Biopsy vs Surgery Results

@ireland1964 That is one way to look at it. The other way to look at it is that 75% of the time the biopsy match is either the same or better; only 25% of the time is it worse. (All depends on whether you’re a “glass half empty” or a “glass half full” type of person.)

Prior to biopsy (these should always be checked, even before MRI):
> PSE test (it’s 94% more accurate than a PSA test)
> % Free PSA
> PSA Doubling Time (or Velocity)
> whether the PSA increase is due to a UTI, prostatitis, or some other non-cancerous reason.

After MRI (prior to biopsy):
> PSA Density
> whether the PSA increase is due to BPH or an enlarged prostate

Prior to a tissue biopsy, there are many liquid biomarker tests to choose from, depending on what exactly you’re looking for:
> (from blood): 4KScore; Prostate Health Index (PHI);
> (from urine): SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS), ExoDx.

A urologist can use one or more of these test findings that are available before doing a tissue biopsy to get a better idea of the true nature of the disease.

Ultimately, a tissue biopsy is considered definitive.

After tissue biopsy:
> Prolaris; OncotypeDx
> genetic (germline) test

(I’ve probably missed others.)

@ireland1964
Regarding the opposite results I mentioned: You posted on a recent post:
"Recent Prolaris results put me unfavorable inter along with good % chance surgery will show upgrade." "My biggest concern is finding out it wasn’t contained After surgery which means I would have elected radiation instead."

My Decipher came back low risk where biopsies had me at intermediate risk. I mentioned not being familiar with Prolaris and asked if class of Decipher.

When I had me tests being done I was 3+4=7 and my insurance (Medicare) covered, MRI/Contrast, MRI/Fusion/Biopsies, Bone scan, PSMA test, Decipher, and second opinion.

Treatment plan I chose. Based on the recommendations by R/Os at Mayo and UFHTPI, and my primary care provider (PCP) I went with proton radiation (30 rounds) not hormone treatments. Both my opinions I got were recommend do not need hormone treatments.

I chose the proton over photon. UFHPTI has been a primary medical institution doing photo radiations since 2006. At the time I had my treatments (2023) Mayo Jacksonville did not have proton just photon.

New cancer center (this year) now offers proton also.

I was 4+3 from the biopsy, 4+5 after surgery. My surgery also detected some adverse factors (bladder neck invasion, cribriform, multifocal and others) so my biopsy really underplayed my actual condition. The surgery results also led me to be more aggressive in follow-up. My PSA was only 0.04 a year after surgery, but was trending in the wrong direction so we decided to move ahead with Lupron and 39 radiation treatments. I've been undetectable since March but the Grade 5 determination after surgery has me watching closely. Next PSA is a little more than a month away.

@anosmic1 Your experience is a textbook reason why it’s never a good idea to rely only on PSA and Gleason score in making a treatment decision.

Though various studies get slightly different results, data from this paper from the UK in 2019 showed that initial grade and pathological grade matched 59% of the time, was downgraded just 16% of the time, and was upgraded just 25% of the time —> https://bmcurol.biomedcentral.com/articles/10.1186/s12894-019-0526-9

(So, 75% of the time the pathological grade is the same or better; only 25% of the time it’s worse.)

There are about a half-dozen other biomarker tests and scans that often can detect when something worse is lurking unseen, and can play a role in making a treatment decision.

@brianjarvis

Thanks for all of that information.

Candidly; I didn't have a lot of these tests before surgery. Pretty much PSA, MRI, Biopsy and then PSMA-PET.

I'm sure it would have been helpful to have more information before making a decision.

The one test I did get was a Decipher test, which was reinforced my decision to pursue surgery as first course of action (just on the edge of aggressive at .61). With that Decipher score, if I pursued radiation as first course, it was recommended that I do six months of hormone therapy. That was a nope. Saving that for recurrence if I need it.

I guess I fit the norm...despite the fact that my surgeon said my post surgery pathology score would likely go up because he felt my biopsy (done elsewhere) was undersampled because it was transrectal and not transpereneal, my final post-surgical pathology remained the same at 3+4=7. So, I was happy about that.

What tests would you recommend off of this list for most people starting their journey?

@fritzo mind if I ask the final results of your prostrate after surgery were compared to the prior test results?

@fritzo I tracked all the PSA-type tests; I wanted to know if anything worse was lurking unseen.
> the PSE test became available in September 2023; I never had that.

After going off active surveillance, I chose proton radiation + 6 months of hormone therapy. (If I have recurrence, I have the options of focal therapy (e.g., cryo), brachytherapy, SBRT (because they’re all very targetable), and even possibly even re-radiation. (I was diagnosed in 2012; had 4 transrectal biopsies during the 9 years that I was on active surveillance.)

For me, I had both the OncotypeDx and Prolaris tests.
> the OncotypeDx test was to help with my decision to go onto active surveillance.
> the Prolaris test was to help with my decision to go off of active surveillance.

Which biomarker test to use would depend on what someone starting on this journey was looking for (& what their insurance will pay for). That’s the in-depth discussion between patient and doctor.

@ireland1964 Yes, of course! My post-surgery pathology report results were exactly the same as my biopsy results, which in my book was good news. Pre-surgery, I had been told that my staging likely could go up because the location of my tumor was hard to sample via a transrectal biopsy (I didn't initially have the option of a transpereneal biopsy at my first doctor...midway through, I switched surgeons to a major center rather than local hospital).

I started out as 3+4=7 and ended in that same place. When I asked the surgeon about my post-surgery pathology report, he told me that it is as good as it gets.

Still, I get very anxious and nothing is a sure thing. Hoping that time lets this anxiety fade....

•••••••••••••••••

Here is the condensed post-surgical report:
Final Diagnosis

A. Anterior fat pad, excision:
• One lymph node and mature adipose tissue, negative for carcinoma.

B. Prostate, radical prostatectomy:
• Prostatic adenocarcinoma
• Gleason score 3+4=7 (Grade group 2, with 30% Gleason 4 tumor).
• Tumor is on the left as a 1.2 cm dominant nodule.
• Tumor involving 2% of prostate tissue examined.
• Tumor is organ-confined.
• Both seminal vesicles are negative for carcinoma.
• All surgical margins are negative for carcinoma.
• Benign prostatic hyperplasia, weighing 66.9 grams (including carcinoma).

@brianjarvis Wow-it seems like you managed your situation brilliantly. I'm sure it's been an incredibly stressful 14 years.

But, you also serve as an inspiration that getting good diagnostic info and making good informed decisions can help make PCa a chronic disease, which is about as good as we can hope for.

I'm guessing that buying that extra time over those nine years before treatment also meant new treatment options. Which ones do you think are the most significant?

@fritzo I think what was initially most beneficial to me was in the mid-1990s coming across newspaper articles (like the two I’ve attached).

From those I became aware of the importance of early and annual PSA screening. Starting in June 2000 (at 45y/o), I began annual PSA tests and monitoring this just as I would any other blood assay.

Over the next decade, I watched my PSA slowly creep higher each year. So, it wasn’t a big shock to me in April 2012 (at 56y), that my urologist told me that my biopsy showed low-grade, localized prostate cancer: Gleason 6(3+3).

I think that over those 12 years I became somewhat comfortable with PSA results - just as with my cholesterol, LDL, HDL, triglycerides, etc. results - No reason to panic or worry that my spouse would be widowed. Simply take it in stride and look for the next diagnostic test.

One important option developed during the time that I was on active surveillance - and I mention this humorously as well as seriously - is the development of rectal spacers for radiation treatment in 2015. Prior to that they used endo-rectal balloons that were inserted and removed at every radiation session - while still leaving the anterior wall of the rectum fully exposed to radiation. (Sounds pleasant doesn’t it?) Today, the rectal spacer is injected just once, lasts through the entire treatment, and reduces radiation to the rectum by up to 70%.

Technology-wise it was the development of Pencil-Beam vs. Passive Scattering systems. Being able to apply proton beams layer-by-layer, delivering a highly conforming dose that matches the exact shape of the tumor, and protecting adjacent healthy organs better than the older scattering methods (taking further advantage of proton’s Bragg-Peak characteristics).

I’m glad I waited…..