Biopsy v non-Biopsy: Can you be diagnosed without a biopsy?

Yup! I have seen 5 different Urologists in the past 4 years, mostly because the Veterans Administration keeps changing their policies. That said, each one has a completely different approach to my case. PI-RADS 4 with no biopsy yet. The latest one wants to scoop my prostate out - I said no thanks. I watch the videos on UTube and they recommend no biopsy yet. Even this group has 50 million different ideas about PC. It ain’t easy!

@csbarry
Sounds to me from all your previous posts you have seen so many different urologists not because of VA policies but because you have gone through very excellent diagnostic tests up through an MRI all pointing that 99% of patients next step is a biopsy which you refuse to get. You make it sound like some crazy urologist said he could scoop your prostate out as his first recommendation. I doubt that. I know many veterans getting outstanding care for prostate cancer through the VA. Many see physicians through through outside referral. Your refusal to accept a biopsy that guides your treatment could save you the pain you seem to not want accepting some painless death march.This group might have different views about different standard and acceptable protocols of care for treatment but don’t turn a blind eye to the specific diagnostic standard of care for a biopsy when it is warranted. Each one has a different approach because your starting point is no biopsy.

Sounds to me from all your previous posts you have seen so many different urologists not because of VA policies but because you have gone through very excellent diagnostic tests up through an MRI all pointing that 99% of patients next step is a biopsy which you refuse to get. You make it sound like some crazy urologist said he could scoop your prostate out as his first recommendation. I doubt that. I know many veterans getting outstanding care for prostate cancer through the VA. Many see physicians through through outside referral. Your refusal to accept a biopsy that guides your treatment could save you the pain you seem to not want accepting some painless death march.This group might have different views about different standard and acceptable protocols of care for treatment but don’t turn a blind eye to the specific diagnostic standard of care for a biopsy when it is warranted. Each one has a different approach because your starting point is no biopsy.
Without the biospy their is no definitive diagnosis of prostate cancer and degree, level or severity of that prostate cancer and therefore standard of care protocols treating that cancer. There is no standard of care for for undiagnosed likely known cancer with a PIRADS 4 because of not knowing as I said the Gleason score and make up of the cores and other information from the biopsy. No doctor is going to start a treatment protocol not knowing that information so you could go to eight different urologist’s at the VA it ain’t going to change. You may feel you can just ride likely prostate cancer into the sunset because you believe it is slow growing but it just as likely is not and will metastasize and give you the pain you don’t want, while a biopsy can be relatively painless, if at all and then give your doctor the information he needs to provide care and maybe not even need to experience that pain

@csbarry Yeah, it's brutal and definitely not easy.

It seems like normally, you listen to the doc and do what they recommend. With prostate cancer, the docs say spin the big wheel and see where it lands in your head.

The good news in all of this is that there are treatment options. The easy ones are perhaps kick the can down the road options and the ones that are more effective have lots of kick in your quality of life. Just glad there are options.

@wheel1
That’s dumb! My starting point isn’t a biopsy, it’s trust! The “best” Urologist in Florida never heard that there are bio-markers in your urine that indicate PC - that’s the “best”? No! He should at least know what the Mayo Clinic is talking about - I would think. And if a doctor is working for the VA at minimum wage - there is a reason.

For your information The best Urologist in Florida seems to be pretty smart. He knows Bio Markers in Urine do not diagnose prostate cancer and its type, grade, and how to proceed with a treatment, except in cases of continuing with AS in Gleason 6 cases, maybe a favorable 7(3+4), all taken in context with PSA numbers, MRI such as someone who has a PIRADS 4. The bio markers may help determine the standard of protocol treatment. By your inference that all anyone needs is a bio markers urine test misses the light that is on.

Regardless of your 4 MRI’s and likely high PSA’s that led to your MRI’s, none of your 5 urologist’s good even begin to diagnose you with prostate cancer even if a bio marker urine test, PSE blood test, ExoDx test, on and on without a biopsy. They can say you likely high a probability of cancer , but then any treatment protocol is dependent on you actually having diagnosed type of cancer and the information from a biopsy about your specific type and then that dictates treatment. No doctor is going to start any specific intervention treatment based on likelihood of prostate cancer and be subject to malpractice

@csbarry and @wheel1, please note that I have moved your comments related to biopsy to the original discussion started by csbarry to stay on topic:
- Biopsy v non-Biopsy: Can you be diagnosed without a biopsy?https://connect.mayoclinic.org/discussion/biopsy-v-non-biopsy/

A reminder about the Community Guidelines https://connect.mayoclinic.org/blog/about-connect/tab/community-guidelines/ Please review.
Specifically note the following:
- Share your own experiences. But do not tell others what they should do.
- Show respect for members even when you do not share their views.
- Disagreements are fine. But mutual respect is essential.

@csbarry
PIRADS4 Does imply that there is a possible problem with cancer. Doesn’t always happen, But it is a major indicator that there could be a problem. I couldn’t imagine a urologist that wouldn’t want to do a biopsy of that specific spot in your prostate, and 15-20% of the time there is actually cancer in other spots that don’t show that. A guided biopsy would make a lot of sense.

You could get a PSE test, which can detect whether or not prostate cancer is found in your system. If it is then getting a biopsy is highly recommended so you can find out what your Gleason score is, Something that can tell you how aggressive the cancer is. The biopsy can also find out if there are other aggressive issues If cancer is found.

I know the VA allows you to go to doctors outside of the VA. Not sure exactly how that works. Ancan.Org Has a veterans group that meets twice a month. They are very informed about prostate cancer and how to get the best treatment from veterans Doctors. They also have Multiple prostate cancer meetings, the advanced meeting meets once a week, But you need to have a biopsy before you can attend that particular meeting And get answers. Their other meetings for low annd immediate and active surveillance really do need more specific information about your case before they can help you with ideas about treatment. A biopsy is what is normally needed unless you have had a scan which shows multiple metastasis.

I’m including a chart of all the possible test you could take like the PSE Test to find whether or not you have prostate cancer before doing a biopsy.

@csbarry Actually what the urine biomarker tests do is predict the absence of significant prostate cancer. That is the NPV (negative predictive value) from the chart that Jeff posted. The prediction of cancer (PPV) is only good about 1/3 of the time. Also note that MRI is wrong about half the time and does a much better job predicting no cancer with a clean MRI. Even a PIRAD4 turns out to be benign (no cancer, not even low grade that would not even be treated) about 1/3 of the time. That is why no doctor will treat based on MRI or biomarker tests. However, it is useful to get the urine biomarker test to rule out biopsy. I agree that a lot of urologists in your typical local practice are not up on the latest diagnostic tests.