25th January 2008
[QUOTE=able5;3408792]...
Do yourself a favor, encourage your husband to "paint by the numbers" for now and jump through the hoops that the urologist tells him to jump through, namely, GET THE BIOPSY. It'll give you some peace of mind...
Able5's points make a lot of sense to me too. I want to emphasize that, because the amount of space below covering some other alternatives might make it seem that those alternatives are better. Not so in my view.
Also, if you've read other threads, you've seen that able5 often makes the point that we are not doctors on this board. I want to emphasize that too. I hope that what follows can provide leads to you and your husband and is food for thought, but I have no medical authority and have had no enrolled medical education. Rather, I've picked up these points during the course of dealing with a difficult case for eight years and communicating with a lot of fellow patients and doctors.
But if your husband is really reluctant to do the biopsy, there is another test that can go a long way toward clarifying whether there is cancer. It adds information independent of the PSA and free PSA.
It is known as the PCA3Plus test, and it is an improved version of an earlier test known as the uPM3. The uPM3 also added information, but the PCA3Plus test is apparently superior. It is strong where the PSA test is weak, and vice versa, also complementing results from a free PSA test, so using all results goes a long way toward clarifying whether there is cancer. :) It is a urine test following what's called an "attentive" or intensive DRE, basically a massage of the prostate for about a minute, designed to cause some prostate cells to be shed into the urine. This test is often helpful to patients who have one or two negative biopsies but still have reason to suspect cancer. However, it is also helpful in determining whether a biopsy is needed. The sample can be shipped from anywhere to one of the labs that can run the test. It has not yet been approved by the FDA, but I've heard the director of one of the labs that runs the test say that insurance coverage is good.
Another approach is to go on prescription finasteride, a drug considered fairly mild, for at least six months. If the PSA drops by at least 50%, it is a good sign there is no cancer, and vice versa. If it does not, then that is another clue suggesting cancer. Dr. Eric Klein, MD, of the prestigious Cleveland Clinic, has described this approach. Research suggests that finasteride also improves the results of DREs, and once the new, lower baseline PSA is determined, finasteride improves the interpretation of PSA velocity and density as indicators of cancer. Finasteride has been proven to help prevent prostate cancer, decreasing the incidence by 25% (with analysis since 2003 indicating strongly that it is safe and does not cause high grade cancer), but it seems to be effective with low-grade, low-risk cancer and may not help much with high Gleason Score cancer, at least when used alone. Able5 raised the possiblity of a concern about a rapid increase in PSA. If that happened to your husband, waiting six months for the result of finasteride could involve a risk of delay in diagnosing an aggressive cancer in my layman's opinion. (Finasteride is FDA approved for benign prostatic hypertrophy, BPH, otherwise known as an enlarged prostate.)
If there is cancer, it is probably very small and may be missed by a standard biopsy, so you and your husband might want to consider a "saturation" biopsy. I've heard that is typically done under general anesthesia, and can involve from 40 to 70 cores at some institutions, or as few as 18 to 21 cores. Daff's reply also discussed this. If it were me trying to find a tumor(s) that was(were) likely small, I would want at least 12 cores taken, which has become fairly standard in the US. Another option is a color Doppler ultrasound biopsy done at one of the handful of institutions in the US with the experts and equipment to do it well. I've heard it is excellent at revealing the size, shape and location of tumors, as well as some other important details. A doctor I respect highly says that the saturation biopsy is the best for revealing cancer, but that the CDU is also excellent. You and your husband have a real role to play in deciding not just whether to get a biopsy but also what kind to get. You don't have to just leave this totally up to the doctor. My impression from talking to fellow survivors is that doctors will often just follow their routine approach; if a regular biopsy shows nothing, then they are content to watch the PSA and do another regular biopsy, and maybe a third, etc., until the cancer is finally found. As a patient, I would much rather get it right, either cancer or no cancer, the first time.
One final point that may help overcome reluctance to do a biopsy, especially if it is based on a concern about possible overtreatment if low-risk cancer is found, a concern that many doctors now share. If the biopsy gives you high confidence the cancer is low risk, your husband could use an active surveillance approach. (Low risk would be indicated by clues like Gleason of 6 or lower with no Gleason 4 or 5 - especially if confirmed by an expert pathologist; a small percentage - or best, only one - of biopsy cores that are positive; only a small percentage of the core(s) that is cancer; no abnormal findings such as perineural invasion; no indication that any cancer is near an easy route to exit the capsule (such as adjacent to nerves, or near the thin boundary at the apex); and the DRE reveals a T1c or T2a stage; together with that low PSA and without an increase of greater than 2.0 in the year prior to diagnosis. Formal, published medical research supports all of these points. It is possible to get even greater assurance with more blood tests and special examination of biopsy cores can provide them.) While most active surveillance programs like to see older men in their program, some are comfortable with younger men, like your husband, provided their cases are carefully assessed and that they are monitored diligently. Putting a program of nutrition, exercise, stress reduction and perhaps low key medication (finasteride, Avodart, a statin drug, perhaps a bone assessment and a bisphosphonate drug) can also help and may be all that is needed for a low-risk case, from what I've heard and read.
Good luck to you both with your decision, and take care,
Jim
Do yourself a favor, encourage your husband to "paint by the numbers" for now and jump through the hoops that the urologist tells him to jump through, namely, GET THE BIOPSY. It'll give you some peace of mind...
Able5's points make a lot of sense to me too. I want to emphasize that, because the amount of space below covering some other alternatives might make it seem that those alternatives are better. Not so in my view.
Also, if you've read other threads, you've seen that able5 often makes the point that we are not doctors on this board. I want to emphasize that too. I hope that what follows can provide leads to you and your husband and is food for thought, but I have no medical authority and have had no enrolled medical education. Rather, I've picked up these points during the course of dealing with a difficult case for eight years and communicating with a lot of fellow patients and doctors.
But if your husband is really reluctant to do the biopsy, there is another test that can go a long way toward clarifying whether there is cancer. It adds information independent of the PSA and free PSA.
It is known as the PCA3Plus test, and it is an improved version of an earlier test known as the uPM3. The uPM3 also added information, but the PCA3Plus test is apparently superior. It is strong where the PSA test is weak, and vice versa, also complementing results from a free PSA test, so using all results goes a long way toward clarifying whether there is cancer. :) It is a urine test following what's called an "attentive" or intensive DRE, basically a massage of the prostate for about a minute, designed to cause some prostate cells to be shed into the urine. This test is often helpful to patients who have one or two negative biopsies but still have reason to suspect cancer. However, it is also helpful in determining whether a biopsy is needed. The sample can be shipped from anywhere to one of the labs that can run the test. It has not yet been approved by the FDA, but I've heard the director of one of the labs that runs the test say that insurance coverage is good.
Another approach is to go on prescription finasteride, a drug considered fairly mild, for at least six months. If the PSA drops by at least 50%, it is a good sign there is no cancer, and vice versa. If it does not, then that is another clue suggesting cancer. Dr. Eric Klein, MD, of the prestigious Cleveland Clinic, has described this approach. Research suggests that finasteride also improves the results of DREs, and once the new, lower baseline PSA is determined, finasteride improves the interpretation of PSA velocity and density as indicators of cancer. Finasteride has been proven to help prevent prostate cancer, decreasing the incidence by 25% (with analysis since 2003 indicating strongly that it is safe and does not cause high grade cancer), but it seems to be effective with low-grade, low-risk cancer and may not help much with high Gleason Score cancer, at least when used alone. Able5 raised the possiblity of a concern about a rapid increase in PSA. If that happened to your husband, waiting six months for the result of finasteride could involve a risk of delay in diagnosing an aggressive cancer in my layman's opinion. (Finasteride is FDA approved for benign prostatic hypertrophy, BPH, otherwise known as an enlarged prostate.)
If there is cancer, it is probably very small and may be missed by a standard biopsy, so you and your husband might want to consider a "saturation" biopsy. I've heard that is typically done under general anesthesia, and can involve from 40 to 70 cores at some institutions, or as few as 18 to 21 cores. Daff's reply also discussed this. If it were me trying to find a tumor(s) that was(were) likely small, I would want at least 12 cores taken, which has become fairly standard in the US. Another option is a color Doppler ultrasound biopsy done at one of the handful of institutions in the US with the experts and equipment to do it well. I've heard it is excellent at revealing the size, shape and location of tumors, as well as some other important details. A doctor I respect highly says that the saturation biopsy is the best for revealing cancer, but that the CDU is also excellent. You and your husband have a real role to play in deciding not just whether to get a biopsy but also what kind to get. You don't have to just leave this totally up to the doctor. My impression from talking to fellow survivors is that doctors will often just follow their routine approach; if a regular biopsy shows nothing, then they are content to watch the PSA and do another regular biopsy, and maybe a third, etc., until the cancer is finally found. As a patient, I would much rather get it right, either cancer or no cancer, the first time.
One final point that may help overcome reluctance to do a biopsy, especially if it is based on a concern about possible overtreatment if low-risk cancer is found, a concern that many doctors now share. If the biopsy gives you high confidence the cancer is low risk, your husband could use an active surveillance approach. (Low risk would be indicated by clues like Gleason of 6 or lower with no Gleason 4 or 5 - especially if confirmed by an expert pathologist; a small percentage - or best, only one - of biopsy cores that are positive; only a small percentage of the core(s) that is cancer; no abnormal findings such as perineural invasion; no indication that any cancer is near an easy route to exit the capsule (such as adjacent to nerves, or near the thin boundary at the apex); and the DRE reveals a T1c or T2a stage; together with that low PSA and without an increase of greater than 2.0 in the year prior to diagnosis. Formal, published medical research supports all of these points. It is possible to get even greater assurance with more blood tests and special examination of biopsy cores can provide them.) While most active surveillance programs like to see older men in their program, some are comfortable with younger men, like your husband, provided their cases are carefully assessed and that they are monitored diligently. Putting a program of nutrition, exercise, stress reduction and perhaps low key medication (finasteride, Avodart, a statin drug, perhaps a bone assessment and a bisphosphonate drug) can also help and may be all that is needed for a low-risk case, from what I've heard and read.
Good luck to you both with your decision, and take care,
Jim