How can my 74 yr old ex husband make an informed decision about his super high PSA results?

September 8, 2009 11:12 PM

I am good friends with my ex husband. He learned a couple of months ago that his PSA was over 20. He was also having a serious problem with his leg at the time (he had a femoral by pass surgery). That surgery went well and he has recovered from it..but during that time the high PSA results were put on the back burner until he could get through the surgery.

Ex was buoyed by reading that very high results can be accounted for by other reasons aside from cancer and his urologist prescribed Avodart and scheduled a new PSA test (which came back recently..much improved..down to 8).

Far from congratulating my ex for this improved number the urologist told him today that ex very likely has prostate cancer and he should have a biopsy and whatever treatments the biopsy indicates. The trouble is that ex h and I have both read articles that indicate that biopsies might actually cause cancer to get into the bloodstream (and if you think of it this seems very logical). When this concern was raised with the urologist today (according to ex's account) the Doctor lost patience and told ex that it is all his decision and he can't decide for him..and further, that the article my ex cited is "old."

Ex's problem is complicated by the fact he has a colostomy and his prostate can not be accessed by normal means. I realize all these health problems I have described make him sound like a total wreck..but he isn't, he has had quite good health for most of his life and he is strong and youthful.

I know you aren't his doctor...but what about his age (74) and the idea that biopsy can spread cancer? How can anyone be expected to make a good decision with so many conflicting ideas about both PSA and biopsy?
This is quite a terrible predicament where you have to rely on people who make money with surgeries and strategies that you have no way of knowing are going to extend life or not! When ex asked the dr what would he do if he were in ex's position the answer was naturally biopsy and surgery!

Please help us to figure out where to go for better easy to understand information that can help him to determine a good plan.

posted by naplesyellow to health & fitness (9 comments total)

The article you link to makes no claim that a biopsy can 'cause' cancer to get into the bloodstream. It sounds pretty illogical to me - it can't spread anything that wasn't already there, and if it is there then the biopsy will make sure you get treated for it.

cancer.gov says that various things can be used to indicate the presence of cancer but says that you need a biopsy to confirm. So, what he wants to know in order to make a decision is what the various outcomes are likely to be if

a) he has cancer and does/doesn't get the biopsy
b) he doesn't have cancer and does/doesn't get a biopsy
posted by jacalata at 12:05 AM on September 9

No procedure in medicine is risk free. Even if the biopsy needle did displace some, let's say cancerous cells for the sake of simplicity, into the bloodstream that doesn't mean that they will all develop into tumors elsewhere. Other things need to happen beyond that. But the prostate is a highly vascular organ and it's very likely that if he does have cancer, those cells will invade a blood vessel at some point and spread all by themselves.

Basically the risk of doing a procedure is always considered against the risk of not doing it. His urologist knows much more about his health status than anyone on MeFi and is obviously in the best position to make the right decision.

And there are several surgical approaches to the prostate. Having a colostomy doesn't rule the possibility of surgery out.

Good luck.
posted by sero_venientibus_ossa at 4:41 AM on September 9

Prostate cancer is very slow-growing, but it grows, no matter where it goes in the body. If the biopsy procedure were causing prostate cancer cells to spread outside the prostate, then the millions of men who have had biopsies would be getting secondary cancers all over their bodies, and this is simply not the case. There's no way to know whether, in a minuscule percentage of cases, it does happen, but even then, the benefits of proper diagnosis and treatment far outweigh the risks. A PSA of 8 is serious business and strongly suggests there is significant cancer. He should have the biopsy.
posted by beagle at 4:42 AM on September 9

If your ex-husband feels conflicted about the advice he received from his doctor, the natural course of action is to seek a second opinion at a (different) university affiliated medical center. You husband can state clearly to the second doctor that they will not be considered for follow-up treatment, and thereby remove the (very unlikely) financial motivation for any recommended course of action.

Risk/benefit analysis is part of every surgeon's job, and they should be given the benefit of the doubt that they have primarily a patients best interests at heart. Doctors frequently become exasperated when people without sufficient scientific knowledge to properly analyze studies reach contrary conclusions based on their imperfect reading of a study. It is not a great trait, but it is understandable when you see firsthand how many patients base risk/benefit analysis and life-altering decisions on misunderstood or incorrect information found on the internet.

The best designed studies can be criticized in valid ways, but well-trained physicians and surgeons are able to critique both studies and critical reviews of studies, and properly classify conclusions that are proven and conclusions that are interesting but are not fully supported by the available evidence and may require further research. Your ex could ask the current doctor or the next doctor for a brief summary of why the article you believe is relevant may not be relevant in his case. A good doctor will be happy to briefly explain their reasoning, provided they feel you are open to reconsidering your position based on factual information. If you appear too sure of all the answers already and are merely asking them to back you up, you may not receive the response you hope for.
posted by McGuillicuddy at 5:43 AM on September 9

Regardless of what a bunch of benign strangers advise, he needs the advice of a patient and dispassionate professional, which the urologist seems not be. That doctor's totally unhelpful emotional reaction coupled with throwing the decision back in the patient's face (and yes, of course it is the patient's decision; that's not the point) are a huge red flag that you need to seek someone else's opinion - another, more mature, urologist. Not a "second opinion" - a new opinion (the first is totally unreliable), and quite possibly backed by a second reliable opinion. Do totally discount the current urologist's advice; he sounds like he's too involved (ego? remuneration? who knows?) to be trusted.
posted by TruncatedTiller at 5:56 AM on September 9 [1 favorite has favorites]

{Oops - too quick on the 'submit'}
... And best of luck, with both your further choice of physician/advisors and with whatever treatment he decides to pursue.
posted by TruncatedTiller at 5:57 AM on September 9

There has been some debate recently about whether the benefits of screening for prostate cancer outweigh the harms -- treatment for prostate cancer is available, but the side effects can be unpleasant (incontinence, impotence). Often prostate cancer is slow-growing & asymptomatic, but not always. I heard a story on NPR about this last week -- apparently a federal task force recommended against PSA screening for men older than 75 for these reasons.

That being said, if I were your ex-husband, I would seek a second opinion from a physician not inclined to blow off my concerns.


Disclosure: IANAD, but I've worked in research at a cancer center for the last 4 years.
posted by oh really at 6:33 AM on September 9 [1 favorite has favorites]

My Dad was recently diagnosed with prostate cancer. His PSA was 13, and his cancer was determined to be moderately aggressive.

He is having the DaVinci procedure done next week. It's robotic-assisted surgery that is minimally invasive.

As I understand it, any PSA above 4 is reason for concern. If your ex-husband has a biopsy, the doctor can determine his Gleason Score and the severity of the cancer. From there, your ex and his doctor can decide what to do. If it's slow-growing, many men just take a "watchful waiting" approach. There's also seeding, radiation, high-intensity focused ultrasound therapy, and other treatments available.

My Dad's doctor was able to do a digital exam as well, and by this alone he knew it was cancer from the way my Dad's prostate felt.

I have found the Cancer Survivor's Network Forums (run by the American Cancer Society) to be extremely helpful in understanding prostate cancer.

I have not run across any accounts of biopsies causing cancer. Usually the doctor will want to do a biopsy first, and then if the cancer appears aggressive, he/she will order a bone scan, MRI and cat scan to make sure that the cancer hasn't metastasized.

It's easy to think Cancer = Death Sentence, but that's not true, especially not with prostate cancer. The fact that your ex is strong and youthful bodes well for recovery if he does decide to do surgery.

Also, check into local prostate cancer support groups. They are a great source of information, especially when it comes to the best doctors and surgeons in your area.
posted by Ostara at 7:21 AM on September 9 [1 favorite has favorites]

Results of a major study were reported earlier this year, concluding that the PSA number, by itself, means nothing, but that the trend of the PSA number over time is important. If it's rising, it indicates the possibility of prostate cancer. (There's at least one other test, the PCA3, that is a more reliable indicator — he might consider getting that test.)

Seconding looking for a support group, preferably led by a medical professional, to discuss his issues before he goes to a different doctor. (That first one sounds like a real jerk!)
posted by exphysicist345 at 8:43 PM on September 9 [1 favorite has favorites]