a Bart Simpson ” damned if you do and damned if you don’t” issue..what to do with a high psa and one negative prostate biopsy?

Recent comment/question on this blog

I recently had a PSA of 17 and so saw a urologist and he ordered antibiotics for a month and another test. Tested the same and so he performed a biopsy with the 12 small cores you mentioned. Biopsy came back negative for cancer. I should mention there have been no symptoms, no urination problems, nothing at all which I have read is very common.

My urologist has recommended another biopsy in 6 months. My thought is to have another PSA check in 6 months and if PSA is the same avoid the second biopsy until and if I ever see an increase from 17. What do you think? From What I have read the biopsy should be avoided unless necessary.

T.M.

This question comes up often and is troublesome for both the patient and the urologist. Here are some salient points to consider. Also view this issue as if you are the patient (who doesn’t want to be prodded unnecessarily) and as the urologist( who doesn’t want to be sued for not diagnosing a prostate cancer in the face of a markedly abnormal PSA):

• There is no real harm to having multiple  biopsies of the prostate. No evidence that it spreads cancer, and the risk of infection or bleeding is the same each time not increased.
• In my career I have diagnosed prostate cancer after two negative biopsies only a smattering of times. Only once was the cancer of an aggressive nature ie. Gleason’s 8.
• If you have had one prostate biopsy and it was negative that is a good thing on two fronts. One on cancer was found, and if you are found to have prostate cancer on a subsequent biopsy it is usually small volume and low Gleason’s.
• If you have a high PSA, it is an abnormal value, that must be followed. Whether you proceed with a second or third biopsy is a decision that is reached with input from both the doctor and the patient. Remember , “no one can make you do nothing.”
• The chances of finding cancer decreases with each successive  biopsy.
• Today I diagnosed a small volume low Gleason’s on a fourth biopsy and a PSA of 20. The 20 PSA is probably unrelated to the small amount of cancer found. But what were we to do? 

So what would I recommend for the patient and the above question. A lot of what will be done will be determined by the mindset of patient. The anxious patient will wholeheartedly want to have another biopsy. The patient who is pleased with the current result and reluctant to have another biopsy (due to fear, mistrust, the cost, the pain) and this outweighs his concerns about cancer-won’t have another biopsy.

Now my recommendation for this patient: I feel that another biopsy would give peace of mind to the doctor and the patient and would recommend another biopsy…at some point. I’d repeat the PSA at the next visit to be sure it is still elevated (PSA’s are notorious for changing up or down.) If the second biopsy is negative, I’d only repeat another one if the PSA changed dramatically, ie-maybe from the 17 to mid twenties.

Something to remember, a biopsy is usually twelve cores and that samples a very small portion of the prostate.

I did a biopsy yesterday, the fourth the guy has had over 10 years, because his PSA went from 25 to 50. The biopsy was negative.

In conclusion, the decision to have another biopsy for an elevated PSA is tricky and depends  a lot on the personality and mentality of the patient.  The urologist in general being “risk averse” will always offer the suggestion of a “re sampling of the prostate” because if he does not and the patient ultimately has prostate cancer, he rightfully could be at risk legally.

I would do another biopsy in this case if the PSA is still in the 17 or higher range and then be hesitant to do another one unless dramatic changes. If I recommended a biopsy and the patient says no, that is fine with me. I simply dictate that the patient declined the test and then I work out with the patient the parameters by which he is comfortable that would prompt another biopsy. For instance, in this case we do exactly what this patients wants. No biopsy unless big changes. We discuss the options, pros and cons, and move forward together. No need for another urologist, an honest well thought out plan vetted through the prism of the urologist who does this type of thing on a daily basis.

About “avoided unless necessary” that’s tricky too. If you do a breast biopsy for a palpable nodule and it is negative…was the biopsy necessary?  The problem with this case is that you have a PSA that is four times normal and in the back of the mind of those concerned is the possibility (we don’t know how great) that there is an undiagnosed prostate cancer that may have elements of Gleason 7 or 8. I have been repeating biopsies in this scenario with attention to the anterior portion of the prostate and taking a few samples of that area.

It’s tricky but a solution can be reached by a patient  and a urologist willing to work together and vet each other’s concerns.