Optimal and Outer limit interval from mpMRI to Biopsy and Treatment

@kalsen
In the meantime, you could take the PSE blood test to confirm, likely or unlikely, with 94% accuracy, regarding whether you have prostate cancer.
When you get a biopsy, you might want to include a Decipher test from Oxford Biodynamics regarding aggressiveness. Doctors do use the results for treatment.
Consider spaceoar to help separate the rectum from the prostate, if you are getting radiation.

Unless one is willing to fly around to center of excellence urologists.. we are all doing work arounds within the medical institutional scheduling and management restrictions as well as insurance companies. The "umbrella claim" is slow growing so one has time but many of us want to treat right away as, as you said, each of us is different. Once the biopsy is done, doctors are better able to assign a more medically oriented priority which may help you.

Here is a link to an older NIH study about delays from biopsy to treatment, basically saying around 83 days is ok regardless of the grade of cancer. Personally, a lot has changed since the study.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6410755/

Every hospital/center and Urologist office is different in their backlog.

From my experiences the past year, general urologists are more difficult in scheduling an appointment. They are seeing general population and 2-5 month backlogs are common.

After my initial MRI and Biopsy with a general urologist and local hospital, I have been going to City of Hope Cancer Center.

Appointments to see Radiation Oncologist, Surgeon, MRI, Biopsy, etc have been in the 2-6 week window.

Since you have a PIRADS4 lesion, I would recommend finding a good Cancer Center for the initial biopsy.

From your information of no EPE seen on the MRI, you should not feel rushed to get the biopsy.

A biopsy is needed, but whether it in July or anytime during the rest of the year, will be fine (in most cases).

Finding a urologist good at Biopsies is more important than when the biopsy is performed.

Also, fusion biopsies are just a sampling and have alot variation due to small and difficulty in sampling.

Even though the MRI image is fused (overlayed) with ultrasound in rectum, it is still difficult to be precise in both grid and targeted needle biopsies. In the past 9 months I have had 2 fusion biopsies. I have a PIRADS (5) lesion about twice the size of your lesion. Out of 6 targeted needles (using the MRI to target lesion) only (2) of the needles found the lesion. (2) of these needles did not even have prostate tissue. Surgeon said even with the best imaging and lots of experience, sampling lesions is still difficult. Over the two biopsies, I have had (5) “Grid” needles with over 90% grade 3+3 or 3+4 cancer cells. The targeted needles only showed 5-20% cancer.

I was on an Ancan webinar this past Monday. One person indicated his PIRADS 4 lesion was not cancer but his cancer was found in a different location in the prostate. He made this assumption due to targeted needles showing no cancer but grid needles showing cancer. He said since it was a fusion biopsy, surely the Doctor was able to sample the lesion and the results were no cancer in the lesion. That is a possibility, but my experience and feeling is: It is difficult to precisely biopsy the prostate. It is likely, the grid needles sampled the Pirads4 lesion and the targeted needles did not.

UCLA doctor discussed this at a conference in 2021 or so. Tge question was whether a Transrectal or Transperineal biopsy was best. He indicated equipment, imaging and practices for transrectal had been in place for many years. He still performed more Transrectal biopsies. He said with the use of antibiotics and good practices the risk of infection was very, very, low. This is different from a general urologist performing a transrectal biopsy without best practices to prevent infection.

Best wishes

Your PSA is quite low. Around 10% of people who have prostate cancer do not produce PSA as a result they have very low PSA’s, but still have prostate cancer.

Your PIRADS 4 Could imply there is cancer, But as mentioned by others, Cancer may or may not be in that particular lesion, but could be in other areas of the prostate.

A PSE test could definitely narrow down whether or not a biopsy is necessary.

Getting a free PSA test could also give you an idea about whether or not you have prostate cancer, Though that may not be relevant if you Do not produce PSA with cancer.

bens1, charlesprestridge, Jeff Marchi:

Thank you - all 3 of you have raised valid points that I need to incorporate into my planning.

@charlesprestridge:

Your point on targeted / grid needles etc. left me thinking. Thank You.
2 Follow up questions please:
a). Does a PSMA-CT fill the gaps in biopsy sampling?
b). Should I be insisting on a PSMA-CT even if Biopsy classifies the lesion as G 3+3?
Thank You ...

@kalsen

I do not think you will want to get a PSMA pet until you have more information.

I had a PSMA pet a few months after 1st biopsy because of possible extracapsular extension with a Pirads5 (2cm) lesion. If MRI does not indicate possible ECE and biopsy is 3+3, my inclination would be to defer PSMA pet until future MRI/Biopsy indicated a change.

My experience is to balance tests/info and then try to determine when more info/tests will help.

Last September my MRI indicated Pirads5 lesion with possible ECE. Biopsy had 5 cores of 3+3. However, 5 targeted cores only had 2 positive with small amount of cancer. Random cores had over 90% of the core at 3+3.

Working thru this initial info.

1. MRI indicated lesion may have higher than 3+3 and ECE was possible.

2. Just because targeted needles did not sample lesion well, assumption was cancer was in the lesion.

3. With your Pirads4 lesion (and a decent size lesion), I would ask Urologist to send biopsy off for a Decipher score, even if all positive cores are 3+3. If the Decipher score is 0.3 or lower, it will give some indication further tests may not be necessary for 6 months (followup PSA). If Decipher is approaching 0.5 or higher, more caution and thought may be wise.

4. In my case, I had a repeat MRI/Biopsy in six months due to Pirads5, 0.48 Decipher, and possible ECE. Repeat Biopsy had 4 cores of 3+4. I am working thru treatment decision process. When to schedule treatment, radiation or RP, genetic testing, Prostox test, etc

Best wishes

@kalsen If in US PSMA PET tests typically cost $10K+ and are not likely to be covered by insurance unless biopsy shows at least a Gleason 4+3. They look for metastases of the cancer. Cannot find cancer in the prostate since it will always light up with the PSA present in a normal prostate. As mentioned, the fusion imaging is not the best but should be better than Charles encountered. I got 6 of 6 hits on the 2 targeted lesions and all 3 cores were the same on each lesion. They will also do a TRUS random sample of the prostate. Mine had nothing of interest in the random part. My biopsy was transrectal with only local anesthesia. Had no issues with pain. Drove home within 20 minutes. Only after effect was blood in semen (due to all the holes the biopsy puts in prostate).