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Cancer: Prostate Message Board


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[QUOTE=ThinBones;3928838]My husband had a PSA of 3.5 a little over a year ago along with DRE revealing an enlarged prostate. He has been on Flomax. He went to urologist a few weeks ago for follow-up and PSA was 4.6. Immediate biopsy was ordered, no DRE done. This was solely based on the increase in PSA. I asked about the test for free antigen, nurse said that would not tell us anything. All the recent news articles have me confused and concerned. What concerns me more is my husband had a massive heart attack less than two years ago, now stable with plavix, etc. Going the route of biopsy, etc. has me concerned as he has to stop his blood thinner for a week before biopsy and I believe he should at least have blood test to show free or attached antigen. Not sure I am wording this right, but anyone have any opinion? No cancer in family history, but also no cardiac history either. He is 56. Thanks for listening.[/QUOTE]

Hi, ThinBones,
I give a second to the posting by Daff. Your husband is lucky to have a spouse helping him with health issues and the decisions that accompany them. His urologist, knowing his cardiac problems, must be convinced the benefits of his advice justify the risks. With his not repeating the DRE, I presume no suspicious areas were detected in the one done last year.
I would like to underline the point Daff made about the value of not counting on just the statistical probability of a problem. I did not have a free PSA...and the PSA was of no help. I had prostate cancer...and am very pleased that I did not wait on the PSA (free...or non-free) to finally indicate a high probability of cancer. If it had been detected later, the treatment would not have been as likely to have a good outcome. The urologist must be concerned enough about the level for his age...and for the rise in one year...and, knowing about the heart problems...is pretty convinced the level and rate of the rise are not related to infection or other non-cancer causes.
If you are uncomfortable about the biopsy decision and the answers to your husband's questioning the urologist, perhaps Daff's wondering about a second opinion would be reassuring to you and your husband. This is too personal and too important for laymen to recommend a decision or course of action. It is a complicated matter--even without having had a "massive heart attack." I am not minimizing the feature of the combined problem (my brother had cancer diagnosed after having had a massive heart attack; not an easy combination with which to cope). Thinking of my brother's effective but tough treatment for cancer, I would say that having a gentle non-intrusive treatment of cancer sounds very desirable for a CAD patient. Detecting cancer early before it has spread to remote areas has the great advantage of allowing a patient more choices...including optimistic choices. I had the treatment that Daff had: proton therapy. That therapy ...for me...took out most of the fear and dread about having cancer. If my brother is ever detected with prostate cancer that has not spread, I will be happy that Chicago will have by then TWO treatment centers (if he would have before the construction is finished, he can spend a couple months in Bloomington,IN, Jacksonville, FL, or Loma Linda, California.) The treatment would be very gentle on his heart and the other body parts.
Good luck. I hope your husband finds these postings helpful in getting optimum benefit from his doctors. I guess you found this web site helpful in giving and receiving information and support. We welcome him.
Dale2035
[QUOTE=ThinBones;3928838]My husband had a PSA of 3.5 a little over a year ago along with DRE revealing an enlarged prostate. ... He went to urologist a few weeks ago for follow-up and PSA was 4.6. Immediate biopsy was ordered, no DRE done. This was solely based on the increase in PSA. I asked about the test for free antigen, nurse said that would not tell us anything. All the recent news articles have me confused and concerned. What concerns me more is my husband had a massive heart attack less than two years ago, now stable with plavix, etc. Going the route of biopsy, etc. has me concerned as he has to stop his blood thinner for a week before biopsy and I believe he should at least have blood test to show free or attached antigen. ... No cancer in family history, but also no cardiac history either. He is 56. Thanks for listening.[/QUOTE]

Hi ThinBones,

(By the way, your name applied to me too, but I'm doing very well in my ninth year controlling the bone density with Fosamax for most of the time, then Boniva, both with calcium and vitamin D3 supplements. I'm now at close to normal for bone density. :) )

But back to your post (1st on thread) - Dale and Daff have made many good points. I would just like to join their chorus and make a few other points.

First, I don't wonder that you are confused by that news about whether screening for prostate cancer is worthwhile. I lot of people I know who are fairly knowledgeable about the disease are also confused. However, when carefully thought through, the case for screening is clear and strong. There are a couple of recent threads about it. Unfortunately, it appears that a strong motivation to hold down health care costs, coupled with a low regard for the value of lives of senior men, is clouding the vision of many in the health care community. :( :mad:

Second, that nurse is just ill informed about the value of the free PSA test, from my viewpoint, but I am a layman and may be missing something. It is possible that infection would throw off the free PSA score so that it looks like your husband could have cancer, but the score would not be thrown off if the problem is just an enlarged prostate. (Also, see about the PCA3Plus test below.) I think one of you should call back and ask WHY they don't think a free PSA would be worthwhile. This is a good opportunity to practice that sometimes challenging combination of tact and assertiveness.

The one answer that would at least be reasonable would be that they are convinced that a rise of 1.1 in about a year warrants a biopsy regardless of what the outcome of the free PSA would be. If it were me, I would want the information from that free PSA. It could turn out that the free percentage was high - say 30%; that would not be conclusive, but it would suggest fairly strongly that your husband did not have prostate cancer.

That rise of 1.1 could also be the result of BPH alone, of an infection, or a benign combination - BPH plus infection without any cancer. Then too, it could be all of those things plus a little cancer.

Of course, it is possible, but I think unlikely, that it is due mostly to cancer. Here's some good news for you to consider: very important, highly regarded research published in 2004 and 2005 discovered that the rate of PSA rise (its "velocity") in the year before diagnosis was an important clue to the aggressiveness of prostate cancer, and that this clue was independent of the other long-established main clues, primarily the stage, PSA level, and "Gleason Score" (which you get from a biopsy). Since your husband's velocity was 1.1 or lower (how much lower depending on how much more than a year passed between tests), he is clearly on the good side of this important yardstick! :D

You can check out these papers yourself on a website we are allowed to use on this board because it is Government sponsored, known as PubMed, for Public Medicine. It's a unit of our National Institutes of Health, in particular the National Library of Medicine, and the address is [url]www.pubmed.gov[/url]. You can search with your own string, but you will also be able to find the results using this: " d'amico a [au] AND (2004 [dp] OR 2005 [dp]) AND PSA velocity ". I just ran that exact string and got 5 hits. The two main papers are hits 3 and 5, and both are available free using the link on PubMed, though you can click on the hypertext (blue) authors' lists and get a short abstract of each.

If you study the papers, you will see what a huge difference this factor makes (whether the velocity is more than 2.0). In fact, you will see that your husband is even more fortunate by having a rise as low as about 1. And, part of that increase is almost surely due to his enlarged prostate, meaning that any rise due to cancer was very likely lower than 1.0. :D

About enlargement of the prostate - Each cubic centimeter of healthy prostate tissue accounts for about 0.066 of PSA. Therefore, if the prostate is enlarged - let's use 50 for an example instead of the more normal 20 to 30 - you would expect a PSA of about 3.3. Let's say it's [U]really enlarged[/U] but within the range of what can happen - say 100 cc; you would expect a healthy PSA of about 6.6. Get the idea? (By the way, this figure (0.066) is from research, and is described with a reference, in the book "A Primer on Prostate Cancer - The Empowered Patient's Guide," by Dr. Stephen B. Strum and Donna Pogliano, page F4. That book is an outstanding resource. It also describes free PSA and other staging techniques, among its wealth of topics that patients should know about.)

You or your husband should ask the urology office whether they have an estimate of the size of the prostate based on last year's DRE. You could then use the 0.066 multiplier to see how much of last year's PSA had a likely benign explanation. If he got a new DRE now, the sizes could be compared, and possibly some of that 1.1 increase likely explained as due to further enlargement that was probably not related to cancer. (In my opinion, the doctor should have recorded his opinion of that previous DRE; my urologist does that and notes his estimate of the size and any observations about the feel and shape.)

Has your husband talked to his cardio doctor about stopping that blood thinner? That seems like an important base to touch.

There is another simple test that is better than free PSA as a followup. It's known as PCA3Plus, and it could go a long way toward ruling prostate cancer in or out. The PCA3Plus test is [U]not[/U] affected by inflammation of the prostate (including infection), as I understand it - fairly sure that's correct. The PCA3Plus test involves a massage of the prostate by the doctor for about a minute to cause some cells to be shed into urine, and then the urine is collected and shipped to a special lab. You can probably find a nearby doctor who would do the massage and shipping - perhaps the urologist your husband is now seeing. If not, you could call the company that makes the PCA3Plus kits.

Even if your husband does have prostate cancer, it's a disease that many men can live [U][I]with[/I][/U] very well with no treatment at all [U][I]if[/I][/U] they have a truly low risk case. Even if the case is not so low risk, for a man who has had a massive heart attack, the dominant health threat is almost surely heart related and not prostate cancer related as I understand it as a savvy layman. (The key is to base your decisions as best you can on how serious the cancer is: it can vary from what one prominent doctor compared to a "case of dandruff" at one end of the range to a case of aggressive pancreatic or lung cancer at the other end. Research has proven that many men actually have quite mild cases of prostate cancer. However, those who have aggressive cancer really need to jump on it and hit it hard!)

A large group of doctors is now arguing that many men should not even be screened for prostate cancer because of the risks and expense of overtreatment. I don't agree with them in general, for what I believe are compelling reasons, but I'll agree that their case is much stronger for a man who has had serious heart trouble. I still think screening is appropriate for a man like your husband, but I'm convinced, based on what I think I understand from experts specializing in prostate cancer, that he should not get just the usual workup without allowance for his heart condition.

You and your husband might want to handle this by non-biopsy methods for now. In addition to watching the PSA trend, the free PSA result, the PCA3Plus result, and another DRE, your husband could have some imaging work done. Trans Rectal Ultrasound (TRUS) is normally used as part of a biopsy, but it can be done without doing the biopsy. It can at least give a pretty tight estimate of the size of the prostate, which helps with interpretation of other clues as I mentioned before. In the hands of an ultrasound expert who specializes in prostate cancer, it can also provide other clues.

Another newly emerging approach to possible prostate cancer is to use the generic drug finasteride (also known as Proscar) on a "challenge" basis. Basically, PSA should fall by about 50% in six months. If it does, prostate cancer is still possible but not likely. If it does not, that too is not conclusive, but it is a basis for increased concern. As you may know, finasteride is an important drug for treating BPH, so your husband could get a double benefit. He actually would get a triple benefit, as finasteride is the only agent [U]proven[/U] to reduce the risk of prostate cancer (by about 30%, formerly thought to be 25%), and we are now virtually certain that it does this safely. It is a mild drug, though there are a few possible but unlikely side effects, which are reversible if the drug is stopped. The recent thread on finasteride discusses some of this. The drug Avodart could probably also be used in this role, and there is preliminary evidence that it is even more effective than finasteride. We should know more soon if results of a large clinical trial are released later this spring, as expected.

Simple dietary, nutrition, supplement, exercise and stress reduction tactics also seem to help a lot both with prostate cancer and cardiovascular health. A heart-healthy diet will cover most of the prostate cancer bases as well. Are you already into that?

I guess all this is my way of saying that I too would think twice about getting that biopsy at this point. Not doing it would run some risk, but, from my layman's viewpoint, that risk does not look large, especially when balanced with overall risks your husband faces, including a very small risk from the biopsy itself given his health history. I would sure ask the heart specialist about that. (He may well not know much about prostate cancer - medicine is highly specialized these days.) As you have probably already figured out, surgery would very likely be ruled out for your husband because of his history. There are some other options if it becomes clear that prostate cancer is a major threat. One of them would be "active surveillance" and deferral of major treatment, provided the aggressiveness level is not too high.

Well, this is getting long, and I don't want to overload you with information. Please stay in touch with the board and follow up with any questions you or your husband might have.

It's clear you both have had some health challenges. Keep your spirits up, and good luck to you both.

Take care,

Jim :wave:





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