Advice needed on Prostate Biopsy etc

[R123]

Recently as my PSA test result had increased the urologist who I consulted in Pattaya gave me the option of a Prostate Biopsy or 3 months of medication namely Tomsulosin (harrel ocas) which treats an enlarged prostate. I opted for the later for the time being.

Today I read this article:

http://www.dailymail.co.uk/news/article-2536823/Invasive-tests-prostate-cancer-failing-spot-disease-Thousands-men-forced-painful-biopsies.html

If this article is accurate, no way would I have a prostate biopsy.

Has anyone any input and any experience of either the aforesaid biopsy or instead the availability and having the MRI Prostate scan in Thailand?

Many thanks in advance.

[Tolley]

I would never have one. You could take the MRI which also might pick up other things but I think a PET scan is even better for detecting cancer.

[FBN]

PSA results alone are not enough to justify a biopsy. You did not mention levels or if the PSA test result have been repeated or if the current recommendation is a result of a series of tests that showed an increase over a few weeks/months.

What is the result of the rectal examination? Any nodules detected?

If this recommendation to have a biopsy, or indeed treatment, I would suggest to seek a second opinion from a reputable urologist rather urgently..

[R123]

PSA results alone are not enough to justify a biopsy. You did not mention levels or if the PSA test result have been repeated or if the current recommendation is a result of a series of tests that showed an increase over a few weeks/months. What is the result of the rectal examination? Any nodules detected? If this recommendation to have a biopsy, or indeed treatment, I would suggest to seek a second opinion from a reputable urologist rather urgently..

In November 2012 my PSA level was 4.86 and end of December 2013 it is 5.97. The rectal exam suggests enlarged prostrate. No mention of nodules.

(by the way I am 63).

so any further input?

Thanks the replies .

It will be my intention at some stage to seek a second opinion. Seems at least the meds I am on as mentioned above are appropriate.

[Kitsune]

It's doing more harm than good, to prevent prostate cancer, eat well.

[Sheryl]

I would not agree that the PSA test across the board "does more harm than good" but its results need to be intelligently reviewed with reference to the larger clinical picture, the overall trend of the PSA levels over time, the patient's age etc. It is also useful to look not only at the PSA level but also at the percentage of free PSA

"Indications for prostate biopsy are not set in stone. Initially, patients with a prostate-specific antigen (PSA) value higher than 4.0 ng/mL were believed to have an absolute indication. Biopsy typically was also recommended for patients with suspicious findings on digital rectal examination (DRE). However, the current established practice is that no PSA value exists that can establish with absolute certainty whether a patient does or does not have prostate cancer. Thus, the decision whether to proceed with prostate biopsy must be individualized in every case. Nomograms and predictive models have been developed to assist in this decision, but none have been able to provide a definite go/no go decision." http://emedicine.medscape.com/article/1949728-overview#aw2aab6b2b2

In the OP's case, the PSA is only mildly elevated (normal range in a 63 year old is up to 4.5) but the DRE showed an enlarged prostate. Very possible this is benign prostatic hypertrophy (BPH) but cannot be certain there is no malignancy. It would be helpful to know the ratio of free to total PSA. See http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/81944.

In addition to the free PSA:total PSA ratio, the PSA velocity (speed with which it rises) is useful in differentiating BPH from prostate cancer. The PSA rises in both conditions but the rate of rise is faster in cancer. Here again OP's findings are somewhat borderline. Usually in BPH the rise year to year is less than 0.75, his was 1.11 -- higher but not drastically so and this is from only 2 readings. Most urologists would agree that a rise by more than 0.75 over a year demonstrated over 3 separate tests (i.e. a two year period) warrants a biopsy. Whether the single finding from two tests does is more difficult to say. It would not be unreasonable to wait another 12 months and repeat the PSA and DRE. If at that point here has been a further increase of >0.75 and/or a further increase in prostate size despite treatment with tamusulosin, then a biopsy really is essential. You can certainly insist on an MRI-guided biospy, and that will reduce the risks of a false negative.

While a prostate biopsy is not something to rush into, the Daily Mail is not a good source of medical information and the article cited is a bit slanted. Also note it does not advise against biopsies, only that they be done better using newest techniques and if possible preceded by an MRI as this helps pinpoint the location where cancerous cells are likely to be found and thus help decrease the risks of a false negative. If an MRI is done and is positive, a biopsy is still necessary. MRIs are not an alternative to biopsy, just a means of rendering biopsies more accurate. http://www.ncbi.nlm.nih.gov/pubmed/23495081

While not a fun experience, most men do not describe prostate biopsy as being as painful as the news article implies (do a search in this forum for "prostate biopsy" for some first hand accounts).

[R123]

Sheryl:

May I thank u so much for your detailed and useful posting.

U mention:

"It would be helpful to know the ratio of free to total PSA. See http://www.mayomedic...erpretive/81944."

According to the Lab report it reads:

Free PSA........................................................................: 1.15 ng/mL

Free: Total PSA..............................................................: 0.19

So, in the light of that if u have further input I would be most grateful,

Kind regards.

Edited January 10, 2014 by R123

[Sheryl]

As you will see in the mayo clinic link, a 0.19 ratio is comparatively low risk for cancer, less than a quarter of men your age with that finding have cancer whereas almost half do when the ratio is 0.10 or less. Of course, a 20-23% chance of cancer is not negligible but it is better than it could be. Ultimately you and your doctor have to decide but most doctors would be comfortable with waiting another 12 months and then repeating the PSA and DRE, treating for BPH in the interim. If you do that and it still shows a further significant rise, then biopsy is unavoidable. I am assuming of course that the enlargement on DRE did not include any nodules and seemed consistent with BPH. From what you indicate the doctor said, seems so (assuming he is a well qualified and experienced urologist).

[bannork]

I would like to add my experience of treatment of prostate cancer in Bangkok, it may help some poster one day.

Last year I went to Vajira hospital on Samsen road with problems of frequent urination. A blood test showed a PSA of 60 , Gleason score of 4/3 ! I had a biopsy there, 2 nights in hospital, the results were cancer so the doctor recommended a bone scan. I was shocked, just found out I had prostate cancer and now it's to determine to see if it's reached stage 4! I later found out it was standard procedure as other treatments other than hormone therapy would be pointless if it had.

But it was the doc's attitude that concerned me -' If it's reached the bones, treatment is easy' was his reply, -'so you'd prefer it if it had' were my thoughts.

The cancer hadn't but the doc seemed to have no clear plan for treatment, plus I was on a catheter by this time as the biopsy had inflamed the prostate and urinating was impossible.

This was when I came on here and Sheryl, the moderator, recommended a doctor in a hospital on Sukhumvit for a consultation, I knew I couldn't afford the treatment fees but at least I might get an idea of what choices I had.

I didn't see the doctor she recommended but the doctor I saw was very helpful and said first I needed a CT scan to see how much the cancer had developed.

I had that at the very new hospital for kidney diseases, results the same day, impressive service and treatment. By now I had moved hospitals to Ramathibodi hospital on Rama 6 road on the advice of a Thai colleague.

Here I was under Dr Kittirat, who incidentally knew my doc from Vajira, he was in the year before during training.

He said the CT scan was not conclusive, I needed an MRI scan focusing exclusively on the prostate region to get more absolute data.

That showed the cancer breaking out of the prostate capsule, he recommended removal of the prostate-the MR1 showed 90% of one side cancerous, 60% on the other.

He only does 2 types of operation of removal of the prostate, keyhole surgery for 100,000 baht or keyhole with robot for 200,000 baht, the benefit of the latter is enlargement viewing of the area, hence greater accuracy, life expectancy post op was the same for both. I'm just a poor teacher but luckily mother offered to pay so I had the robotic surgery.

Excellent treatment and post op care, I was out within 4 days, the doc said he didn't know if he had cleared up all the cancer or not, I would have a blood test in early May, ( op was early January) but radiation was not a good idea until the sphincter muscle had healed allowing control of urination, otherwise the radiation would destroy it. He said they had a year post op before radiation would be essential.

I had also been put on Casodex hormone pills to try to slow down the cancer, I first bought them from the hospital for the extremely expensive price of 20,000 baht for 28 pills, one a day, but luckily I know someone who knows a pharmacist supplying hospitals and now I get them for 8,000 baht a month. The doctor thought that was very amusing, perhaps we could go into business together!

Back for my blood test in early May and my PSA had fallen to 0.02 or 0.2 I can't remember, from 60 pre op!, he said this was obviously an excellent sign, radiation was delayed another 3 months as I still hadn't gained full control of the bladder. Strangely at night I could wake up and go for a steady stream in the bowl, but in the day, no control. I assume this maybe due to gravity, I notice standing up quickly causes me to go!

Anyway, Dr Kittinat said by now, 4 months post op, I should have better control and I was urged to increase the pelvic floor muscles from 3 times a day to 10. It's true I have been negligent in that area as I've been working hard on the family farm the last 6 weeks.

I realize that Vajira hospital is only funded by the BMA not the government, they are overwhelmed by the number of patients and treatment is certainly cheaper than elsewhere, but I must say I heartily recommend Ramathibodi hospital and Dr Kittirat, not only does he seem to be good at his job, he is also very sympathetic and cheerful, and all round care and service from the nurses is excellent.

And many thanks to Sheryl for pointing me in the right direction initially.

[GaryB1263]

Excellent post. Thanks everybody.

[Lefty]

Just to provide my experience, while in Houston in 2012 I had a PSA test which showed an 11.5,extremely high..Saw a Urologist who did rectal exam after which recommended a biopsy.This was 12 specimen biopsy and done in office. Not much pain or discomfort.Results were positive for cancer.Next step was visiting M.D. Anderson in Houston,probably within the top 1-3 cancer hospitals in U.S..Offered 2 options- operation or radiation. Chose radiation after much discussion with doctors.

Underwent a month of radiation, no discomfort.All expenses-about $150,000 was totally covered by Medicare and my medigap policy.,I do a PSA test every 6 months here in Korat and email my Cancer doctor the results which have been running 0.004-0.006. No adverse effects.

Lefty

[uptheos]

I would never have one. You could take the MRI which also might pick up other things but I think a PET scan is even better for detecting cancer.

Are there many hospitals here, with PET scanners?

[healthbkkbkk]

Hi,

The doctor did do at least an Ultra Sound to determine the size of your prostate? Or perhaps it had been done previously?

We can discuss and debate medical conditions all day but doing so over the internet won't produce any valid feedback vis-a-vis a medical standing. At the minimum you should seek a second opinion before going any further with diagnostic and treatment options.

On a personal level, after experiencing bleeding and EXTREME pain after ejaculations, I consulted with 2 Urologists, had the basic tests done and in the end decided to allow nature and G_D to proceed as they think best. Under no circumstances would I allow a biopsy or curative treatment at my age. I feel, and this is just me, that the disadvantages outweigh the possible benefits. If I were a younger man and my family absolutely needed me to live then of course I would do everything possible to survive but these days I feel rather redundant. (I am not advising you to do the same as these are decisions only a Man's conscience and heart can make).

I feel for you and wish you all the best in courage and in health.

Xavier

P.S. I have no experience with the new urine tests available but here is a link:

http://www.pcf.org/site/c.leJRIROrEpH/b.8833993/k.EC93/New_Urine_Test_for_Prostate_Cancer_Available_Unlike_PSA_Test_is_UltraSpecific_for_Prostate_Cancer.htm

Edited May 11, 2014 by healthbkkbkk

[healthbkkbkk]

I've been debating about writing this then I thought that if I were in your place I would want someone to inform me.

Tamsulosin and Cardura have about the same efficiency but Cardura does not have the (sometimes) sexual side-effects of Tamsulosin. In fact Cardura often improves erectile function.

Just a thought that you might want to discuss with your doctor. Cardura is also sold as a generic here and is very inexpensive (but not the slow release form).

Edited May 12, 2014 by healthbkkbkk

[Sheryl]

I would never have one. You could take the MRI which also might pick up other things but I think a PET scan is even better for detecting cancer.

Are there many hospitals here, with PET scanners?

No

Ultrasound, CT, MRI and (where available) PET scans can determine if a lesion is present, its size and location (which is helpful in guiding a biopsy) and may indicate how suspicious it is for cancer but cannot diagnose cancer.

Only a biopsy can do this. In addition a biopsy not only determines if cancer but the type of cancer cell which can be very important in terms of how likely the cancer is to respond to radiation or chemo and how aggressive it is likely to be. In older men with prostate cancer especially, the aggressiveness of the cancer is an important consideration as sometimes it is bets just to let the cancer be. (Not so in younger men and may not be so even in older men if it is a very aggressive cancer...death from prostate cancer usually occurs after bone metastases occurs first and is thus very painful.)

Many posts in this forum on prostate biopsy and almost all attest that it s not that bad to go through.

In the OP's case however there was advice to wait a while before proceeding to biopsy for reasons specific to his situation.

[bannork]

The biopsy I had was really a piece of cake, okay it's mildly humiliating, your legs are strapped in to 2 stirrups and hoisted upwards as if you're about to give birth but everyone is a professional doing their job and it only took about 15 minutes. I experienced no pain, the doc gave a local anaesthetic and really I was ready to leave within half an hour but they kept me in for observation in case of infection.

The CT scan is okay, it's like being at the dentist's, you just have to imagine you're somewhere else, The MRI was marginally more uncomfortable as the machine makes all these heavy industrial sounds like bad German heavy industrial rock, out of tune Kraftwerk or house music, but they give you headphones to lessen the noise and the detail available from the MRI is tremendous.

[giddyup]

Has anyone heard of Prostatic Artery Embolisation? Only came across it researching the subject, it basically blocks the blood supply to the prostate by using tiny beads to block the artery that supplies the blood.

[cheeryble]

Hi R123

Some months ago or more I gathered a whole load of evidence to make decisions about my own PSA results which were similar to yours (modest urinary symptoms too) and presented it in this forum. (One of them you can google if you're good at reading evidence is the USPSTF policy statement on PSA testing….the longer version with background which is a mine of information which is generally somewhat relaxing)

Without looking up right now I can remember a couple of things which may be very relevant.

1. At age 65 approx half of men have SOME FORM of prostate cancer (some are so benign it has been suggested they are called something other than cancer). Before you freak their danger can be judged by that fact only about 1 man in 35 in the US actually die of prostate cancer.

2. Whilst PSA readings, absolute and rise over time, are poor indicators, the one thing PSA predicts well is prostate size.

Well many men get enlarged prostate, BPH.

In my own case I said to the doctor hang on if my prostate is 50% or more bigger in any dimension it means its over three (1.5 cubed) times bigger in volume, so should I not be EXPECTING a matching high PSA reading? He kinda agreed. Your own urinary symptoms suggest you also have an enlarged prostate like this…….had an ultrasound to measure it?

3. The most dangerous form of cancer oddly does NOT produce much PSA…..which may mean that those men with a prostate will always be at danger of a virulent cancer which can get them perhaps quicker than they can respond.

4. Sheryl in our previous discussion pointed out that types of tumour can flip to a more dangerous type after some period of years…..so perhaps this needs to be in the equation as it means one may prefer to be better aware of whats going on down there. (Hope I represent you faithfully Sheryl).

We decided against the biopsy for then and to check again which is now overdue.

He mentioned the PSA can be useful in that if it goes over 20 you really can't ignore it.

I'm still kinda on the fence about whether to just take my chances of the pretty low death rate (and MOST of those deaths importantly when they DO come are at a HIGH age), though sometime i may well need reduction of the prostate to treat BPH for which I get mildish urinary symptoms.

Now I'm on the path of PSA testing (which you probably know is NOT now recommended for symptomless men as leading to more harm than good), I shall probably go for my check soon, but right now pretty relaxed.

My last point is a very old friend recently visited from abroad…..he had had PC travelling across to his spine he said.

Anyway the prostate was removed and it all seems successful, and he said far from losing something he felt that with no sexual desire (antiandrogenics too) he enjoyed life more…..was a more relaxed person all round.

Hope that helps……it's a complicated one!

Edited May 13, 2014 by cheeryble

[Sheryl]

....I'm still kinda on the fence about whether to just take my chances of the pretty low death rate (and MOST of those deaths importantly when they DO come are at a HIGH age), though sometime i may well need reduction of the prostate to treat BPH for which I get mildish urinary symptoms.

The death rate varies greatly according to how aggressive the cancer type is and the age at onset.

Another point to consider is that dying of (of as opposed to "with") prostate cancer is highly undesirable even at an advanced age, because it mestastizes to bone and can be excrutiatingly painful. So avoiding death is not the only concern.

But Cheeryble at this point there is no reason to think you have PC. You may just have BPH. The course you have chosen is reasonable enough under your circumstances, for now, but don't skip on follow up PSAs.

[cheeryble]

Thanks Sheryl agreed

Sent from my iPad using ThaiVisa app

[apiwan]

My bit.

I was told my psa was high in the UK.

While waiting for biopsy tool a medical in Los .

Told me the usual cholesterol blah blah.

But said my psa was good

I will keep an eye on it .

Biopsy can and will cause infection . And so on .

If you really don't need it don't do it.

I'm 46 today :-)

Sent from my SM-N9005 using Thaivisa Connect Thailand mobile app

[giddyup]

<script type='text/javascript'>window.mod_pagespeed_start = Number(new Date());</script>

....I'm still kinda on the fence about whether to just take my chances of the pretty low death rate (and MOST of those deaths importantly when they DO come are at a HIGH age), though sometime i may well need reduction of the prostate to treat BPH for which I get mildish urinary symptoms.

The death rate varies greatly according to how aggressive the cancer type is and the age at onset.

Another point to consider is that dying of (of as opposed to "with") prostate cancer is highly undesirable even at an advanced age, because it mestastizes to bone and can be excrutiatingly painful. So avoiding death is not the only concern.

But Cheeryble at this point there is no reason to think you have PC. You may just have BPH. The course you have chosen is reasonable enough under your circumstances, for now, but don't skip on follow up PSAs.

I'm not sure I needed to hear about the agonizing death part.

[cheeryble]

I'm not sure I needed to hear about the agonizing death part.

Yeah that's for the other guy eh giddyup?

Sent from my iPad using ThaiVisa app

[Sheryl]

<script type='text/javascript'>window.mod_pagespeed_start = Number(new Date());</script>

The death rate varies greatly according to how aggressive the cancer type is and the age at onset.

Another point to consider is that dying of (of as opposed to "with") prostate cancer is highly undesirable even at an advanced age, because it mestastizes to bone and can be excrutiatingly painful. So avoiding death is not the only concern.

But Cheeryble at this point there is no reason to think you have PC. You may just have BPH. The course you have chosen is reasonable enough under your circumstances, for now, but don't skip on follow up PSAs.

I'm not sure I needed to hear about the agonizing death part.

Actually what I said was"can be excrutiatingly painful" which does not mean the death has to be agoning, proper use of narcotics can help quite a bit (though can be problematic to get in Thailand).

This was posted in response to others saying in effect "no point in diagnosing or treating if you are very old". Life expectancy is not the only issue to consider although it is what is largely being used in debates about the "cost effectiveness" of prostate cancer screening and treatment.

[giddyup]

<script type='text/javascript'>window.mod_pagespeed_start = Number(new Date());</script>

<script type='text/javascript'>window.mod_pagespeed_start = Number(new Date());</script>

The death rate varies greatly according to how aggressive the cancer type is and the age at onset.

Another point to consider is that dying of (of as opposed to "with") prostate cancer is highly undesirable even at an advanced age, because it mestastizes to bone and can be excrutiatingly painful. So avoiding death is not the only concern.

But Cheeryble at this point there is no reason to think you have PC. You may just have BPH. The course you have chosen is reasonable enough under your circumstances, for now, but don't skip on follow up PSAs.

I'm not sure I needed to hear about the agonizing death part.

Actually what I said was"can be excrutiatingly painful" which does not mean the death has to be agoning, proper use of narcotics can help quite a bit (though can be problematic to get in Thailand).

This was posted in response to others saying in effect "no point in diagnosing or treating if you are very old". Life expectancy is not the only issue to consider although it is what is largely being used in debates about the "cost effectiveness" of prostate cancer screening and treatment.

I would think it's a pretty fine line between "excruciatingly painful" and agonizing, here's hoping I never have to experience either.

[giddyup]

<script type='text/javascript'>window.mod_pagespeed_start = Number(new Date());</script>

I'm not sure I needed to hear about the agonizing death part.

Yeah that's for the other guy eh giddyup?


Sent from my iPad using ThaiVisa app

I wouldn't wish it on anybody.

[blackcat21]

Hi,

I see that you're in the Pattaya area but I can't see anywhere in the posts which hospital you sent to or the name of the Doctor. It can make a lot of difference, for anything to do with prostate - Dr Wanchai at Phyathai Sriracha hospital is very good. I've just noticed that they sponsor this forum, actually so maybe you can just click on the banner. They have an English guy working there who is very helpful, his name is Gavin and his number is 089 7500 293 - I would recommend Dr Wanchai 100% just for advice or a second opinion even if you don't get any treatment. He is very fair and doesn't go over the top with pricing just because you are a farang like some of the hospitals in Pattaya do.

[cheeryble]

Anyone interested in informing themselves not only on prostate cancer but all elements of health and an eclectic mix of statistical interest like the Monty Hall dilemma may enjoy a wonderful new book which was featured on the lighthearted "fact" analysis program More or Less from BBC Radio, a favorite not only of mine but of Dame Stella Rimington ex head of MI5.

An excerpt:

While running for president of the United States, former New York City mayor Rudy Giuliani said in a 2007 campaign advertisement:

"I had prostate cancer, 5, 6 years ago. My chance of surviving prostate cancer—and thank God, I was cured of it—in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.”

How Rudy Giuliani Was Misled

The first reason is called lead time bias. Imagine two groups of men with invasive prostate cancer. The first consists of men in Britain, where screening for prostate-specific antigens (PSA) is not routinely used and most cancer is diagnosed by symptoms. The second group is made up of men in the United States, where routine use of the test began in the late 1980s and spread rapidly, despite the lack of evidence that it saves lives.

In the British group, prostate cancer is detected by symptoms, say at age sixty-seven (Figure 10-1 top). All of these men die at age seventy. Everyone survived only three years, so the five-year survival is 0 percent. In the U.S. group, prostate cancer is detected early by PSA tests, say at age sixty, but they too die at age seventy (Figure 10-1 bottom). According to the statistics, everyone in that group survived ten years and thus their five-year survival rate is 100 percent. The survival rate has improved dramatically, although nothing has changed about the time of death: Whether diagnosed at age sixty-seven or at age sixty, all patients die at age seventy. Survival rates are inflated by setting the time of diagnosis earlier. Contrary to what many people have been told, there is no evidence that early detection and subsequent treatment of prostate cancer prolongs or saves lives”

"“The second reason why survival rates tell us nothing about living longer is overdiagnosis bias. Overdiagnosis happens when doctors detect abnormalities that will not cause symptoms or early death. For instance, a patient might correctly be diagnosed with cancer but because the cancer develops so slowly, the patient would never have noticed it in his lifetime. These cancers are called slow-growing or nonprogressive cancers.4 PSA screening detects both progressive and nonprogressive cancers but, like most other cancer screening tests, cannot tell the difference between them. Figure 10-2 (top) shows 1,000 British men with progressive cancer who do not undergo “screening. After five years, 440 are still alive, which results in a survival rate of 44 percent. Figure 10-2 (bottom) shows 1,000 Americans who participate in PSA screening and have progressive cancer. The test, however, also finds 2,000 people with nonprogressive cancers—meaning that they will not die from them. By adding these 2,000 to the 440 who survived progressive cancer, the survival rate leaps to 81 percent. Even though the survival rate increases dramatically, the number of men who die remains exactly the same”

Excerpt From: Gerd, Gigerenzer. “Risk Savvy: How to Make Good Decisions."

$12 on Kindle. Well worthwhile.

http://www.amazon.com/Risk-Savvy-Make-Good-Decisions/dp/0670025658/ref=sr_1_1?ie=UTF8&qid=1401718124&sr=8-1&keywords=Risk+savvy

More or Less BBC4 podcast

http://www.bbc.co.uk/podcasts/series/moreorless

Sent from my iPad using ThaiVisa app

Edited June 2, 2014 by cheeryble

[cheeryble]

On reflection I gave a longish book quote but I think it's compensated by my hearty recommendation for the book and the serious importance of this type of information on a thread like this. An airing like this should be welcomed by he publisher.

BTW the book particularly highlights physicians' seriously poor abilities at assessing risk for example with breast cancer screening. We're not talking hillbillies here we're talking about western doctors and being completely unable to give anything like factual risks of cancer given a positive test largely overestimating tenfold with all the anxiety that brings to countless women.

Sent from my iPad using ThaiVisa app

Edited June 2, 2014 by cheeryble