Biopsy recommended, is this correct next step?

@stevemcdonald
Your results of the MRI are not really significant for prostate cancer as you know. Your PSA on the other hand is pretty high Though there are other things that can cause a High PSA. Your prostate is large, And that could be part of it. BPH issues can raise your PSA as well.

Between the Large prostate and BPH that may be your only problem. Have they given you antibiotics for the BPH, or have they determined there is no infection involved? That could resolve it and also drop your PSA. It could be that you really only need treatment for BPH, This is something you need to discuss with a urologist.

A radiation oncologist at Mayo said that he doesn’t like working on a Prostate larger than 75 cc, Yours does exceed that. Getting rid of the BPH can get it down below 75 ml..

You don’t mention your age and that is another factor in PSA.

While you had an EXODX test the PSE test is much more accurate. Check out the results of it in the slide I included. You should get another test because the results can change over time. If the PSE test finds you do not have prostate cancer. You do not need a biopsy.

Again, thank you all for your thoughtful responses!!
@jim18 and @jeffmarc , your responses last night were very helpful. Jeff, I am 70.

First, I should try an antibiotic to address possible inflammation (as probably in 2025 and certainly in 2022).

I also was not paying attention to % free PSA before, and am now. 3/2026 test was (Free PSA 1.15, % free PSA 13.9%) vs 3/2025 (Free PSA 1.12, % free PSA 19.3) so I am moving in the wrong direction since higher is better for % free PSA

I was not aware of the PSE test before yesterday, and it does seem a better test than ExoDx.

So I think I will engage with my urologist to suggest that they order antibiotics, and then a PSA retest including free, %free PSA, a PSE, and perhaps a 2nd MRI, as prudent first steps before a biopsy. Biopsy seems appropriate and I am ok with doing it based on the comments in this forum, but these seem like appropriate first steps to inform any subsequent action like biopsy..

Thank you!!!

@stevemcdonald
As others have said, you might want to get the PSE test. It is a blood test your doctor can order. The PSE test was initially created to see if cancer existed and to make a decision, with 94% accuracy (vs 55% with PSA alone), whether a biopsy is necessary. The report says you are either likely, or unlikely to have cancer.

My PSA was as high as 10.2 while my brothers never got above 6.5. His cancer was far worse and ended up using ADT therapy while I did not. PSA is one indication but not perfect.

I had a transrectal biopsy but I was given the Michael Jackson drug and slept through mine. I have known a few people that had the biopsy without being "in a bit of twilight". They were not happy. If I had to do it again, I would do the MRI guided fusion biopsy, if available. Request a Decipher test as part of your biopsy process. It provides a feel for cancer aggressiveness and doctors do use it for treatment decisions. The more sources of lab data you can get for you and your doctor, the better the decision-making process.

@stevemcdonald

I asked about your age because PSA rises with age 3.5 to 4.5 if you are 70 and older, The second table says even 6.5 is normal for somebody over 69.

It would be interesting to see your latest free PSA and PSE results.

Next mpMRI:
...3T Siemens, GE or Phillips
...gadolinium dye if kidney function OK and no allergy.
2nd read preferably digitally by AI methods
I used DeepViewImaging.com. Authorize & Direct the release of the digital file to them at the outset. A disk is not helpful. You signup first and authorize payment if the third party does not pay. If ever you repeat the mpMRI they can review and compare it to the first.

-_

Jeff,
I might just add it is so important for individuals to track their PSA over the years it is taken and have it taken as part of a physical. This way it can rule out fairly quickly that your PSA is at a level that the Doctor feels is appropriate for your age. Many patients have prostate cancer in their late 60’s early 70’s at PSA levels below the age guidelines. If a patient has his first PSA at 70, and it is a 4, the Doctor thinks it is fine, but without anyone knowing if had been taken annually before that for years at 2, then jumped to that 4, no one would know. That was my case and initially I was told my PSA was fine, until I went home and charted my last 10 years and showed it jumped and went sporadic and brought that back to him. I know PSA routine testing age guidelines have changed but would encourage everyone over 60 to even if they pay to monitor a baseline PSA.

your case is interesting. I would say with your age and prostate size, a PSA in the 7-8 range is not out of the ordinary. But the best way to nail this down would be to have the biopsy done. I am 72 and was diagnosed with Gleason 6 about 3 years ago and my PSA was under 4. I have been on A/S ever since. My only other suggestion would be to have a consult with a center of excellence. They typically have the latest in treatment options, research, best doctors, etc. Also since they usually offer just about all of the treatments out there, they tend to not suggest the one treatment that a smaller facility may suggest. I have had both a transrectal biopsy with my original urologist and then a transperinal at the Mayo Clinic where I went for my standard of care follow up confirmatory biopsy one year later. My MRI's never showed a lesion so both biopsies were the random grid type. I now get PSA tests every six months and then a MRI if the PSA takes a big jump. You can always still go to your original urologist after the center of excellence consult. Keep us informed. I will say a prayer all goes well for you.

If you repeat the mpMRI get it on a 3 Tesla resolution machine from GE, Siemens or Philips. If the kidneys are good gadolinium dye helps. Immediately ask for disk copy but authorize and direct that thee digital file be sent to an Artificial Intelligence MRI second reading servive. I used Deepviewimaging.com
Which Tests Are Really Worth It?
If you’re unsure whether to pay for a battery of lab tests, consider the approach taken by Dr. Andrea Klemes: If it doesn’t have strong clinical trial backing, she doesn’t recommend it.

Klemes is chief medical officer at MDVIP, a network of concierge medicine practices. She scours the literature for diagnostic tools that show promise in clinical trials, and only a handful make the cut.

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“We’re looking for things you can do something about,” she says.

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Other tests that aren’t part of the standard work-up include epigenetic and telomere tests, which aim to gauge a patient’s biological age, and full-body MRI scans, which can detect abnormalities that aren’t clinically significant but still prompt follow-up procedures like biopsies.

One of the best tests, she says, is low tech. Clinical studies tie grip strength to longevity in older adults, so she recommends that for MDVIP patients.gence

@jeffmarc My point exactly, what you posted "Much better today that they have guided biopsies after an MRI"
But what about when an MRI shows nothing? Wouldn't the biopsy be a "blind" biopsy if nothing to guide or target from an MRI showing nothing. Blind biopsies can also miss cancer. Guess I should have been more clear if a biopsy is done when MRI and other blood test like the PSE or ExoDx show no cancer then I would call that unnecessary & barbaric!

Thank you all for your thoughts. This forum is a wonderful resource! I have decided to proceed with the biopsy, and also to have a conversation with my urologist about a possible course of antibiotics and/or a PSE test before the biopsy to hopefully add additional data points. I will ping back when I have additional info to tell you. Thank you!!!