Bad doctor, bad diagnosis, or bad luck?

July 17, 2015 12:28 PM

How do I respond to a puzzling prostate cancer possibility?

First off, I know you are not my doctor.

I am a 48-year-old Caucasian male. Both my father and his brother have been treated for prostate cancer. Last year my was PSA 1.5 and DRE results favorable. This month my PSA was 2.4. My urologist did not perform a DRE. He immediately had me schedule a biopsy. Gulp.

A little Googling shows me that the PSA test is not regarded as a useful diagnostic tool. And a biopsy sounds like an unpleasant and expensive experience.

I don't feel particularly comfortable with this doctor, and I am having a hard time finding a positive way to deal with this situation.

I honestly do not know what to do. Should I ignore the PSA? Should I find another doctor? Or just do exactly what the urologist says and get the biopsy?

posted by anonymous to Health & Fitness (15 answers total)

The PSA is a tool physician use for screening and monitoring purposes. With your family history, it's a smart move. A continual rise in PSA is a sign. I think he's taking the fastest and route to diagnosis. You could see another physician, but they may recommend you watch and wait and have your PSA tested again and frequently; but the fear is that you wait too long and don't catch it at an early stage.
posted by Sara_NOT_Sarah at 1:01 PM on July 17, 2015 [4 favorites]

I'm not a doctor and I'm not a man, but I've had a bunch of friends/family who have had prostate cancer and/or prostate cancer scares, and as a general rule I am of the opinion that overdiagnosis (of many diseases, not just prostate cancer) is a big problem. And in your shoes, I would have the biopsy.

I would also probably find a different urologist, one you're comfortable with, for a second opinion anyway.

But you are at an age at which prostate cancer can be virulent. You don't say at what age your father and uncle were treated, but in my layperson's language, there are two kinds of prostate cancer -- Old Guy prostate cancer, which most men die *with*, and Young Guy prostate cancer, which some men die *of*. Young Guy prostate cancer really does require treatment and it doesn't get better, more fun, or less invasive if treatment is put off.

If I were you, I would want to know.
posted by janey47 at 1:03 PM on July 17, 2015 [6 favorites]

Seconding the other posters, based on my reading (I'm not a doctor, just a patient), I'd say have the biopsy. And then, if it's positive, have surgery. Take care of this.

I've had two prostate biopsies. One was pretty unpleasant. Based on that, and on discussions with others, I'd recommend you take a serious painkiller before the biopsy, like an opiate. Get it from the urologist, or from another doc.

Urologists, being surgeons, sometimes don't really understand pain.
posted by JimN2TAW at 1:44 PM on July 17, 2015 [1 favorite]

I've read that article you linked. They warn about too many "false positives." My attitude is that a positive PSA test can't be a "false" positive if it leads you to have a biopsy and find out what's really going on, particularly in view of the family history. Ruling out prostate cancer is a benefit in itself.
posted by JimN2TAW at 1:59 PM on July 17, 2015

Your family history makes a biopsy a reasonable thing to do. Definitely find a uro you're comfortable with and get a second opinion. That's a a pretty sizeable one-year jump; search for "PSA velocity" to get an idea of its significance.
posted by Johnny Wallflower at 2:05 PM on July 17, 2015 [1 favorite]

I'm going to chime in on the other side. I'm a 54 year old male with past prostate problems. I would wait and have another PSA test in a few months to see the trend. One elevated PSA can just be an outlier. With me it just turned out to be a persistent infection that required two courses of different anti-biotics. I had the prostate biopsy and I will never have another one unless my PSA is way out of whack. Graphic description of biopsy follows, you have been warned.
You will get a local anesthetic and be turned on your side. A probe will be inserted into your rectum. A series of biopsies will be taken by a spring loaded needle into your prostate. They will take several samples (I think 12 or 16 is the normal number, I don't remember). After that you'll be given pain meds and sent home. You will be very uncomfortable (hurt like hell) for a couple of days. You will have blood in your ejaculate for the next dozen or so times you have an orgasm. That can be very disconcerting. Like I said, it was an overall very unpleasant experience and I hope to never have to do it again.
posted by Grumpy old geek at 2:20 PM on July 17, 2015

Might I recommend this book.
posted by kevinsp8 at 3:41 PM on July 17, 2015

PC survivor here. I agree that a retest is in order before the biopsy. PSA results vary for various reasons. My doc ordered a sonogram before he went to the biopsy. My biopsy experience was not as frightful as described above, though it was along the same lines.

PC in younger men is sometimes more dangerous than what is typical in older men.

I think saying their is over diagnosis is incorrect. The problem is over treatment.
posted by SemiSalt at 4:37 PM on July 17, 2015

My husband was 50 years old when his PSA showed 2.1, he had the biopsy done. Be sure and ask for a nerve pill and a pain pill before hand, it is not pleasant. His biopsy came back positive, he had the robotic surgery that removed the prostate. Thankfully the cancer was contained and he is cancer free. He said he would do it all over again if he had to, there are side effects but he is happy to be alive.
posted by just asking at 4:47 PM on July 17, 2015

I think you're right to be skeptical about a biopsy. From a 2011 NPR report:

Doctors call it "PSA velocity," the change in the level of a chemical in the blood called prostate-specific antigen. In recent years, many doctors have come to rely on it as the best indicator for when it's time for an initial biopsy to check for prostate cancer.

But PSA velocity has come under challenge. A recent article in the Journal of the National Cancer Institute concludes that a rising PSA is no better sign of incipient prostate cancer than the old signal — a PSA level over a specific threshold. That's often 4 nanograms of PSA in a thousandth of a liter of blood. (A healthy man's PSA level can range from zero to 10 and beyond.)

Here's the journal article.

If you are concerned about the increase in your PSA level, why not go to another physician, probably your primary care physician, for a repeat PSA test and possibly a DRE?
posted by Snerd at 6:55 PM on July 17, 2015

You might ask your urologist about the various diagnostic tests that can be done after a slightly higher psa but before biopsy. These include phi, 4Kscore, pca3, and others. They can provide more information before going through with a biopsy. These diagnostics may be expensive though and/or not covered by insurance.

Disclaimer, my employer has a financial interest in the use of these diagnostics.
posted by Tandem Affinity at 7:18 PM on July 17, 2015

Here's my experience as the former wife of PCa patient. First, when you have a biopsy insist on having it somewhere where you are given mild anesthetic. Some doctors just take the samples, basically plugs of tissue without any pain relieving meds at all...it was very unpleasant. Secondly, given your family history this is a wise decision, but there are factors that can increase your PSA. Did you have sex within 10 days of the blood draw? Any inflammation issues? To get a true reading you need to clear out those factors first. The prostate gland gets very little blood flow and so taking anti-inflammatories or an antibiotic to clear up a case of prosititis takes some time to really take hold. Wait until those issues can be cleared out and then take another PSA. Third, don't let anyone rush you. There are multiple treatment options. We elected to have radioactive seed implants and that was a good choice. BTW, my ex was 44 at time of diagnosis and is 59 now with a good outcome.
posted by OkTwigs at 7:58 PM on July 17, 2015

Go to an academic cancer center. I can't state that such a place will automatically be better than where you are -- but the incentive to churn procedures is less and the desire to practice defensive is less (from my experience) in such places. Also, repeat the PSA. (Perhaps you went to an academic place and it's moot).

In good hands, the getting a sample of your prostate should be safe, but you are young and your father and uncle's prostate cancer history might be more significant depending upon when they were diagnosed (younger for them could be worse for you).

If you can stomach it, you can wait a couple months and recheck the PSA.

Good luck either way and it's good you're doing your homework on it.
posted by skepticallypleased at 9:42 PM on July 17, 2015

Did you get an ultrasound? are there specific nodules that the urologist wants to biopsy? If not, then demand it.
If so, yes, you should submit to this procedure with this urologist (or another urologist if this one isn't cutting it for you) Getting the peace of mind from a negative biopsy is fantastic, and knowing what you're contending with otherwise is time and pain well spent.
posted by Cold Lurkey at 10:04 PM on July 17, 2015

the trendline idea is a good one. Seasonal variation in PSA testing:
http://www.medscape.com/viewarticle/737351
posted by egk at 6:10 AM on July 19, 2015