8.60 Exodx: What criteria is helpful to decide to biopsy or not yet?

Your fortunate mine was 77 for atleast 3+4 or greater currently awaiting treatment.

Sorry to hear. Does 3+4 mean it has gone beyond the prostate?

No

Hey, I'm happy for you for that result, and the numbers would indeed support the decision by you and your doctors to monitor.

That said, I'm going to share again what I did when you posted about this the last time: I also had a single PI-RADS 3 lesion, alongside an ExoDx score under 8, a PSA of 5.8, and a PSA density of 0.20, all of which gave me a very low probability of clinically significant cancer as a 50-year-old with no family history of prostate or breast cancer. The odds were something like 2-4% chance I'd have anything more than Gleason 6.

But I went for the biopsy anyway because my oncologist said there was no obvious explanation for the elevated PSA and the risks of biopsy were so small.

That decision may have been the difference between localized and metastatic cancer for me. Turns out I had 3+4 with highly aggressive histological markers (cribriform, IDC-P) and a 95th percentile genomic risk score. We scheduled surgery asap and I'm now ~15 months out with a PSA <0.01. No one can say with certainty what the impact would've been for me had I waited and monitored, but men with similar traits tend to see comparatively rapid progression of their cancer and limited windows for definitive cure.

We could say this is just as simple as me being in that unlucky 2-4%, and maybe if we lined up another 24 men with similar numbers, they'd all report success and happiness with having waited rather than gone to biopsy.

But I look at it this way: there's a difference between appropriate treatment guidelines at the population level, and what's the optimal decision for a given man. Biopsies take money, time, and human resources and there's good reason for hospitals and insurance companies to want to minimize the number of "unnecessary" procedures. But there's a very asymmetrical risk for patients: the downsides to a biopsy that doesn't find cancer are limited (seriously, biopsies are incredibly routine now and genuinely not a big deal) but the downside to foregoing a biopsy that would've found cancer can be massive.

I only have one life, and one chance to do my best to identify and treat what might befall me. I'm so glad that I trusted my doctor and went with the let's-just-check route rather than play what were objectively good odds.

I don't know, but with that PSA, I would consider an MRI. Biopsy, I know you hear a lot of negative info and they are a bit uncomfortable, but not terrible. But would differently get a MRI before biopsy. TheMRI don't hurt and is a little more insurance all is well.

@diverjer He's already had an MRI that showed a PI-RADS 3 lesion.

@notpetecrowarmstrong
Thanks, I need to read more. That makes the decision a bit more difficult. My MRI showed 1 RADS 5. During the biopsy the RADS 5 location had 3 biopsy done and all were no big deal 3+3. However, they took biopsy from 12 more locations and found cribforms, and 5 or 6 4+3 and some 3+4. Short version the MRI spot found wasn't much, but did make them want to check further and all the bad stuff didn't show up in the MRI. I should add my PSA was 4.3 at the time.

Glad your PSA is down to .01. 6 weeks and 16 weeks after removal, I got down to .06 on both. Had PSA done locally here in Topeka and they said their tester will only go to .04 and didn't see any reason to get a uPSA.

@notpetecrowarmstrong

Amen to that !
My husband unfortunately had an urologist who did only one biopsy in almost 6 years and decided that yearly MRI was enough since he found only one 3+3 core and genomic score showed low chance of aggressive cancer in 30 years : (((( ! He offered another biopsy only after second small lesion appeared on MRI (first one got SMALLER BTW) and new biopsy found only one core 4+3 and 2 - 3+3 but there were "possible IDC" and "small cribriform according to one lab, a some big according to another lab".

VERY small tumor burden and guess what - Decipehr came back 1 - yes, the highest score.

They advised surgery but said "take your time, no rush , no rush " , PSMA showed no spread, MRI showed no spread, they even did some special ultrasound technique and saw no spread. PSA before biopsy was 7, after biopsy fell to 5.2 blah blah blah

To make the story short he had RP and they discovered that he had unifocal EPE , one iffy margin and gleason was actually 4+5 (still tiny tumor burden - only one tiny spot).

So, can "small burden" escape - it can !

Does PSAM see it all - NO

Does MRI see it all - NO

The ONLY correct parameter of my husband's type of cancer was Decipher !

I agree with above poster - maybe our cases are rare, but they exist and I would never dismiss Decipher as a major warning sign . I am saying all of this in hope to save some poor soul from going through this hell that we are going through just because we were told "no rush" by some "big names" in PC world, and because we had idiot as an initial urologist 🤬.

@notpetecrowarmstrong We all make our own decisions but I could t agree more with your advice. Biopsy is nothing when compared to the risk of uncertainty.

On the other hand, the purpose of the exodx is to allow patients to avoid unnecessary biopsies. I'm glad your biopsy went well, but that's doesn't seem to be always the case. Also, my 5.95 psa can just be due to my 94cc prostate. When you point out that there is a difference between statistics and the truth about an individual patient, don't forget, the patient could line up with the statistics as well as not, although the former is by nature, so to speak, more likely. One more thing, not even biopsies are 100% telling. Still, I do appreciate your concern and good will, but I, think, as you agreed, it is reasonable for me to "monitor" for the time being. Thanks again!