25-30% range. So now the question is this: given that your risk is approximately 1 in 4, do you want a biopsy? Is your health and overall disposition such that, if you are the 1 in 4, you would want to know that you had prostate cancer?
Arnon