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Is biopsy the right decision?

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User
Posted 25 Aug 2018 at 22:34

HI all,

Long story short!

Annual work health check showed PSA of 3.9 and I'm 53 years old, almost 54!

GP referred me as he's instructed to do and I saw consultant who said DRE felt normal but slightly enlarged.

He referred me for another blood test, ultrasound and MpMRI which I had 10 days later.

Saw another consultant today in outpatients who said PSA still 3.9, ultrasound and MRI both clear.

Then the chat started over merits of having a biopsy still and almost felt like he wanted me to, just to ensure there was no comeback later! He said it was unusual for someone with raised PSA not to be asking him for one.

Anyway, after some deliberation I decided to complete the diagnostic trail and have the TRUS biopsy.

He did say he's had patients with no PSA elevation that turned out to have cancer and my slightly raised PSA could be caused by a slight enlargement but that really they're not sure.

It does seem that once you have these PSA tests and if there's a raised level, there's a pathway you must complete.

Probably a very good thing however I was expecting him to say MRI and Ultrasound normal, off you go! 

User
Posted 26 Aug 2018 at 21:02
All I can say to reassure you is that pretty much everyone here has had a biopsy and got through it OK. I've personally had both types, a TRUS and a template biopsy. It's not the way I'd choose to spend an afternoon, but on the unpleasantness scale I'd put it on a par with having a filling at the dentist.

You'll survive it just like we all have.

Chris

User
Posted 26 Aug 2018 at 07:49
A TRUS biopsy with no target from MRI will not be definitive proof of NOT having cancer. Template maybe BUT as the article below discusses a "clear" 3T MP MRI may be a valid diagnostic tool on its own for people in future:

https://www.practiceupdate.com/content/aua-policy-statement-on-the-use-of-mri-in-the-diagnosis-staging-and-management-of-prostate-cancer/58028/62

Other articles on that site have concluded that MPMRI is reliable at detecting "clinically significant" PC ie the sort that would warrant intervention.

So it would be worth asking your urologist if you are a candidate for active monitoring with MPMRI. Or at least what his opinion is.

User
Posted 26 Aug 2018 at 08:24

There is a danger of overreacting, and panic driving you down a pathway which might not be justified.

I was reading an article recently which was proposing that in the early stages (like you and me) we eliminate the big scary word of "cancer"!!!!!!!, and say you have an Indolent Lesions of Epithelial Origin. The reasoning being that in the vast majority of cases it's so slow growing that it will never spread and be an issue before we die of something else.

Whilst I am in no position to recommend anything, it gives a different perspective to the decision making process.

If you want to follow it up, Google will help. 

User
Posted 26 Aug 2018 at 09:07

Originally Posted by: Online Community Member
Other articles on that site have concluded that MPMRI is reliable at detecting "clinically significant" PC ie the sort that would warrant intervention.

Perhaps worth noting that I had a clear mpMRI scan, but a biopsy subsequently found Gleason 3+4 T2C cancer. Mind you, my PSA was 32, which was a bit of a clue that something was there to find!

Chris

 

User
Posted 26 Aug 2018 at 11:59

PSA is under 4 is classed as ‘normal’ for your age, according to the NHS, but clearly not classed as ‘normal’ by your consultants!

mpMRI scans can be done by older machines at 1.5T (Tesla) resololution, and the newer and more accurate machines at 3T - think Hi-Def, 4K, UltraHD - which have much improved imaging. What resolution was your scan? In your case, where there is no obvious lesion, it could be crucial. If you’ve got a big 15mm lump like I had, it would be picked up on both 1.5T and 3T scanners, but 3T is more likely to pick up small spots of extra-prostatic spread.

I would tend to have another PSA in three months, and if it has increased, ask for a 3T scan if yours was not, and then if recommended, go for a template biopsy.

Read elsewhere and on here regarding opinions about TRUS v template. If you have the first one you may end up having to have the second later!

Best of luck.

Cheers, John

Edited by member 26 Aug 2018 at 12:23  | Reason: Not specified

User
Posted 26 Aug 2018 at 12:54

Hi Stevev,

In my case I had a PSA of 12 and a slightly enlarged prostate. I was 63 at the time. The first MRI (3T) showed nothing and so I left it for eighteen months whilst monitoring my PSA every four. It stayed stable. Finally the strain of wondering if I was playing Russian Roulette for too long got to me and I consulted another Urology team who used a contrast agent on their 3T MRI machines. That showed two legions, which through a TP biopsy returned a Gleason 4+3 T1C.M0N0 diagnosis. The ethics of using a trace agent on MRI's is a whole different subject which I won't go into here but there is growing concern that the Gadolinium based agents used are highly toxic and might well be banned in future.

Frankly at your age with a PSA of 3.9 and nothing showing on an MRI you would be sound in deciding to watch and wait, but there is a bit of an 'industry' that pushes people along a path regardless of their condition. The first urologist I consulted made it clear that unless I submitted to a TRUSS biopsy, cystoscopy and MRI then he was not interested in talking to me! Needless to say I went elsewhere.

If you do go for the biopsy then make it a Trans Perennial one. The TRUSS method is crude, painful and not without considerable risks. It has also been likened to putting two black golf balls into a bucket full of white ones and asking the Urologist to pick them out with his eyes shut. The TP is far more accurate, it's done with a general anaesthetic in one day and apart from imitating John Wayne's walk for a day or so free of pain. 

If you are unhappy about being  led along the 'pathway' then jump off at any time, but don't be afraid to consult other Doctors when you're ready.

 

 

User
Posted 26 Aug 2018 at 14:02

Hi Steve,

If I were in your position with private health insurance I would check if the scan was at 3T first of all. Sounds like it might have been.

But as I said in the first place, have another PSA in three months and take it from there. You may very well be clean as a whistle, and I know am playing fast and loose with a complete stranger’s health, but just sayin’!

The TRUS biopsy is the NHS’s way of saving money to the detriment of your wellbeing. Get a template biopsy done privately if it is deemed necessary, which would be particularly apposite in your case with nothing showing.

If there is cause for concern, consult a top urological surgeon specialising in prostate cancer for an opinion and likewise a top oncologist with the same speciality. You can easily find who they are as they cannot be named here. You need to obtain all your medical notes including the DVD of your scan (if 3T) before you see them.

Hopefully all a false alarm!

Cheers, John

Edited by member 26 Aug 2018 at 17:48  | Reason: Not specified

User
Posted 26 Aug 2018 at 16:04

If you're MRI came back without showing anything you would have a strong argument in asking for a TP biopsy. The TRUSS method would be a pure fishing trip based on no prior knowledge. At best it might catch something, at worst it would be a painful and risky waste of time. I looked at privately funding a TP one and it worked out about £2.5k for a basic one, and about £4.5k for one with a superimposed MRI image. My surgeon told me not to bother spending the extra as he could get the same results working from the MRI report. In the end I had it on the NHS. As far as I am aware you are entitled to request the treatment that you desire. You are not forced to accept whatever the 'default' is in your area. 

The bottom line is to ask yourself how worried are you likely to be over the coming year or two if you postpone any further investigation. I did exactly that (and I had a much higher PSA) but in the end decided that knowing was better than not doing so. Each one of us is different. 

Having a low PSA is not a sole reason to ignore the risk of Pca. I have a close friend who's just had a T3 tumour removed via surgery and his PSA never went above 4! That said, he could feel it when he sat down and what came out was as hard as a walnut. His GP had simply never probed far enough on the DRE to feel it.

Good luck with your MRI results. The pathway is up to you. You can climb aboard the train or jump off at any point. No one is forcing you to do anything.

Go with your heart and do what you feel is right for you. The help line nurses here on PCa UK are great and will happily talk you through things. I used them a number of times prior to deciding on treatment and they were all marvellous. 

 

 

Edited by member 26 Aug 2018 at 16:08  | Reason: Not specified

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User
Posted 26 Aug 2018 at 07:49
A TRUS biopsy with no target from MRI will not be definitive proof of NOT having cancer. Template maybe BUT as the article below discusses a "clear" 3T MP MRI may be a valid diagnostic tool on its own for people in future:

https://www.practiceupdate.com/content/aua-policy-statement-on-the-use-of-mri-in-the-diagnosis-staging-and-management-of-prostate-cancer/58028/62

Other articles on that site have concluded that MPMRI is reliable at detecting "clinically significant" PC ie the sort that would warrant intervention.

So it would be worth asking your urologist if you are a candidate for active monitoring with MPMRI. Or at least what his opinion is.

User
Posted 26 Aug 2018 at 08:24

There is a danger of overreacting, and panic driving you down a pathway which might not be justified.

I was reading an article recently which was proposing that in the early stages (like you and me) we eliminate the big scary word of "cancer"!!!!!!!, and say you have an Indolent Lesions of Epithelial Origin. The reasoning being that in the vast majority of cases it's so slow growing that it will never spread and be an issue before we die of something else.

Whilst I am in no position to recommend anything, it gives a different perspective to the decision making process.

If you want to follow it up, Google will help. 

User
Posted 26 Aug 2018 at 09:07

Originally Posted by: Online Community Member
Other articles on that site have concluded that MPMRI is reliable at detecting "clinically significant" PC ie the sort that would warrant intervention.

Perhaps worth noting that I had a clear mpMRI scan, but a biopsy subsequently found Gleason 3+4 T2C cancer. Mind you, my PSA was 32, which was a bit of a clue that something was there to find!

Chris

 

User
Posted 26 Aug 2018 at 11:59

PSA is under 4 is classed as ‘normal’ for your age, according to the NHS, but clearly not classed as ‘normal’ by your consultants!

mpMRI scans can be done by older machines at 1.5T (Tesla) resololution, and the newer and more accurate machines at 3T - think Hi-Def, 4K, UltraHD - which have much improved imaging. What resolution was your scan? In your case, where there is no obvious lesion, it could be crucial. If you’ve got a big 15mm lump like I had, it would be picked up on both 1.5T and 3T scanners, but 3T is more likely to pick up small spots of extra-prostatic spread.

I would tend to have another PSA in three months, and if it has increased, ask for a 3T scan if yours was not, and then if recommended, go for a template biopsy.

Read elsewhere and on here regarding opinions about TRUS v template. If you have the first one you may end up having to have the second later!

Best of luck.

Cheers, John

Edited by member 26 Aug 2018 at 12:23  | Reason: Not specified

User
Posted 26 Aug 2018 at 12:28
Hi John,

Regarding MRI resolution, I don't honestly know other than it was done by an external company that parks up outside hospitals in those lorries!

I did ask the radiologist and he replied that their scanners were the very latest 'state of the art scanners and in most cases better than the ones in the hospitals', so I'm hopeful it was one of the highest resolution ones.

I am lucky enough to have private healthcare however the NHS pathway route seems very quick in Kent so I see no benefit in going private unless I need anything further following biopsies.

User
Posted 26 Aug 2018 at 12:54

Hi Stevev,

In my case I had a PSA of 12 and a slightly enlarged prostate. I was 63 at the time. The first MRI (3T) showed nothing and so I left it for eighteen months whilst monitoring my PSA every four. It stayed stable. Finally the strain of wondering if I was playing Russian Roulette for too long got to me and I consulted another Urology team who used a contrast agent on their 3T MRI machines. That showed two legions, which through a TP biopsy returned a Gleason 4+3 T1C.M0N0 diagnosis. The ethics of using a trace agent on MRI's is a whole different subject which I won't go into here but there is growing concern that the Gadolinium based agents used are highly toxic and might well be banned in future.

Frankly at your age with a PSA of 3.9 and nothing showing on an MRI you would be sound in deciding to watch and wait, but there is a bit of an 'industry' that pushes people along a path regardless of their condition. The first urologist I consulted made it clear that unless I submitted to a TRUSS biopsy, cystoscopy and MRI then he was not interested in talking to me! Needless to say I went elsewhere.

If you do go for the biopsy then make it a Trans Perennial one. The TRUSS method is crude, painful and not without considerable risks. It has also been likened to putting two black golf balls into a bucket full of white ones and asking the Urologist to pick them out with his eyes shut. The TP is far more accurate, it's done with a general anaesthetic in one day and apart from imitating John Wayne's walk for a day or so free of pain. 

If you are unhappy about being  led along the 'pathway' then jump off at any time, but don't be afraid to consult other Doctors when you're ready.

 

 

User
Posted 26 Aug 2018 at 13:43

I'm getting the vibe that if I'm going to have a biopsy, go for a TP one and not the TRUS.

Not actually sure if the NHS gives me a choice or not if I'm honest, I'm guessing that TRUS is the default?

I could dive off into the private path I guess which would probably let me choose and certainly have a chat with a chosen consultant rather than one of his registrars that I saw the other day.

Decisions decisions....

 

User
Posted 26 Aug 2018 at 14:02

Hi Steve,

If I were in your position with private health insurance I would check if the scan was at 3T first of all. Sounds like it might have been.

But as I said in the first place, have another PSA in three months and take it from there. You may very well be clean as a whistle, and I know am playing fast and loose with a complete stranger’s health, but just sayin’!

The TRUS biopsy is the NHS’s way of saving money to the detriment of your wellbeing. Get a template biopsy done privately if it is deemed necessary, which would be particularly apposite in your case with nothing showing.

If there is cause for concern, consult a top urological surgeon specialising in prostate cancer for an opinion and likewise a top oncologist with the same speciality. You can easily find who they are as they cannot be named here. You need to obtain all your medical notes including the DVD of your scan (if 3T) before you see them.

Hopefully all a false alarm!

Cheers, John

Edited by member 26 Aug 2018 at 17:48  | Reason: Not specified

User
Posted 26 Aug 2018 at 16:04

If you're MRI came back without showing anything you would have a strong argument in asking for a TP biopsy. The TRUSS method would be a pure fishing trip based on no prior knowledge. At best it might catch something, at worst it would be a painful and risky waste of time. I looked at privately funding a TP one and it worked out about £2.5k for a basic one, and about £4.5k for one with a superimposed MRI image. My surgeon told me not to bother spending the extra as he could get the same results working from the MRI report. In the end I had it on the NHS. As far as I am aware you are entitled to request the treatment that you desire. You are not forced to accept whatever the 'default' is in your area. 

The bottom line is to ask yourself how worried are you likely to be over the coming year or two if you postpone any further investigation. I did exactly that (and I had a much higher PSA) but in the end decided that knowing was better than not doing so. Each one of us is different. 

Having a low PSA is not a sole reason to ignore the risk of Pca. I have a close friend who's just had a T3 tumour removed via surgery and his PSA never went above 4! That said, he could feel it when he sat down and what came out was as hard as a walnut. His GP had simply never probed far enough on the DRE to feel it.

Good luck with your MRI results. The pathway is up to you. You can climb aboard the train or jump off at any point. No one is forcing you to do anything.

Go with your heart and do what you feel is right for you. The help line nurses here on PCa UK are great and will happily talk you through things. I used them a number of times prior to deciding on treatment and they were all marvellous. 

 

 

Edited by member 26 Aug 2018 at 16:08  | Reason: Not specified

User
Posted 26 Aug 2018 at 17:38
N.B. T3 stage cancer is not the same thing as 3T resolution of an MRI scan!
User
Posted 26 Aug 2018 at 19:27

Hi Steve,

A TRUS biopsy is uncomfortable but not painful for the vast majority.  It does 12 samples whereas the other does about 40.  I don't know how many TRUS biopsies are done every year but it might be over 40,000.  There are 44000 cases of PCa and some more will be benign.

The latest thinking is to have a mri first.

At 53 normal psa is below 3. Yours is still quite low compared to most on here so it could small or benign.

What isn't helpful is there's always the exception and so it's how comfortable you feel about it. Some are more able to handle uncertainty. I'll admit I wasn't good with uncertainty  but the results were plainly not good.

User
Posted 26 Aug 2018 at 20:40

Hi steve yours sounds a similar story too mine , im nearly 53 with a PSA OF 3.8 ( WITH A SCORE OF 2.5 , being the normal for my age) my GP referered me to the specialist telling me too try not too worry as only 1 in 10 need a biopsy after i asked for blood test querying the frequency of my trips too the loo . now the specialist at the hospital was telling to get the atibiotics prescribed before as they will  be needed if they go ahead with the biopsy , when i quired was that not a waste of resources if not needed this % then went upto 50/50 .... they do seem too be pushing for me too have the biopsy , my main concern is the DRE X2 was bad enough and there is now way i could have a large probe inserted for 15-20 as someone on here described when the doctors fingers x2 was bad enough for me . i wonder could i be put out cold for the opp if i am going to under a local anesthetic ? hear you not suppossed to google too much ( could be wrong info ) but did see one report say 75% of men have a biopsy that they didnt need ? how much does this procedure cost the NHS as i presume they wont just dish them out willy nilly 

User
Posted 26 Aug 2018 at 21:02
All I can say to reassure you is that pretty much everyone here has had a biopsy and got through it OK. I've personally had both types, a TRUS and a template biopsy. It's not the way I'd choose to spend an afternoon, but on the unpleasantness scale I'd put it on a par with having a filling at the dentist.

You'll survive it just like we all have.

Chris

User
Posted 30 Aug 2018 at 21:26

I had a TP biopsy fourty needles in the template ,seven were cancer the rest were clear ,it was painless just take the recommended dose of paracetamol for a couple of days and you won’t suffer at all.

User
Posted 09 Sep 2018 at 10:15
Have they started you on any treatment? I'm waiting for my results and am not sure how watchful waiting to radiation etc are determined. Were 7 out of 40 considered needing any course of treatment? I know I'll have to wait and see and discuss it with the Urologist. If there is any cancer found that is. Waiting is quite stressful, as we all know...
User
Posted 09 Sep 2018 at 10:44
Your biopsy results will be discussed by the regional multi-disciplinary team (MDT), who will collectively decide what options are appropriate to offer in your case. This may be nothing at all (Active Surveillance) or they may offer surgery, hormone therapy followed by radiotherapy, or give you the choice. In my own case they recommended against surgery due to my comparatively high PSA of 32, so I was put on HT, with RT to follow next February.

Chris

User
Posted 09 Sep 2018 at 17:55

After the results of the biopsy which had a small cancerous tumor,my consultant sent me for a bone scan to see if it had spread,it hadn’t so two weeks later I was having a radical prostectomy my Prostate was as big as a tennis ball ,so radiation or ht wasn’t an option my symptoms were urine retention in January 2018 my operation was April 17 everything is great apart from some erectile dysfunction which seems to be showing some slight improvement my recent PSA score was undetectable. So to sumerise I had all the scans, biopsies operation in three months all on the NHS .

User
Posted 09 Sep 2018 at 18:07

Ask your consultant for a TP biopsy it really was painless if you take your pain relieve tablets nobody l know has had a trus biopsy it’s old fashioned 

 

User
Posted 09 Sep 2018 at 18:39
If you have a TRUS (cheapo for the NHS) biopsy and your results are marginal, you may well be referred for a proper template biopsy afterwards.

If you have substantial cancer it would be picked up either way. So cut out the middle-man and go for template right away in the first instance.

Cheers, John.

 
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