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Thread: Decisions, Decisions......

  1. #1
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    Decisions, Decisions......

    Referred to urologist because GP Doc thought he felt something on one side of the prostate. I'm 67 and in good health.

    Urologist says "You have a nodule." He schedules me for a biopsy. I say ok. (What do I know?)

    Then he sends me for a blood test to get a PSA count.

    I say, "When will the results be back?"

    He says, "I don't know." Disinterested. Doesn't look at me, just keeps tapping on his computer.

    I give him a confused stare and presently he says, "It doesn't make any difference. We need to do the biopsy." He mumbles something about the results being useful in determining treatment options.

    Now, maybe my attitude is tainted by the fact that he was a bit rough with the exam. He did everything except put his foot in there and pretend my prostate was a cigarette butt he was grinding out on the pavement.......but I started to distrust and dislike him at the point he said, "I don't know."

    I mean, technically--I suppose he didn't know EXACTLY when the results would be back, but he could have said, "Usually in a day or two," or something friendly and helpful. I am, after all, pretty vulnerable at this point and friendly answers to questions would naturally be appreciated.

    I go home and start researching and I find that the PSA should be taken BEFORE the poking and prodding of the prostate--NOT after.

    I also find that he really glossed over the risks and problems of the biopsy. He quickly said that infections sometimes occurred.

    Never mentioned that the biopsy can spread existing cancer.

    Never mentioned that infections have recently been INCREASING and that bacteria that are resistant to penicillin are an INCREASING problem.

    Never mentioned a rectal swab to check for dangerous bacteria.

    Never gave me any numbers to assess the risks but did manage to alienate me.

    Basically, I felt a bit railroaded, treated like a piece of meat and offended by his callous attitude and the total absence of empathy.

    So.......I learn a lot on my own on the internet and find that the biopsy is dangerous in at least a couple of ways and find especially interesting a story about three doctors who were in my situation and all three chose NOT to have the biopsy and INSTEAD have some sort of MRI as their first test.

    I find that the head of the MAYO Clinic teaching operation has referred to the current biopsy procedure as "medieval and barbaric."

    So.......when I find that my PSA turned out to be 4.8, I cancel the biopsy appointment. A 4.8 is NORMAL for a 67-year-old man according to what I've read.

    I will get together with my GP and talk things over and if he insists I'll start again with a new urologist that will have better social skills and hopefully, better and safer options for tests.

    The way I see it, we have ZERO evidence that the nodule is dangerous.

    Actually, I can remember a doctor telling me that one side of my prostate was a little hard about 30 years ago and I think it's been mentioned a couple of other times.

    Also, from what I've managed to glean from the internet......at age 67 there's a fairly good chance that I could have a slow-moving form of cancer anyway.

    So why get this prostate all riled up by brutally stabbing it with 12 needles?

    Should we let a sleeping dog lie or poke it with sharp objects?

    I really don't know, but maybe some of the folks here can speak to me from their greater experience and add to my now very limited knowledge.

    Thanks in advance.

  2. #2
    Moderator Top User HighlanderCFH's Avatar
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    Hi,

    I agree with some of what you posted and disagree with others. First, if your urologist was that callous to you I would find another doctor. Can't blame you for that. Especially if he sent you for a PSA blood draw immediately after a DRE. DRE's, sex, bike riding, vigorous exercise, etc., should NOT take place in the 72 hours before a PSA blood test.

    The results of the biopsy should normally be available within 3-5 days, so again the urologist seemed to be a bit uninterested.

    There are some misconceptions you seem to have also, though.

    It is highly unlikely that a prostate biopsy would spread any existing prostate cancer. The chances of this are extremely rare. Remember that literally THOUSANDS of biopsies are performed every day.

    I also am not familiar with any news that biopsy infections are increasing. As long as the doctor takes the normal precautions, infection is quite unlikely. Also, I haven't heard of a rectal swab as a standard process.

    I don't know what the head of Mayo Clinic teaching said, but biopsies are performed at Mayo every day. Any type of invasive procedure could be termed as "barbaric," but they are still necessary "evils" in healthcare. Maybe in Star Trek's time there will be non-invasive procedures, as demonstrated by Dr. Leonard McCoy of the U.S.S. Enterprise. But that is HUNDREDS of years into the future.

    Also, please be aware that many men have prostate cancer even with LOW PSA readings. Do you have a track record of previous PSA tests to compare the 4.8 to? Tracking PSA on an annual basis is valuable because it is the INCREASE in PSA that can be suggestive of PC.

    With all of that said, you probably SHOULD agree to a biopsy since you have that suspicious spot on your prostate. It needs to be biopsied to rule out PC.

    A biopsy is not really that big of a deal -- except in the instances where it reveals an aggressive cancer and saves a life.

    If you should have prostate cancer, remember that you only get ONE shot at a cure. If it goes too far before being diagnosed, the end result will not be what you woud want.

    Good luck to you -- and please feel free to ask any questions that we can help you with.

    Take care,
    Chuck
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Eight annual post-op exams 2012 through 2019: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

  3. #3
    Urology with rectal exams and scopes, etc. is not the most glamorous medical field and many doctors seem kind of crude. Many do DRE's that are kind of aggressive.
    You could get a FreePSA blood test from your GP. (High is better on this test.) There are other blood tests that are also informative.
    The chance of complications from a biopsy are low. I got Cipro before and after the biopsy.
    I would suggest further blood tests at the least. Good luck.
    DOB Sept. 1947. Prostate cancer Gleason 7 (3+4), PSA 5 in Oct 2010. Cryoablation Jan. 2011. Had some complications.
    Experienced nocturia, irritable bladder summer 2011. "Agent Orange"compensation from VA Oct 2011.
    PSA: .05 01/26/2012, .06 6/26/2012, .04 12/24/2012, .04 6/26/13, .05 1/27/14, .05 10/21/14, .04 10/15
    I am eating vegan mostly plus a little fish. Take some supplements.
    (Any advice given is the personal opinion of a layman and is not intended to replace the advice of a health professional.)

  4. #4
    Well, ideally you would have been better served by having him tell you to wait a few days or a week for the PSA blood draw. If that was easy for you.
    Either way, your PSA would probably have been 4.0 or more.
    Do you know your PSA history?

    The doctor was not wrong to do some extensive "digging around" in the exam. That is exactly the right thing for him to do before making you get biopsy.

    Right now you may want to get another urologist, but then he will have to re-examine your prostate again and you'll still have to get another PSA..
    This time do it prior to the exam, and if possible long enough ahead of time for the new urologist to have the results when you see him for the exam.

    Then, he'll probably tell you to get a biopsy.

    Still in the long run, better to deal with someone you feel comfortable with.
    Whether your PSA is 2.8 or 4.8, with the nodule, they'll tell you to get a biopsy.

    Or, you can just forget all this and take your chances. Odds are good you'll die from something else before prostate cancer, if you have any, gets to you.
    That is not a totally unreasonable approach, though some may object to such ideas.

  5. #5
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    Thanks for the info.

    As to questions, yes.......I did ask and would still like to hear about alternatives to the biopsy from those who have some knowledge of emerging and state of the art testing......I'd also like to hear why nodules are assumed dangerous without evidence.

    The info on infections is probably fairly new and still a developing story. http://www.bloomberg.com/news/2013-0...-concerns.html

    From the article:
    “Greater recognition of the infectious risks of biopsy has led us to be much more careful about who we select for prostate biopsy,” said Stacy Loeb, assistant professor of urology and population health at New York University. “All patients should be evaluated for risk factors for resistant bacteria and infection, and should be counseled about the risks and benefits of proceeding to biopsy.”
    That article also mentions that a hospital in Florida has gone to the standard use of the rectal swab before a biopsy to identify dangerous bacteria that might be present, so I don't doubt that others have done the same and more will in the future.

    I'm quite sure that highly respected medical leaders RARELY call a lot of invasive procedures "barbaric".......probably only the very worst......it appears the prostate biopsy is about the worst.

    Anyway, when one of the leaders at Mayo calls it "barbaric," I'm going to sit up and take notice.

    As to your statement on the needles spreading cancer--I can't find any indication that anyone is really keeping track or doing serious research to determine the facts of the matter.

    Obviously, cancer often spreads to other parts of the body at some point after biopsies, but as to WHY it spreads or whether the biopsy might have been part of the reason it spread........nobody seems to be keeping tabs on it or trying to find correlation between the biopsies and the spread. Maybe they should? Maybe there is reasonable doubt until they do?

    I don't have a track record of PSA tests although it would be completely normal for them to show as slowly rising to the currently normal 4.8 as I progressed through my 50s and 60s.......and so, that again would be normal and it would only tell us that I'm normal.

    I welcome all the information I can get and thanks to all who can share.

  6. #6
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    Quote Originally Posted by Otago View Post
    Well, ideally you would have been better served by having him tell you to wait a few days or a week for the PSA blood draw. If that was easy for you.
    Either way, your PSA would probably have been 4.0 or more.
    Do you know your PSA history?

    The doctor was not wrong to do some extensive "digging around" in the exam. That is exactly the right thing for him to do before making you get biopsy.

    Right now you may want to get another urologist, but then he will have to re-examine your prostate again and you'll still have to get another PSA..
    This time do it prior to the exam, and if possible long enough ahead of time for the new urologist to have the results when you see him for the exam.

    Then, he'll probably tell you to get a biopsy.

    Still in the long run, better to deal with someone you feel comfortable with.
    Whether your PSA is 2.8 or 4.8, with the nodule, they'll tell you to get a biopsy.

    Or, you can just forget all this and take your chances. Odds are good you'll die from something else before prostate cancer, if you have any, gets to you.
    That is not a totally unreasonable approach, though some may object to such ideas.
    Thanks for the info. Yes, doctors tend to want to........doctor. I wish I could get advice from a totally unbiased yet well-informed source. This is an area where almost everybody has at least a little bias, it seems.

    Yes, the idea that death from something else could save me is a bit counter-intuitive, but it's probably true in this case--the only difficulty is in figuring the odds and making a decision.

  7. #7
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    Quote Originally Posted by lancepeace View Post
    Urology with rectal exams and scopes, etc. is not the most glamorous medical field and many doctors seem kind of crude. Many do DRE's that are kind of aggressive.
    You could get a FreePSA blood test from your GP. (High is better on this test.) There are other blood tests that are also informative.
    The chance of complications from a biopsy are low. I got Cipro before and after the biopsy.
    I would suggest further blood tests at the least. Good luck.
    Thanks much. I'm hoping for a test that will assess the "dangerousness" of the nodule. That seems to be the Holy Grail that is still the target that many are searching for.......the fact that those three doctors had MRIs as their FIRST test when they themselves had nodules keeps coming back to me.

  8. #8
    Welcome Walnut. You will get great insight and advice here. I had Gleason 7 PC with a PSA of 2.9 so that in and of itself is not that indicative of PC. Do you have other symptoms like weak urine flow or ED issues which point to an enlarged prostate? I had three biopsies ever 6 years to check for PC and never had any issues of infection or pain. I had what I considered a very conscientious and experienced urologist who I trusted enough to do my surgery and believe he has got me cancer free. They do exist and I would suggest you find yourself one.
    Good luck and stay positive,
    Fran
    BD 1950
    DRE in 2005 showed right lobe enlarged/hard
    Biopsies in 2006 and 2009 both negative
    Biopsy May 2013 positive 1 of 14 cores
    4+3=7 T2a. PSA 2.9
    daVinci surgery 7/17/13 by Dr. Dennis LaRock
    Final pathology 7/29/13
    Tumor size 1.5 cm
    PC found on both lobes (biopsy indicated one)
    T2b Gleason 4+3=7
    Negative margins
    first post surgery psa 8/30/13 undetectable
    second post surgery psa 11/23/13 undetectable
    18 month post surgery psa 2/17/15 undetectable
    5 year post surgery psa 3/20/18 undetectable

  9. #9
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    Hi Walnut, The dilemma here is that you don't know if you have cancer. But you could certainly have it, but then the question is how aggressive is it? It sounds like your visit to the doctor sent you down a bit of an emotional path to prove him wrong... trust me, I know the feeling. But what if you do have cancer? The only real way to get a chance of knowing if you do and how bad it might be is to have a biopsy. Really the biopsy should be an easy decision for you IMHO... without it, you just don't know. Of course you could just continue to monitor your PSA and hope that the nodule is nothing and if you have cancer it is not aggressive...
    Age 60, DOB 11/1957, 6'2", 230#
    2013 PSA Jan:4.5, Mar:3.4, Jul:4.6, Oct:8.1, Nov:7.7
    Normal DRE
    08/29/2013 Biopsy: 2/12 positive (RLM,RLA), <5%/core, Gleason 3+3
    09/24/2013 John Hopkins Pathology: 2/12, 5% & 10%, G3+3, 2 HGPIN
    01/16/2014 RALP by Dr. Tewari, Final Path: G6, 5% involvement, neg Margins
    No incontinence, minimal ED issues after two weeks post-op
    NICE Guidance & NCCN Guidance

  10. #10
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    Quote Originally Posted by Flkjr View Post
    Welcome Walnut. You will get great insight and advice here. I had Gleason 7 PC with a PSA of 2.9 so that in and of itself is not that indicative of PC. Do you have other symptoms like weak urine flow or ED issues which point to an enlarged prostate? I had three biopsies ever 6 years to check for PC and never had any issues of infection or pain. I had what I considered a very conscientious and experienced urologist who I trusted enough to do my surgery and believe he has got me cancer free. They do exist and I would suggest you find yourself one.
    Good luck and stay positive,
    Fran
    Thanks, I'm sexually functional (a little slowed down at 67, but working without drugs so far) and I can sleep through until five or six a.m. most nights, so I'd regard my urinary function about par for age maybe better than some.

    Yes, I suppose there will be a second try at a urologist sooner rather than later. I'm just hoping to hear of better tests coming along.

 

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