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Cancer: Prostate Message Board

Cancer: Prostate Board Index

Hi Folks. This is my first post, 53 year old male. A year ago I was experiencing frequent urination for the first time and went to my GP who did a DRE (normal) and PSA test. The number was 1.8. He also prescribed Cipro although that did not really seem to do the trick, so I went to a urologist for further evaluation. He also did a DRE (normal) but no PSA at the time, but suggested I try Finasteride to see if that would alleviate the symptoms. About three months into the Finasteride, I saw the Uro again and had a PSA and DRE (again normal) and the PSA was 1.0. He mentioned at the time, that because of the Finasteride he would like to see the number go below 1.0, but said not to worry that it probably will in time. Fast forward to last week (10 months later) and I saw him again and he did a very thorough and "normal" DRE, but also informed me that my PSA had gone up to 1.3, which is really more like 2.6 when you factor in the Finasteride. He told me to come back in 6 months for another PSA.

Is this cause for concern? My father had PC at age 71, and it was an aggressive form, although he had a very successful prostatectomy and is thriving and living well at 84. My gut tells me that I should pursue a biopsy, even though I really don't want to, but I need to be proactive. My health is decent otherwise, but my work keeps me up long hours and my diet is variable.

One question : Does anyone know if EVERYONE responds to Finasteride the same way, meaning a full 50% reduction in PSA? Is it possible that one can build up a resistance to it? (OK, that's two questions)


PS The only study that I could find where they actually specifically tested for the reduction in PSA of Finasteride was this one, but there is a caveat as all of the 3000 men tested had also been diagnosed with BPH (I was not diagnosed with that and each time my doctor said my prostate did not feel enlarged). It would seem that the PSA reduction would be skewed greater in BPH patients :

"Finasteride causes a decrease in serum PSA levels by approximately 50% in patients with BPH, even in the presence of prostate cancer. This decrease is predictable over the entire range of PSA values, although it may vary in individual patients. Analysis of PSA data from over 3000 patients in a long-term efficacy and safety study confirmed that in typical patients treated with Finasteride for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men. This adjustment preserves the sensitivity and specificity of the PSA assay and maintains its ability to detect prostate cancer."
[COLOR="DarkGreen"]Hi Willies,

Welcome to the board, though hopefully you will not become a full member. ;)

Baptista has already covered important points, but I hope this will catch you in time to reconsider getting a biopsy now. It may be the best course, but the decision deserves some more information and thought. I'll add some thoughts in green using your post #3 as the base:

First I am reconstructing your information as follows. Is it correct?

-mid-February 2010: See GP for frequent urination:
normal DRE, prescribed Cipro and finasteride.

-late July 2010: See uro as frequent urination continuing. First PSA 1.8 after five to six months of finasteride; DRE normal. (There was no October consultation based on your detailed review of the record.)

-mid-May 2011 See uro: PSA 1.3; thorough DRE normal, advised to get another PSA in six months.

[QUOTE=TheWillies;4760263]Hi Baptista. Thanks for your assessment. I had to go back and look at my medical records this morning and discovered that ...That first test was 1.08 (actual number from the result page). The second test 10 months later was 1.29, so approximately a 20% increase. (if you factor in the Finasteride at 50%, then the actual numbers are closer to 2.2 on the first test and 2.6 on the second).

Even with that, I am concerned enough to go back to the Uro and request a biopsy.[/QUOTE]

[COLOR="darkgreen"]Your current decision is reasonable, but it may not be the best course, and your uro's plan is also reasonable. A point toward going ahead now is that increasing PSA after finasteride has cleaned up the picture by reducing "noise" in the PSA signal from any BPH. Finasteride appears also to eliminate low-grade prostate cancer - the kind that is almost always not lethal, thereby eliminating another kind of noise.

On the other hand, there can be substantial day-to-day variation in PSA, and it could also well be that a subtle infection is still driving part or all of the elevation. A short course or even a longer course of just one antibiotic like Cipro is frequently not sufficient to eliminate an infection or inflammation of the prostate. Are you still experiencing frequency of urination, which is often a signal for continuing infection?

So what's the cost of doing a biopsy now? The best source I know on this is an outstanding recent book (August 2010) entitled "Invasion of the Prostate Snatchers - No More [I][U]Unnecessary[/U][/I] Biopsies, Radical Treatment or Loss of Sexual Potency," (my Italics and underlining) by Ralph H. Blum (the doctor's patient) and Mark Scholz, MD, an expert medical oncologist whose practice is dedicated to prostate cancer. Chapter 8, pages 79-86, is entitled "To Biopsy or Not to Biopsy: Opening Pandora's Box." Here are some sentences that explain the chapter title: "Very few men understand what they are getting into when a biopsy is recommended. Family doctors and urologists schedule biopsies at the first sign of an elevated PSA, rarely educating their patients about what is likely to follow. Once a diagnosis of cancer is made, irrational fears drive most men into immediate radical therapy, even though [I]Low-Risk[/I] [author's emphasis] prostate cancer is not life threatening. Having a biopsy can be like opening Pandora's box."

The chapter goes on to discuss how biopsies often lead to overtreatment, a widely acknowledged fact, several rare but real risks of biopsies, substantial but limited effectiveness of biopsies (fail to pick up cancer 20% of the time while succeeding 80% of the time), insurance considerations (pre-existing conditions, a concern that will be erased for many by the new health reform law), BPH and its influence on PSA and biopsy decisions, PSA density, PSA velocity, other causes for a PSA increase, the role of the DRE, PCA-3 tests (more about this below), and two approaches the doctor does not care for ("free PSA" testing - because it is thrown off by infections, which often produce low scores (meaning less than 10%), and age-based PSA standards, because there is too much variation among men in each age range).

The doctor recommends simply repeating the PSA test as a first step; that can smoke out day-to-day variation. He follows that with a standard recommendation to try to discover and eliminate any infection. If those don't eliminate the concern, he suggests doing a PCA-3 test, a color Doppler ultrasound of the prostate (done by one of the few experts with special CDU equipment; reveals vascularity - new blood vessel formation, which is associated with cancer), or a spectrographic endorectal MRI. Among other clues, this will establish prostate size, permitting calculation of PSA density. (A version of the PCA-3 test, PCA3Plus, is analyzed by the highly respected pathology company Bostwick Laboratories in Richmond, VA.) Doctor Scholz summarizes as follows: "If the PCA-3 and PSA density are favorable, and if imaging fails to reveal any worrisome lesions, active surveillance with frequent PSA and PCA-3 testing, along with periodic imaging, may be preferable to an immediate biopsy." Of course, if the doctor is able to find the appropriate antibiotic for an infection, that may drive the PSA downward and resolve the issue.

One of the concerns the doctor mentions is risk of infection that will require hospitalization. This is still considered rare, but a recent research paper indicated it is a growing concern, a concern mentioned by experts, especially for patients who may have been exposed to bacteria that are resistant to antibiotics. While the biopsy itself would be very unlikely to directly cause such an infection, the biopsy needle may open the door to a harbored infection as it transits through the rectum. The bottom line here is that biopsies are very important and well-worth the rare risks they entail, provided they are employed in a sound manner.

I'm impressed that your urologist is actually looking for another PSA data point at this time rather than rushing to a biopsy; that's a good sign that he is keeping up with research and sound practice. Here's what I would do as I try to see the world from your viewpoint: have a repeat PSA now, and perhaps again in three months, and have a PCA3Plus test done (requires an "attentive" - meaning fairly vigorous, minute long prostate massage, which causes some prostate cells to be shed into urine, which is then collected and analyzed). [/COLOR]

[QUOTE]Given my family history, it's entirely possibly that it's only a matter of time before I am diagnosed with prostate cancer, so I may as well get it over with sooner than later, especially when the prognosis will be potentially better. [/QUOTE]

[COLOR="darkgreen"]That sure is not the way I would look at it! First, [I][U]genes are not destiny[/U][/I], and we already know a lot about how lifestyle tactics, such as diet, exercise and stress reduction, appear to influence prostate cancer. The "epigenetic" environment that determines whether genes are turned on or not is very important. Second, while some men are very fortunate in being able to have curative therapy with minimal impact on their lives, the vast majority is not so fortunate. Curative prostate therapy is [U]not like an appendectomy[/U] where you can get it done and over quickly without a long tail of side effects. Therapy is worth the burden when the risk posed by the cancer is major; often it is not major, something that was not realized as recently as eight years ago when the first success for "active surveillance" began to be published.

Also, if you have cancer and it is appropriately assessed and monitored, your prognosis should be virtually as good even if treatment is deferred. That is the sound and appealing approach known as "active surveillance", an approach whose effectiveness has been well documented during the past ten years. Meanwhile, while treatment - if it is ever necessary - is deferred, your outcome should be much better due to the constant pace of substantial improvement in prostate cancer technology. One option - surgery - is often considered inadvisable once a patient turns 70, but you are a long way from age 70, and surgery is far from the only option, and is arguably not the best option for many patients.[/COLOR]

[QUOTE]I was focused on the effect of the Finasteride more from a wishful thinking perspective, that not everyone responds in such a predictable way to it and that perhaps it was not having as much of an effect on me as it did on others that were part of the study. Maybe too analytical and optimistic ...

All The Best.[/QUOTE]

[COLOR="darkgreen"]That course of finasteride is likely preventing any low-grade prostate cancer, and it has provided you with a clearer signal, triggering legitimate concern. Just don't get spooked. Try to find out the rest of what is going on.

Take care and hang in there,

Jim :wave:[/COLOR]
Jim, you're response was awesome and much appreciated! Just to clarify (we may have been writing at the same time) - I just repeated the PSA yesterday (after six weeks) and already got my results. Here is a synopsis :

February 2010 - Almost overnight experienced frequent urination for the first time in my life.

February 2010 - Went to GP right after and got a DRE (normal, maybe slight enlargement) and PSA (result 1.8) He put me on Cipro and Finasteride (5mg).

April 2010 - Frequency was still an issue, so went to Uro who did a DRE (normal) but no PSA. He said I should follow-up with him in 3 mos. to see where we were with the Finasteride and another PSA.

July 2010 - Uro does another DRE (all of these were "normal") and a PSA (result 1.08). He was moderately happy with this but wanted the number a little lower taking the Finasteride into account.

April 2011 - Went to Uro for a checkup. Did PSA. On follow-up informed me that the number was 1.3 with the Finasteride, which was a concern. He then did a DRE and told me to see him in 6 mos. for a further evaluation. I start doing some research and found that an effective PSA of 2.6 is not all that great for someone my age and decide to go back to the Uro in 6 weeks for another PSA.

May 2011 - Was reminded by wife that we had a very active night and morning before the last PSA (how could I forget?), plus I started looking at the date and that weekend I had also done a 45 mile bike ride and my test was the following Monday. This time I abstained for 6 days and did no bike riding prior and the result just came back at .87, which the Uro was comfortable with. For me, I will keep after this from now on and do a PSA every 6 months until I feel that the number has stabilized and then review that with my Uro who is pretty pro-active.

Jim, thanks again - I know that I probably did not present this info as carefully as I should have. I'll come back and post again if things start getting dicey. If so, I will definitely consider your suggestions with regards to further testing (PSA3Plus) versus immediate biopsy.

All The Best!

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