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Active Surveillance and Chasing PSA
Active Surveillance and Rising PSA (Multiple Negative Biopsies)
I’ve been reading many threads here and have learned a lot—thank you all for sharing your experience and knowledge. I wanted to post my own situation and see if anyone has had something similar.
I’m 65 and have been followed by the same urologist since I was 57 for PSA and BPH. My BPH has been well controlled with medication, but my PSA trend continues to be the main question.
Timeline / key results
Age 57: routine annual bloodwork showed PSA 5.2 → referred to urology.
Diagnosed with BPH; started/maintained on medication (including finasteride).
2018: 4K blood test returned high risk (81%).
2018: initial biopsy (16 cores) was negative.
Over the years: PSA checked about every 6 months and DREs performed; all DREs have been negative.
On finasteride: PSA ran steadily ~2.0–2.5 for years.
Most recent PSA: 4.08 (about double the test 6 months earlier).
Took a course of antibiotics to rule out infection; repeat PSA was 3.96.
It had been just over 2 years since my last MRI/biopsy, so I underwent a “saturation” biopsy (24 cores): all negative.
In total, I’ve had four biopsies, four MRI scans, and 73 cores taken. Across all of that, there has only been one finding of low-grade cancer (in 2018).
My earlier MRIs showed a PI-RADS 3 lesion, but the most recent MRI did not note any PI-RADS lesions. (That last MRI was done at a different facility than the prior three.)
My questions
Has anyone had PSA rise like this (especially while on finasteride) despite repeated negative biopsies?
Have you seen differences in PI-RADS reporting when switching MRI facilities, including a prior PI-RADS 3 no longer being reported?
What additional questions or tests would you discuss with your urologist in a situation like mine?
I have a follow-up appointment next week to review the biopsy findings and discuss the plan going forward.
Thanks for listening, and I appreciate any thoughts.
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Your PSA does seem to be pretty high since you double it if you’re on finasteride, Which makes it close to eight.
One thing you don’t mention, is the size of your prostate. Had a friend with a huge prostate, his PSA was always around 50 never found anything with a biopsy he died of something else.
You could get a PSE test to see if it shows that Prostate cancer was found in your body, But the purpose of that test is to decide whether or not you need a biopsy and you already had one or two or three.
Lots of people with BPH have a large prostate so find out what the size of yours is and maybe that will give you some answers.
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1 Reaction@jeffmarc
Thanks Jeff, The MRI report called it a bullet volume of 47.5ml.
Jeff is right these 4k snd PSE assist in the decision making process of going forward with a biopsy which you have done multiple times and recently. I believe the PSE might have a little more accuracy than 4K and determine risk a little different Possibly repeat the 4k to confirm previous one or supplement with the PSE. If the PSE comes back similar high risk, i would say something is being missed. Then move to another MpMRI since that has been two years. A lot can change in two years and even your recent saturation biopsies can miss things. It could be a new MRI could identify something in your case for just a targeted biopsy , not any additional random cores. I think with your PSA and 4K and a two year old MRI regardless of the last biopsy should justify another MRI especially if the PSE results corroborate your 4k
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1 ReactionYou might want to immediately schedule a telehealth appointment with a radiologist and a doctor that does removal. They will look at your tests and potentially give you additional insight especially from a center of excellence...Mayo, Cornell Weill, MSK...
@wheel1
Hey thanks for your input. Maybe I wasn’t clear on the MRI, I just had a new one and it was from a different imaging center than the previous three. It did not call out any PIRADS lesions like the previous three. I will ask again about repeating the 4k. I appreciate your comments
@bgunn6305
I might go with the PSE. That would corroborate your 4K. In addition bens1 recommendation for consultation with not only the highly respected ones he mentioned but any center of excellence (COE) that you might be closer to visit for a second opinion would be well worth it. You don’t mention if your own Urologist thinks your case is a little puzzling, but if so I think he would encourage this second work up at a respected cancer center.
Re: different MRI results:
"Matthew Cooperberg, MD, MPH, of UCSF, has emphasized that prostate MRI interpretation is subject to wide variability. Research associated with his team highlights that this variability exists not only across different institutions but also significantly among different radiologists at the same institution. "
@bgunn6305
That’s not large enough to cause a big rise in PSA, Unless BPH was involved.
I’m wondering if you had a Transrectal Or Transperennial biopsy. The Transperineal Biopsy can get to more areas of the prostate, Maybe that’s what you need in order to get your biopsy to show something.
I just can’t think of anything else. You don’t want to start treatment if they don’t find anything In multiple biopsies. Maybe getting a PSE test would end the search for an answer. At least it would tell you, you do not have any signs of prostate cancer.
With all those MRI's and biopsies and only having 1 core of Gleason 6 I would think you should stay on A/S. Like others have said, I think your PSA is reasonable considering your age and size of your prostate. I've heard 5 and 6 PSA numbers are not alarming, by themselves, with someone over 60. My prostate is 22 cc, so much smaller, but I am on finasteride as well. I am 72. Two biopsies, one at mayo, on transrectal, one trasperinal, they both found about 4 cores of Gleason 6. I have had 3 MRI's, first one was pirads 2, no lesions. Second at Mayo was also pirads 2, no lesions. Third MRI was also at Mayo, supposedly on a new, better machine, this time Pirads 1, no lesions. So all of these things move around. One thing I would do is get that one core of Gleason 6 from 2018 genetic tested like Polaris or Decipher. That may help in the analysis of the high 4K. But that 4K may only report on the fact you have cancer (even low grade), not how aggessive the cancer is. The genetics tests look at the cancer from that angle. Lastly I would go to a center of excellence. I did that switching to the Mayo after original diagnosis. The COE's tend to have the best research, training, equipment, doctors. They will recommend that which is best for your cancer, not the one treatment that some places only offer. All in all you situation does not seem bad at all to me, but I will say a prayer all goes well. Takc care.