Low PSA, Positve MRI, Negative Biopsy, today High ExoDx, next steps?

You could get a PSE Which is more accurate than ExoDx. You should request a Transperennial biopsy. It can reach more of the prostate, and has less chance of infection. Are they using a guided biopsy? How many samples have they taken from the PIRADS 4 lesion.

Here’s a comparison of the tests

@jeffmarc

Thank you again Jeff for your response. Obviously, I am somewhat annoyed by the medical care in my area, central SC. There was no underlying cause or reason to even visit a urologist initially, except I had just turned 60 at the time, 3 years ago. Since then it's been one small hill after the other. After requesting an MRI and being told I had the 3 tumors, I was very shocked, especially considering the potential probability and severity of a pyrad 4 tumor.
Unfortunately, a Transperineal biopsy is not available in this area, the Transrectal was rather barbaric. However, as stated previously, the results were benign. Then yesterday after a ExoDx test 2 months ago, I get the latest news.
I feel like time is passing by, 2-1/2 years now, and there is still the possibility of a significant cancer risk.
So at this point, I am researching where to go for more specific expertise and competence.

Sorry for such a long run on note, I do sincerely appreciate your advice and suggestion for the EpiSwitch test.

LakeOne

A few thoughts —>

You mention “a 10 year avg PSA of 1.0.”
> what is your most recent PSA?
> what is your PSA Doubling Time?
> what is your % Free PSA?
> what is your PSA Density?
Those will help provide more clarity as to where you are right now (without being so invasive).

You mention “a positive MRI in '25 with 2 - pyrad 3 and 1 - pyrad 4 tumors detected.”
> was there any mention about extracapsular extension, seminal vesicle invasion, or perineural invasion?

You mention “a negative fusion transrectal biopsy in Oct. '25.”
> by “negative,” do you mean that every core sample description indicated “benign”?

These MRIs you’re getting, are they 3T MRIs?

As for another biopsy, if it were me, I would only get another one if the MRI indicated a need. Plus, I would request a 2nd (independent) review of the previous MRI scan and tissue biopsy. Much of the interpretation of tissue biopsies (as well as images and scans) is often as much an art as it is a science, and depends on the skill and experience of the person interpreting them. Having a 2nd set of eyes reviewing them is always a good idea.

As for biomarker tests, I used OncotypeDx and Prolaris. There are so many biomarker (genomic) tests, that as with any tool the one you use depends on what you’re looking for,

@lakeone - if you don’t mind traveling a couple of hours, there are these in NC:

Duke Cancer Institute
Duke University Medical Center
Durham, North Carolina
Comprehensive Cancer Center

UNC Lineberger Comprehensive Cancer Center
Chapel Hill, North Carolina
Comprehensive Cancer Center

Wake Forest Baptist Comprehensive Cancer Center
Winston-Salem, North Carolina
Comprehensive Cancer Center

And this one in Atlanta:

Winship Cancer Institute
Emory University
Atlanta, Georgia
Comprehensive Cancer Center

This list is from the National Cancer Institute’s website: https://www.cancer.gov/research/infrastructure/cancer-centers

@lakeone
Others have mentioned, Though here is a really great oncologist to talk with
Duke North Carolina
Dr Daniel James George GU Oncologist
Dr. Andrew Armstrong genetic issues

NCCN has no recommended locations in South Carolina

NCI recommends this place in your state as a center of excellence
Hollings Cancer
Center
Medical University of
South Carolina
Charleston, South
Carolina
Clinical Cancer Center

The MRI discovered lesions of concern, not tumors. A PIRADS3 is benign over 50% of the time; A PIRADS4 is benign over 30% of the time. The ExoDX test has a PPV (see chart Jeff attached) of 36% --- that means that when it says you may have cancer you do not over 60% of the time. It is more accurate (over 90%) in predicting that you do not have cancer. Even if you do have low risk (3+3 Gleason) cancer with a low PSA that is showing minimal increases you would be put on active surveillance (watch it and see if it starts getting bad enough to treat). So yes, you are correct in questioning more invasive procedures while there are still other tests that can be done. Excellent suggestions have been made so I will not add any.

@lakeone

City of Hope in Newnan Georgia has been incredible in my situation.

I do not know how far you are from Atlanta. Newnan is on the south side of Atlanta.

Definitely find a place who can help you determine your current conditions.

I made my 1st phone call to City of Hope last October after having an MRI and biopsy at local hospital. Within 2 weeks, I was able to meet with Surgeon/Urologist and Radiation Oncologist.

They will work with you to minimize travel and perform tests and visits on the same day (whenever possible). All MRI’s, PSMA pet scans, bloodwork, pathology, etc are completed in-house.

In April of this year, I had a repeat Biopsy at City of Hope. 3 days after biopsy, Surgeon called me to talk about results. I have not had to wait more than 4 weeks for any visit or test.

Many drive 6-8 hours, or more to go there. They will help arrange hotel and travel arrangements if needed.

There are other Centers like this. You definitely need to find one. If you are interested in going to City of Hope in Newnan, Georgia, let me know. I will provide names for great Urologist and Radiation Oncologist.

I met yesterday with Urologist to discuss Surgery. He spent more than 30 minutes with me and answered questions and was very willing to send biopsy slides to Dr Epstein and send off for Genetic Testing.

A friend from Church went to City of Hope last week fir the 1st time. He has had advanced prostate cancer forthe past 6 years. Radiation, ADT, and chemo. His Oncologist was retiring and he did not know where to go. I told him I did not what City of Hope would recommend, but he should let them evaluate his condition and treatment. After he went, he said he had never felt such peace after being at a facility for 5 hours. They really try to make the cancer treatment process be as good as possible.

Make phone calls and find a good center.

At City of Hope, it just takes 1 phone call to get started.

Best Wishes.

@brianjarvis

Thank you for your response.
The MRI included none of the potential issues you listed..
In terms of the negative term, yes they were indicated "benign"
I was considering sending the previous MRI scan and tissue biospy to MD Anderson and I received the necessary transfer forms. However, when the results came back benign, I did not proceed with the 2nd opinion. Now that certainly seems like not a very good decision.
Thank you again!

@lakeone
Technology makes getting a second (or third) opinion pretty easy these days. Go ahead and get another highly-regarded center to look at your MRI and biopsy slides. It's well worth doing.

I could not tell from your original post if the first biopsy found any cancer. If it came back with no cores cancerous I would probably just monitor every 6 months, almost like you were on active surveillance.