PSA 8.6, MRI PIRADS 5, Biopsy scheduled, so a bit worried

Dear retireddoc, thankyou very much for post that is very interesting for me.
In my father's family (6 male brothers) everyone underwent prostate surgery (BPH) at a relatively young age (around 60 years old). Four of them died from various cancers but not prostate cancer; although it must be said that they all died between the ages of 69 and 73.
I started with classic BPH symptoms at 38 and had to have surgery (TURP) at 51. Since then I have always had an annual visit to the urologist and a PSA test every 6 months. I am now 66 years old. The PSA went from 1.6 (January 15) to 3.98 (January 24). No suspicious abnormalities were detected on rectal touch. My urologist, suspicious of this gradual and constant increase in PSA, orders me a multiparametric MRI in 2015, then again in 2021. Both results were negative, without suspicion and without alterations, PIRAD 2.
Despite this result, the urologist recommended performing a biopsy. Since it is a very invasive and sometimes very painful exam, I preferred not to do it and repeat the MRI the following year (2022) with identical results to the previous ones. Today my PSA is 3.98 and given its linear and constant increase I think I can already predict what it will be in one or 2 years...
I have consulted several doctors, radiologists and urologists and the opinions are divergent. There are those who think that in the presence of 3 P-RADS 2 MRI and without variations over the years, it is not justifiable to perform a biopsy just because the PSA increases; this increase would be justified by age. There are those (almost all urologists) who recommend performing a biopsy anyway.
If I understand correctly, it seems to me that your case demonstrates that the increase in PSA can indicate the presence of PC, even if the various MRI scans are negative.
Considering your personal experience, as a patient and radiologist, I will really appreciate your feedback

Dear retireddoc, I greatly appreciated your answer, full of wisdom, common sense and great humanity. Thank you very much!
I would just like to make a couple of clarifications. My PSA increased from 1.6 to 3.98 over 9 years, from January 2015 (1,60) to January 2024 (3,98). Thats makes an average growth rate of 20% each year. In all these 9 years I have repeated the test about every 6 months and it has always shown a fairly regular and constant growth, I could say linear, and probably I can guess how much it will be next July. Certanly you are right: urologist are concern to the rise most that to the absolut value.
My MR scans were performed with a multiparametric technique, T2, with and without contrast, and with a superficial and transrectal coil. The study was carried out in a highly qualified center and by a highly experienced radiologist. I live in the North of Italy and here most of urologists send their patients to this radiologist because recognized as very good. Anyway I know that the only way to be 100% certain about the presence of cancer is to wach cells under the microscope. That means biopsy!
Yes! You are right, until now I have procrastinated on the biopsy because I am afraid that it will be very painful. Many friends who have done it say they have suffered real torture. From their experiences it seems that the local anesthesia performed was not effective at all. In Italy it is usual to perform many medical procedures (childbirth, gastroscopy, biopsies) without anesthesia or sedation. Deep sedation, which would allow these procedures to be overcome without the slightest pain, must be practiced with the continuous assistance of the anesthetist, who however is a rare figure and therefore used only when truly essential. But there was also two other reasons
First of all, it is my understanding that PSA is not exactly cancer marker. Rather, a marker that can increase for many other reasons, prostatitis, infections, inflammation, hypertrophy... . perhaps this is why its use is at the center of numerous controversies, even by its own inventor, Richard Albin. I have heard some doctors say that PSA is a terrible indicator, but it continues to be used only because there is nothing better. Something like democracy which is the worst form of government except all the others.
Second. Let's say I take a biopsy now and the result is “No cancer”. Well! But the trend of my PSA already suggests that in a year this will rise to 4.8 and in 2 years it will be 5.8. And suppose that a new MRI showed no suspicion or no changes compared to previous ones? What to do at this point? A new biopsy every year?
However, now the correct choice is certainly to follow the advice of urologists and do a biopsy, even with 3 negative MRI scans. If, as I hope, the result will be "no cancer", I will try to live peacefully next year and then we will think about it. Now I have to look for a place where they do the biopsy under sedation.
I wish you all the best in your journey along this new experience, no longer as a doctor but as a patient. I hope to find you still here in a year.

PSMA Pet scan is probably the most accurate. Biopsy is the best as long as you find the tumor. That may not be as simple, particularly if you MRI cannot find anything.
Dont mind me. I am just another layman trying to make some sense of the whole thing.

A urologist I met some time ago told me that in the pre-MRI era almost all biopsies were negative. In fact, doing a biopsy of a prostate with a clean MRI means sampling at random!. If there is a small cancer, finding it will just be a matter of luck. If only cancer-free areas are sampled, the result will be a clean biopsy, even if cancer is present. So in that case not even a biopsy could give us an answer that we can trust 100%. And this is another reason why I have so far given up on doing the biopsy.
Yesterday I contacted my urologist. He told me that it is possible to do the biopsy under anesthesia, but he asked me to do a new MRI first. I will do it. I therefore have to contact the radiologist and in doing so I will take the opportunity to ask him if a PSMA PET scan could be right for me.
Thanks to every body and good luck.

With Pirad 5 your scan would show the tumor. You should have targetted biopsy.

dear wellnes100, my PIRAD is 2.
(I am not the author of this post; I joined the discussion in replay to retireddoc.
that's probably why you confuse my MRI PIRAD 2, with Greg52's PIRAD 5)

Ooops. Sorry. You are right. You would not need biopsy for PIRAD2. There are awful stories where men went through more than one biopsy and not find anything. PSMA PET scan would be more beneficial, if only to be sure.
As for Greg52, there seems to be no reason for him to wait 4 weeks for biopsy. All the uncertainty is not necessary. He should get going right away.
Dont mind me. I am just another layman trying to make some sense of the whole thing.

This week I will meet my urologist and I will ask him if PSMA PET would clarify better in a situation like mine. However, I read that PSMA PET only comes AFTER a radical prostatectomy. But I don't understand why. Maybe retireddoc can explain it to us