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

@rider51
I’m surprised you liked the tests that tell you whether or not you probably have prostate cancer, but you are not having a decipher test which will tell you your chance of reoccurrence.

Wouldn’t it make sense to get that test so you know if biomarkers in your system are showing there is more of a problem then A PSA test will show you.

I went 3 1/2 years after my prostatectomy before my PSA started rising. It would’ve been nice if a decipher test has been available 16 years ago. It would’ve let me know I’ve had a higher chance of having reoccurrences, And I’ve had four.

@rider51
Here is that chart, but I don’t think it includes tests that Came out recently. I’ve included a second chart which has some newer tests

@lookin4answers
Per my urologist a MRI looks for suspicious areas. It cannot determine if cancer. When my MRI/Fusion biopsies were done it revealed suspicious areas. My urologist gave it a 79% chance of being PC.

Having biopsies is much more accurate diagnosis of your PC and going to give you a Gleason Score. You cannot have a Decipher test without having a biopsy. Those biopsies are what is sent to Decipher for risk rating.

You mentioned pain and discomfort. There are two methods (offered by my Mayo urologist). One is transrectal usually done while you are awake and is through the rectum. It does come with higher risk of serious infection and also anxiety and stress of being awake.

The other is transperineally. It is usually done with anesthesia and you are not awake or aware of what is being done so there is no pain. I had my biopsies done transperineally as did not want the additional risk of infection nor did I want it done through my rectum and also wanted to be under anesthesia as have PTSD and anxiety/panic disorder so very important to me no to worry, stress out, feel pain or discomfort. I felt nothing after procedure was over. If someone had not told me it was over I would not even know it had been done.

There are many new tests out there can be done in addition to biopsies but a MRI is only going to show suspicious areas, tumors', things like that that does not give you a cancer diagnosis.

I had excellent Mayo urologist, excellent R/Os at both Mayo and UFHPTI, and excellent PCP. The information I passed on to you in this post comes from those medical experts.

Might redo the PSA. Hope your journey goes well.

I was admitted to the hospital on 3/26 for renal failure caused by urine retention. They did a CT, MRI, and two ultrasounds. An enlarged prostate was mentioned in all reports but absolutely no mention of possible malignancy or apparent lesions.

Fast forward 3 weeks and urology pretty much insisted on biopsy based on PSA of 30+ and my continued inability to void completely without a catheter. Result - Gleason 9 (5+4) with 10 of 12 cores @ 100% involvement. Because the entire prostate was malignant, there was no contrasting image for them to see. It all looked the same. My conclusion based on my experience, if you want to be sure if its cancer or not, poke it and get a sample. Short of that, it's all a WAG.

@rider51

Wow that’s an amazing result!

Duke University has been using ExoDx for more than five years and it has helped them discern some clinically significant PCa in cases like yours.

However, ExoDx results don’t always predict what may be found in the biopsy and it may turn out that ExoDx is actually a better predictor of clinically significant PCa than a biopsy!

This video describes some of Duke’s findings.

In Case #3 the patient had a PSA of 4.7 and an ExoDx score of 21.4%, but Gleason 4+5 and 4+4 were found in 12 of 12 cores.

Conversely, in case #4, the patient had a PSA of 4.4 and an ExoDx score of 89.3% and yet the biopsy only found Gleason 3+3. The author thinks they may have missed the clinically significant PCa in their biopsy and was planning another biopsy because of the higher ExoDx score.

All that to say, it would be ironic if a test such as ExoDx turns out to be a better predictor of the presence of clinically significant prostate cancer than a biopsy!

@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.

@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
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.

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.