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

My second MRI, 5 years after my first, also came back clean. We decided to do a second biopsy about 6 months later. I also had an enlarged prostrate(volume of 68) and my PSA was up to 7.7. The second biopsy came back with 2 cores of cancer, one at 3+4. I decided on surgery. The pathology report came back at 4+5. Now 2 years later PSA is still < 0.01. Obviously, I was glad I made the decisions I did. Based on my experience I would highly encourage the biopsy, but my advice is to make absolutely sure you have taken the necessary steps so you feel confident with your decision. Best wishes

@hikerbruce2025, being fit will serve you well. I assume you're a hiker. How did the appoitment with the urologist go? Did you decide to proceed with surgery?

Here is a detailed discussion of 2nd opinions on MRI and biopsy interpretation.

Other suggestions in this forum are good. You may want to discuss other factors with your urologist if you haven't already done so: Size of prostate can nudge the PSA # up and still be "normal." Even if the MRI doesn't show lesions, one could still have cancerous cells in there which the biopsy could show. Luck!

@lookin4answers
You might want to get the PSE blood test which looks at biomarkers. It is 93-94% accurate (vs PSA alone) with a report that states whether you are likely or unlikely to have prostate cancer. Part of Oxford Biodynamics goal is to prevent unnecessary biopsies. The link to their web site and the web page for the PSE test is:
https://www.94percent.com/

another issue with transrectal biopsy is antibiotic resistance. Far more antibiotic is used with transrectal. In the U.K. it transrectal biopsy is not done anymore.

@climateguy - I appreciate your situation and hesitation to get the biopsy. I live in ATL and my son is an anesthesiologist that works at Emory St Johns hospital with may of the best Emory Winship Cancer Institute MDs. He connected me to what he felt was the top urologist/surgeon and Radiation Oncologist.

I too inquired about transperineal vs. transrectal biopsies. I had seen some research that transperineal had lower infection rates. But Emory MDs said latest research shows they are almost equal with less than 1 % infection rate. Granted, when you do get an infection it is often very serious.

I was very lucky that after my transrectal biopsy and subsequent 5 weeks IMRT + high dose brachytherapy...I had zero pain, bleeding or other issues. I consider myself very fortunate/blessed in this regard.

I will keep you in my thoughts and prayers!

Good luck to you

@capatov My case is somewhat similar to yours, except more advanced. (5 cores out of 12, seminal vesicles are now also involved). If you had chosen to put your biopsy off for another year, perhaps you'd be in my boat.

I was so concerned early on to avoid a biopsy in case it wasn't necessary, but now that I've been sentenced to 2 years of ADT, and 5 weeks of EBRT, I see that having a biopsy seems trivial.

Urologists seem a bit trigger happy when recommending a biopsy, but they have a very good idea of how serious things can get if you don't find out what's happening in time.

Part of my hesitation was the older idea, that was somewhat set in stone in 2012 by the US Preventative Services Task Force, that no men should be routinely screened with PSA testing. The problem then was way too many men were being tortured with biopsies and treatments with not much to show for it in terms of extended life span for the group. The solution, no testing, is now very clearly seen to have been mistaken. The current emphasis on active surveillance for lower grade cancers that are found on biopsy seems to be a far better idea.

It took me a while to actually look into this impression that I had, i.e. PSA tests shouldn't even be done, to where I realized things had changed since 2012. I did get a repeat PSA test to make sure the results were consistent, then I agreed to a biopsy - months after when I should have had one.

I had a transperineal biopsy in order to reduce the risk of infection that can happen more often with the alternative, i.e. transrectal biopsy. I felt the effects for weeks afterward, but the effects were hardly problematic. There were dark blood stains left by my ejaculate for months afterward but this eventually went away.

I am 67 and had 7.1 PSA but negative MRI. My urologist did a free PSA blood test that showed up to 50% chance of PC in my gland. He suggested and we did a biopsy which showed two positive cores (out of 12) with one low grade 3+4 = 7 and the other 4+3 = 7 intermediate grade. PSMA PET showed PC confined to gland.

I opted for a three pronged approach to treatment - 5 weeks IMRT + one HDR "boost" procedure + 6 months Orgovyx ADT. Going back for follow up 6 month post treatment PSA in January. Hoping PSA remains close to 0

I would recommend getting the biopsy...early detection is key to long term survival with PC

@climateguy
Now that is taking your medical care the way you should!

Sometimes even if uncomfortable discussion you must take an active role in your medical and mental health care.

Getting second opinion was something my Mayo PCP recommended even though my first diagnosis and treatment plan was at Mayo.