High PSA, but MRI is negative. Biopsy or Not?

Your urologist may have good reasons to suggest a biopsy including perhaps the PSA change in the last 12 months or results of a digital rectal exam. And, I am not suggesting that you ignore your urologists advice.

But, you could ask to have one of the relatively new genomic diagnostic tests that are much more accurate and definitive than the PSA in indicating the presence of prostate cancer. My cancer was found due to having an ExoDx test which led to a biopsy in spite of a stable PSA, normal DRE, and normal MRI. There are other tests now that are better than the ExoDx - the PSE test seems to be the best currently available. I would ask the urologist to prescribe a PSE test as a next step, and then proceed with a biopsy if the results of that indicate the presence of prostate cancer.

You may have seen this, but a friend of ours had a huge prostate and had a PSA of around 50. He had multiple biopsies and they never found anything. That was his case.

I know of other people that have had high PSA’s large prostate and nothing found in the MRI but when I biopsy was done, cancer was found.

You could do a calculation of PSA density. You divide the PSA by the number of cc of the prostate. The result is greater than .15 then you probably do need a biopsy. If it’s less than that, then you may not. Something to talk to your doctor about.

@rider51

Thanks for the comment!

I’m intrigued about your statement:

“My cancer was found due to having an ExoDx test which led to a biopsy in spite of a stable PSA, normal DRE, and normal MRI.”

If you don’t mind me asking, What was your ExoDx result and your biopsy determined Gleason score?

Did you get a Decipher score?

Did you have treatment or did you choose active surveillance?

The reason I’m asking is a friend has a similar prebiopsy situation and received an elevated ExoDx result and is trying to determine if/when to proceed with a biopsy.

@rider51 thanks for the reply. My urologist first mentioned the newer urine and blood diagnostic tests last year, but then dissuaded me from them during my visit last week, when he was pushing for a biopsy. After researching some of these tests, it seems to me that they should be part of the clinical progression, especially for someone like me, who has had a MRI that showed nothing (it is a year old now). I'm thinking I should get something like ExoDx AND a new MRI before I go for a biopsy.

@jeffmarc Thanks for your reply. I am new to all of this, and haven't heard of PSA density. Having said that, if I use my latest PSA measurement and the estimated prostate volume from my 12-month-old MRI, I calculate a PSA density of 0.17. Unfortunately, nearly all the diagnostic tests I've done so far over the last few years put me in the "grey zone".

I’m just starting my journey at 67. I made an appointment with my Urologist when bloodwork indicated a PSA nump from 1.7s to a 2.8. She ordered a EoxDx rna urine marker test which came back 80% likelihood of an intermediate to aggressive cancer. An MRI was ordered and fusion biopsy followed. What I want to say to you is the pathology report shows higher gleason scores on the non tumerous part of prostate. Just because the MRI was negative doesn’t mean your prostate is in the clear. I would have chosen the biopsy on the EoxDx results alone. It nailed it. I have an intermediate risk prostate cancer with only a 1.7 to 2.8 PSA jump. The EoxDx results was my urologist’s deciding factor for proceeding with fusion biopsy. I’m glad I did. Now I have a far better prognosis and chance of survival than if I had waited. Best of Luck on your journey.

@lookin4answers
Just something to think about.

I had three transrectal biopsies over 3 years The first two found nothing the third one found 3+4.

After my prostatectomy, it was 4+3. I know people that ended up with 4+5 after their prostatectomy.

You may be in a gray area, but I didn’t really find a biopsy to be all that difficult. Yes, it’s slightly painful when they do it, but I never had any after effects and most people don’t.

You couldn’t request a transperennial biopsy, Which has much less chance of infection and can get some more of the prostate.

The thing is, do you want to find out in another year or two that you have a serious cancer case?

Discuss with your doctor what are the main reasons he feels that a biopsy really is necessary.

@handera : responding to your questions:
I had an elevated and fluctuating PSA for a number of years and was under the care of a center of excellence which included multiple MRI's and biopsies over 15 - 20 years, all of which were negative. I began to see a local urologist in 2023 and during my first visit we reviewed all of my previous history and the urologist did a DRE and a PSA. The DRE was normal - no abnormalities detected and the PSA was stable from the prior reading (basically unchanged for the prior year). At the end of that first appointment I asked about the newer genomic tests I had been reading about on this forum and others and asked if I could have one of those tests prescribed. I was given the ExoDx urine test and it showed a 36% probability of "treatable" prostate cancer. An MRI was done which was completely clear - no lesions or suspicious areas seen. The urologist recommended a saturation biopsy (24 cores) and that showed 2 of the 24 cores with a small amount (5% in each of the cores) of Gleason 4+5 cancer. Due to the high Gleason score, I decided to have an RALP and following that procedure the pathology report on the full prostate examined after removal resulted in the Gleason score being downgraded to 4+3 with tertiary 5. I had no further treatments and have my PSA checks every 3 months have all been < 0.1 (considered undetectable). I did not get a Decipher score.

My case is a bit unusual in that all indications other than the ExoDx seemed to indicate no cancer (normal DRE, stable PSA, MRI was clear) yet the saturation biopsy showed cancer. If your friend has an elevated ExoDx value, I would suggest proceeding with the MRI and on to a saturation biopsy regardless of what the MRI shows (but the MRI has value in case a lesion is seen as then that lesion can specifically be sampled using the Fusion biopsy process.)

Needless to say, my experience has made me a huge proponent of the genomic tests like ExoDx or PSE. My cancer would not have been detected as quickly as it was if I had not had the ExoDx test. Those tests are relatively inexpensive, and I think they should be used as a standard screening tool just as the PSA test is.

@lookin4answers
I agree with your thinking. I posted a more complete summary of my story below which you can read for some more of the details of my particular case. Although I am extremely appreciative of the ExoDx test for pointing me toward what until then had been undetectable cancer, I do think there are better tests available now than the ExoDx. One of the other members on this forum is Jeff Marchi (@jeffmarc) and he has a summary chart that lists a number of the genomic type tests currently available with the accuracy that they are rated at - hopefully he will see this and post that chart for your reference. My recollection is that the best currently available test is the PSE test. So, my recommendation to you would be to ask your urologist to prescribe the PSE test and go on from there depending on that result and your urologists recommendations.