Prostate PCA3 Test

[smiles793]

Does anyone know if this test is available at any hospital or clinic in Thailand? thanks

[AlexO]

Get mine done every year in Pattaya (Pattaya Memorial). Would think most big hospitals will do these tests.

[JoePai]

Did not realise one needs a rectal exam for the PCA3 exam ?

The test is in two parts. You have a rectal examination and then a urine test.

You need to have a rectal examination because this massages the prostate gland and helps the PCA3 to go into the urine. You have to give the urine sample straight after the rectal examination. You normally get the results within a few days.

http://www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-questions/the-pca3-test-for-prostate-cancer

[Sheryl]

Get mine done every year in Pattaya (Pattaya Memorial). Would think most big hospitals will do these tests.

You are thinking of PSA test. He is asking about something altogether different.

I am not aware of PCA3 being available in Thailand. Although it is already commercially available and being aggressively marketed by the company no health authority has yet issued guidelines for its use and research on it is still ongoing

[smiles793]

Thanks Sheryl, yes I am referring to the PCA3 urine test not the PSA blood test.

Sheryl, could you tell me in your opinion the best clinic or hospital in Thailand for prostate diagnosis and treatment (these may be 2 different places for all I know), ie range of up-to-date technologies and procedures, and experience of practitioners thanks.

[Sheryl]

Thetr is no best place, only best doctors.

Dr. Viroj at Bumrungrad is highly recommended.

[smiles793]

Thanks for that. Even the best doctors are limited by the tools at their disposal, and I think it's likely that any hospital or clinic that invests in the most recent technologies will also have invested in practitioners at the top of their profession.

Would appreciate any info on clinics or hospitals that have advanced prostate diagnostic technologies. I already know I can get slice and dice in 80% of the hospitals in Thailand, Thanks.

[Sheryl]

Bumrungrad tends to have the most up to date equipment, but I am not sure what "advanced prostate diagnostic technologies" you refer to?

Anywhere in the world, diagnosis of prostate problems is still a history, urine/semen test if infection suspected, manual digital exam, PSA and if indicated, a biopsy, which can be ultrasound-guided or MRI guided. What other technology did you have in mind?

If you are referring to treatment rather than diagnosis, they have the full gamut from brachytherapy to robotic surgery etc.

BTW the way it works in Thailand, private hospitals do not "invest" in practitioners. Physicians are private contractors, not employees of the hospital, and many doctors have such an arrangement with more than one hospital. Not unusual for the same doctor to have privileges at 3-4 hospitals, sometimes even more.

[smiles793]

Sheryl, I feel you are lecturing me and engaging in semantics, rather than providing any information. If you don't know the answer to my question it would be more appropriate to say so, or to say nothing. Your assumptions about what I may or may not know about prostate diagnosis and the organisation of medical care are just that - your assumptions

If anyone here can provide information rather than opinions I would appreciate it, thanks.

[Sheryl]

I am not attempting to lecture you nor engage in "semantics" but rather to understand what your question is, i.e. what new diagnostic technology is it that you think only some hospitals will have?

Without understanding the question I have no way of answering it.

[Issangeorge]

Sheryl, I feel you are lecturing me and engaging in semantics, rather than providing any information. If you don't know the answer to my question it would be more appropriate to say so, or to say nothing. Your assumptions about what I may or may not know about prostate diagnosis and the organisation of medical care are just that - your assumptions

If anyone here can provide information rather than opinions I would appreciate it, thanks.

Reread what Sheryl, said, I saw no lecturing, she was just informing and asking you what new technologies you were talking about, it was a very polite post.

[JoePai]

You can get the PCA3 test done in Bangkok Pattaya hospital and presumably in the other hospitals of the group, just be seated when they tell you the cost as around 30,000 Baht !!!!

[smiles793]

My question is what advanced prostate diagnostic methods are available in Thailand at the moment. I would say non-advanced include PSA, free PSA, biopsy, DRE (maybe more that I can't remember right now).

Thanks JoePai.

Sheryl, a urologist told me yesterday that spectrum MRI is as good as biopsy for diagnosis of PC. There seem to be many differing opinions about this... what's your take on scans, including PET? and what's available in T-L that you know of ? thanks

[smiles793]

Sheryl, would be interested in whether you think any type of scan can be good for diagnosis or not. I know this is a bit of a minefield of opinion without 100 % certainty. But would welcome your opinion. Thanks.

[Sheryl]

A definitive diagnosis of cancer requires a biopsy. What scans of various sorts are good for is (1) locating the lesion to guide the biopsy; (2) determining the size, shape and extent of the lesion (which in turn can help suggest likelihood of malignancy but still does not eliminate the need for biopsy if findings are suspicious) and (3) identifying whether any metastasis is present.

RSI-MRI is a brand new technique, the use of which in prostate cancer was just published this year. It is not widely available yet, and indeed the team which pionerred it characterized it as having "promise for substantially improving PCa imaging. Further translational studies of prostate RSI-MRI in the diagnosis and staging of PCa are indicated." http://www.ncbi.nlm.nih.gov/pubmed/25559097

i.e. there is not yet enough information/evidence on it, and it is certainly not in general use even in the US where developed let alone Thailand. The initial study was quite small. It is not expected, even if larger studies support the initial promising results, that it will eliminate the need for biopsy for definitive diagnosis. But it may help fine tune who undergoes biopsy.

Regular MRI or MRI spectorgraphy has been around longer, and are useful in localizing and staging Prostate cancer, and any hospital with an MRI machine can do this (and that is most of the large hospitals in Bangkok).

PET scans are used to identify metastasis in people with confirmed prostate cancer, not to diagnosis the cancer initially. For prostate cancers, because the tumors do not utilize glucose to the extent that other tumors do, PET scans are useful only if done with a special tracer, and doing this is also quite new. I am not sure you will find any experience with it in Thailand but could be wrong. Only a few places have PET scans, Bumrungrad, Bangkok Hospital (Bangkok branch) and Siriraj being the ones I know of.

[smiles793]

Really appreciate your take on this Sheryl. It seems to reflect the traditional wisdom that scans take place after biopsies to guide surgery.

Ok, but biopsies frequently give false negatives, and the positives are often low grade or slow cancers that will never harm the person. I am sure you have seen the evidence on this.

Would you recommend anything other than biopsy? A urologist told me 2 days ago that a spectrum mri is as good as biopsy; he only does biopsies, so he's definitely not talking out of self-interest.

[Sheryl]

If you read the literature on spectrum mris they are most definitely not "as good as biopsies" and not used or advocated for that purpose.

It sounds like he was refetring to the potential of RSI-MRI which is still under research but will almost certainly never remove the need for a confirmatory biopsy.

Biopsy provides information on how aggressive the tumor is.

False negatives can be reduced by judicious use of scans to guide the needle placement. As I explained this is one of the ways scans are used.

I really think it is a mistake to focus on technical aspects of scan technology. Even the newest and most promising are just refinements of existing techniques, will not be major game changers and, most importantly, any technology is only as good as the person employing it and interpreting its results. A good practitioner will not always perform the same type of scans on all patients but rather adapt according to clinical findings.

Re biopsy, in some cases the clinical findings are such that it is very clear one needs to be done. In some cases the clinical findings are such that it is more than 90-95% clear that the condition is benign, in which case most drs would not advise a biopsy (though they would prefer the patient understand and accept that there is a small risk of midsing a malignancy).

And then there the in between cases where the clinical findings do not clearly point either way and a good urologist will do more preliminary scans for this situation than for others to help determine whether a biopsy should be done.

As to type of scan used to guide needle placement this should depend on the location of the lesion and the doctor's experience. It will not improve matters to have a doctor skilled in use of ultrasound guided biopsy use mri instead if he has not already done that many times before.

[smiles793]

Hi Sheryl, thanks for your reply, I do appreciate the time you've taken on this thread. Given the incidence of prostate issues in men over 50 I'm sure many men here will find it useful.

Ok, I'm a layman in this area, but I have read the literature on this reasonably extensively and there does seem to be substantial variation of opinion about this among urologists: here are two links for example that consider MRI to be a gamechanger in this area...I'm sure I could find more, but these 2 are taken straight off the top of the google results page.

http://www.harvardprostateknowledge.org/improved-magnetic-resonance-imaging-mri-may-aid-detection-of-prostate-cancer

http://www.abc.net.au/news/2014-08-05/mri-could-be-game-changer-prostate-cancer-test/5650280

But here's my layman's question : if MRI can be used to guide biopsies and surgery to cancerous areas why can't it be used to identify the presence of cancerous areas ? (I understand that scans cannot grade the type of cancer of course, at least not today.)

You write ...

"Re biopsy, in some cases the clinical findings are such that it is very clear one needs to be done. In some cases the clinical findings are such that it is more than 90-95% clear that the condition is benign, in which case most drs would not advise a biopsy (though they would prefer the patient understand and accept that there is a small risk of midsing a malignancy)."

The 2nd occurrence of "biopsy" (the one I underlined - should that say "biopsy" (in which I case I don't understand the paragraph) or "surgery"?

And please believe me I am not focusing on the technical aspects of any diagnostic method; I am simply trying to discover whether there are any non-invasive diagnostic methods available in Thailand (ie any methods other than biopsy), and it would obviously be silly for me to ignore advances in technology. For example, if a combination of PCA3 and some kind of scan could be suffiecient for a urologist to be confident that cancer is not present, I would take that approach rather than biopsy, which is not conclusive in the case of negatives, and results in further biopsies, which do carry risks, and for some people those risks have become serious conditions.

cheers

Edited June 1, 2015 by smiles793

[Sheryl]

Only histopathology (examination of tissue cells directly under a microscope) can confirm cancer. Scans can only show the size and shape of the mass.

No I meant biopsy, not surgery. That paragraph discusses howdetermination of need for a biopsy is made.

Has a urologist recommended a biopsy for you? If not, you may be jumping the gun.

Should avoid going by mass media versions of what mefical studies say as they are almost always inaccurate. Need to go yo the source.

[smiles793]

Yes I know that positive biopsies are conclusive as to the presence of cancer.

But that isn't the issue I'm raising, the issue I'm raising is due to the inconclusive nature of negative biopsies, which usually result in the urologist recommending another, and another: the risks of this are well-documented. My question simply relates to the possibility of a urologist using a method or combination of methods other than biopsy to be confident that cancer is not present. And I'm not looking for a 100% confidence level either, just as a negative biopsy certainly does not provide a 100% confidence level.

"Re biopsy, in some cases the clinical findings are such that it is very clear one needs to be done. In some cases the clinical findings are such that it is more than 90-95% clear that the condition is benign, in which case most drs would not advise a biopsy (though they would prefer the patient understand and accept that there is a small risk of midsing a malignancy)." Could you tell me which clinical methods you are referring to which give rise to a 90-95% confidence level?

I am sure you know that there are significant differences of opinion among the specialists themselves around the diagnosis and treatment of prostate issues these days.

thanks.

[Sheryl]

The findings on DRE alone are often sufficient to make other than benign hypertrophy unlikely. That is often, not in all cases. The 90-95% I mentioned was for some cased, it is not a gixed reliability. An experienced urologist can tell you whether or not, in your specific case, he feels confident the enlargement is benign (and if so, by approximately what % certainty). ...or whether he strongly suspects malignancy. Or anywhere in between. In addition the pattern of change in the PSA as well as its absolute level can be suggestive.

Many millions of men have BPH and most are managed without biopsy. When the clinical picture is unclear making it difficult to decide if a biopsy is warranted then various sscans can be done and these may provide additional information to aid the decision.

It is not common at all for a urologist to keep recommending repeat biopsies. Most men, if they are biopsied at all, are so only once. Repeat biopsy would be done only if there were other findings that continued to suggest malignancy.

The best thing to do is to consult a top urologist who has trained in the west and is comfortable involving the patient in the decision making process (the former usually a precondition for the latter). Tell him you want to avoid biopsy unless really necessary and are prepared to incur a small risk to do so; as he tells you his impression, ask him to estimate degree of certainty.

[smiles793]

Sheryl, ok thanks, DRE and PSA and get a good doctor.

Re PSA, Richard Ablin, who discovered PSA, has described the way it's being used as "a hugely expensive public health disaster" which is not only useless but actually harmful.

Anyway, thanks to Sheryl for your opinions and to Joepai for providing the info about PCA3 in Thailand.

Best to all.

[smiles793]

Sheryl here's a link to research showing a 30% false negative rate for prostate biopsy (TRUS guided I believe). It took me 30 seconds to find; I'm sure there's plenty of other research. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668408/

The problem is compounded for men with BPH (that's a large % of men over let's say 55, as you know, and for every additional year the % is higher), because a larger prostate requires more cores which is more invasive which is more risky. And the risks are real and documented reliably on the net.

There are plenty of case histories on the net about men who have been referred for repeated biopsies - they are not hard to find.

I am not saying that what you are saying is wrong, but I am saying that the picture is by no means black and white. Differences in approach between different western countries are a testament to that.

Anyway, this thread has done it's duty, cheers and thanks for your input.

Edited June 1, 2015 by smiles793

[Sheryl]

Actually I feel it is you who have been presenting things as black and white and I have been trying to explain the complexities and nuances.

Of course there are incidences of men who have had repeat biopsies. But it is not the norm. Reading internet anecdotal reports will not give you a sense of what usually occurs. The people who are inclined to post will always be those who had problems. For that matter, even the medical literature is geared towards publication of unusual case histories.

False negatives on prostate biopsy are often due to poor needle placement which in turn is often reflective of the skill and experience of the doctor.

[bubba]

Bumrungrad tends to have the most up to date equipment, but I am not sure what "advanced prostate diagnostic technologies" you refer to?

Anywhere in the world, diagnosis of prostate problems is still a history, urine/semen test if infection suspected, manual digital exam, PSA and if indicated, a biopsy, which can be ultrasound-guided or MRI guided. What other technology did you have in mind?

If you are referring to treatment rather than diagnosis, they have the full gamut from brachytherapy to robotic surgery etc.

BTW the way it works in Thailand, private hospitals do not "invest" in practitioners. Physicians are private contractors, not employees of the hospital, and many doctors have such an arrangement with more than one hospital. Not unusual for the same doctor to have privileges at 3-4 hospitals, sometimes even more.

Unfortunately, Bumrungrad do not have the newer, higher magnetic field 3T MRI, which provides much more detailed image resolution. Also, they do not do MRI guided biopsies.

I am not aware of any hospitals in Thailand with 3T MRI capabilities for prostate imaging.

[Tolley]

There are simple blood tests around that will give you a good indication if you have cancer or not.

AMAS is one test and the Navarro test is another one as is the Red Drop KT test.

Of course a biopsy is the only approved test for a malignant tumour but a biopsy does carry a small risk of spreading the cancer through the body and is not 100 percent accurate.