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Seesaw PSA
Old 06-04-2007, 01:17 PM   #1
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Seesaw PSA

Got a physical three weeks ago and my PSA was 4.2, just above the magic 4. This was up from 1.6 a year ago so my doc scheduled me with a urologist and said I would probably need a biopsy. Appt is next week. On my own I scheduled another PSA two weeks later because I was not feeling well when I had the previous one. Just saw the doc (a different one) and this time it was 2.88, within limits for my age at 62 (I can be as high as 4.5). The Doc looked at my PSA history and found readings of 3.2 a couple of years ago, then down to 1.6, then up to 4.2, now down to 2.88. He said this is very unusual to have this kind of seesaw numbers.

Been terribly worried over the last three weeks because of the previous high number and now Im feeling a bit better but will still see the urologist. Its been for the good, though, I think Ive thought through what is important in life and what a great support I have in my dear loving wife.

Ive also done a lot of reading about PC and have learned a great deal, more than I really cared to know but feel like I can make a more informed decision about my situation. I will talk to the U guy next week but am thinking that unless I see another 4+ I will forego a biopsy with all the risks it entails.
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Old 06-04-2007, 01:50 PM   #2
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I had a very similar experience just a year ago. My numbers shot up from 1.8 to 4.0 and a second test, after some medication, only got it down to 3.2. After much consideration I went ahead and opted for the biopsy, which fortunately came back negative. I'm to see the urologist for a follow-up on the 11th of this month but he believes that as long as my number stays in that same range that I have nothing to worry about. According to him, the PSA charts are a wonderful tool but he's seen more than a few men whose numbers rise to the high end of the chart and stabilize at that point. He said that he sees this most often in men over 55 (I'll be 59 in three weeks).

Best of luck to you. Whether or not you opt for the biopsy, you are being wise to have those PSA tests, IMO.
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Old 06-04-2007, 03:06 PM   #3
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The Doc looked at my PSA history and found readings of 3.2 a couple of years ago, then down to 1.6, then up to 4.2, now down to 2.88. He said this is very unusual to have this kind of seesaw numbers.
This is a very problematic area of testing. PSAs which are positive indicate cancer is fewer than 25-30% of patients (by biopsy). The other 75% go through all that for no benefit and some real risk. The closer to 4 the lower the risk. Fluctuations are not unusual -- even routine prostate enlargement can elevate the result. Add to that the fact that abnormals between 4 and 10 even with prostate cancer usually do just fine without treatment. Even very reliable national consensus panels aren't sure if screening is even worth it. Consistent increases > 0.75 per year for several years seems to help sort out the borderline cases, but imperfectly.

Better tests are on the way, and I only do screening PSAs if my patient understands all these false results adn is willing to proceed with the test and biopsy (if elevated).

This is a decision to discuss very clearly with your doctor beforehand.
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Old 06-04-2007, 04:02 PM   #4
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Better tests are on the way, and I only do screening PSAs if my patient understands all these false results adn is willing to proceed with the test and biopsy (if elevated).

This is a decision to discuss very clearly with your doctor beforehand.
Thanks for the info, Rich. All of these modern tests are great, but you hit the nail on the head, the patient should be informed ahead of time as to the risks and consequences, and it needs to be discussed with one's doctor before the test.

I think I have a good GP but as far as PSA, it was done routinely, and I was not well informed. I had heard of the PSA but knew nothing about possible fluctuations, about what might happen if they go above a certain threshold, or the risks of a biopsy. I was also not told about avoiding sexual activity ahead of the test or anything that might put pressure on the prostate like certain types of bikes. Nor was I told that a single result should not be taken as certain, that trends are more significant.

There's also something known as free PSA that I'm sure you know about. I got numbers for both PSA (4.2) and free PSA (.3) and was given a chart that said I have a 56% probability of PC based on some study. No explanation, just a chart. What I wasn't told is that 4.2 is close to the threshold where the validity of free PSA studies become questionable, or that the free PSA half life is very short (hours) in comparison with the total PSA half life (days). The implication is that if one happens to have a PSA spike for any reason, and gets tested the next day, the free PSA may have been flushed out by the kidneys but the non-free PSA is still in the blood being slowly taken out by the liver, making the free PSA percentage artificially low for a few days. I didn't know anything about this, I took my own crash course in PSA-ology by googling and reading medical journal articles. Not optimal but it's the only thing I could do without having a doctor to ask. It's been a very difficult few weeks for me, but next week I will finally see a specialist and be much better informed.

Another thing, I had been considering life insurance and now realize that most insurance companies deny you if your PSA is over 4. All in all it's still great that we have such a test, but I think general practicioners and patients should be better informed of the things you bring up.

So, guys, ask lots of questions to your doctor before PSA testing!
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Old 06-04-2007, 04:09 PM   #5
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Better tests are on the way, and I only do screening PSAs if my patient understands all these false results adn is willing to proceed with the test and biopsy (if elevated).
I'm guessing that if the PSA could've been sorted out with a digital rectal exam then this thread wouldn't be necessary.

Are there any other symptoms that would confirm an elevated PSA? What are the risks of a biopsy-- I thought they were fairly straightforward?

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I was also not told about avoiding sexual activity ahead of the test...
Well, screw that! (So to speak.) I'd never heard that before, and no wonder-- no red-blooded American male would ever admit that there was free time on his calendar for a PSA...
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Old 06-04-2007, 05:25 PM   #6
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Well, boys, keep in mind that by the time you're dead at about 80 almost 90% of men will have small foci of cancer in their prostates - they never knew they had it.

Digital rectal for prostate screening: no evidence showing benefit (at either end of the digit).

Free PSA: cutoff for free:total PSA < 25% (higher is better) helps a little in accuracy but not dramatically.

Biopsy: 1% serious stuff can complicate this outpatient procedure, moderate post-procedure discomfort, can miss some cancers.

Promising: urine tests for various cancer-specific antigens, etc.

Overall, the state of the art is not optimal so we do what we can, erring on the overly aggressive side for reasons of human nature, not hard decision analysis. As an aside, I asked my own doc not to bother and he knows my bias. He said, OK, the promptly proceeded to order the PSA out of habit. Glad it was normal.
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Old 06-04-2007, 06:06 PM   #7
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Well, screw that! (So to speak.) I'd never heard that before, and no wonder-- no red-blooded American male would ever admit that there was free time on his calendar for a PSA...
Well, I'll tell you what, I'll never have a PSA again after having sex on a bike! But I'm ex-AF, Navy guys can take the PSA anytime in those long cruises.
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Old 06-04-2007, 06:22 PM   #8
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SoonToRetire, I think your strategy of waiting to see another higher number before biopsy has a lot of merit. See the Uro -- docs have a lot of range in their sensitivity doing DREs, and getting a relationship going with a Uro has its good points.

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Old 06-04-2007, 06:23 PM   #9
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Well, I'll tell you what, I'll never have a PSA again after having sex on a bike! But I'm ex-AF, Navy guys can take the PSA anytime in those long cruises.
I certainly gave them enough blood-- I hope they knew what they were doing with it!
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Old 06-04-2007, 07:52 PM   #10
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Well, I'll tell you what, I'll never have a PSA again after having sex on a bike! But I'm ex-AF, Navy guys can take the PSA anytime in those long cruises.
Seaman?
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Old 06-05-2007, 02:23 PM   #11
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Seaman?
The Wive's Club of a certain era of the USS HONOLULU (SSN-718 ) will live eternally in the submarine Hall of Infamy for their "Welcome Home" poster that greeted the crew upon returning from deployment:
"What's long and round and hard and full of seamen?"

The squadron commodores made the rest of us steely-eyed killers of the deep go to "couth training" to be able to issue proper guidelines for future welcoming ceremonies...
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Old 06-11-2007, 04:49 PM   #12
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Saw the urologist today. We decided to retest in 3 months and biopsy if over 3.5. In the meantime I'm going to be a good boy as far as eating and drinking well and limiting my sex to under four hours at a time.
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Old 06-11-2007, 04:58 PM   #13
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Good luck to you, Soon. I hope everything turns out well.

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Old 06-15-2007, 09:44 PM   #14
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I just found this thread, I've never been to this section of the forum before, but have been posting to PCa forums since I was diagnosed with PCa 5 years ago. I don't disagree in totality with anything in the posts I have read here but I would not take lightly any PSA reading above 2.0 especially if you are under 60 years of age. Of course your PSA can rise for a varity of reasons, but if it is above 2.0 you need to find out why. A PSA reading alone may not tell you much, but coupled with A DRE(Digital Rectal Exam) performed by an experienced doc(and that is the important part) you might get an accurate assessment of your status. If the PSA is elevated above 4.0 and an enlarged prostate or prostatitis have been ruled out, even with a negative DRE, a "Free PSA" test should be run. This number should be expressed as a percentage and should be above 15%. If the PSa is below 4.0, the "Free PSA will not be of any use (as I understand it). I hate to tell you this, but even a negative biopsy is not 100% accurate, and I just had a friend diagnosed with PCa with a PSA of 1.6 (aggressive PCa sometimes produces very little PSA) Luckily he had a doc who was very adept at performing DRE's and who has kept up on the current literature about this disease. What was true about PCa 5 years ago is not necessarily true today. I was one of the unlucky ones. My doc didn't keep up on the literature, and in retrospect gave half assed DRE's and as a consequence I have been fighting this disease for 5 years and will ultimately lose the battle. I have just touched upon a few of the problems with assessing an elevated PSA reading, it would take a book to bring you up to speed on the subject. The current "bible" on this subject is " A primer on Prostate Cancer" by Dr.Stephen Strum & Donna Poligano, and I reccomend it to anyone who is worried about this disease. Good luck to all of you with elevated PSa's, and "BE VIGILANT
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Old 06-17-2007, 08:36 PM   #15
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Good luck to all of you with elevated PSa's, and "BE VIGILANT
Thanks for the info, Jay, and sorry you are having such a struggle with this terrible disease. It's always more real when you hear it from someone who has personal experience. In your case, did they catch it too late for a prostectomy? I understand that if it has metastasized there's no use in removing the prostate but there are other treatments such as radiation and hormonal therapy. As far as books I will look that one up. I got one from Dr Walsch that was recommended to me and it's pretty good also, his Guide to Surviving PCa. Best of luck to you in your continued treatment.
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Old 06-18-2007, 07:13 AM   #16
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Hi "Soon";
You are exactly right, my PCa was found too late for prostatectomy and I was (and am) being treated with radiation and hormone therapy. After aprox a year after my radiation my PSA started rising again and I've been on some form of intermittent HT since. My PSA was doing like yours before I was finally diagnosed. My first PSA was 2.9, second went up 3.6 third went back down to 2.6 and the last one(before diagnosis) went to 6.9, at which time I was biopsied and the PCa was found (age 56). I went to 3 major medical centers hoping to have a prostetectomy, but was refused by all three. Finally I was convinced that radiation was my best option so I sought out the most experienced Rad onc I could find. And I've been dealing with it since.
There are many factors that can influence a diagnosis or lack of one. Busy doc's , doc's who don't like to do DRE's (and this a very common occurrence) doc's not adept at doing DRe's(even more common), small "multi focal" tumors in the center of the prostate (that cant be felt) that produce little PSA but are very aggressive, ignorance or bias, the list could go on and on. Like I said "it would take a book".
The first book I ever read on the subject was Dr, Walsh's book that you mentioned. If I remember right it was a couple of years old at the time. Five more years have passed and alot has happened in the world of PCa, and there is more up to date information out there now( but I still recommend Walsh's book for good basic information). I hope this post didn't come off as an attack on doctors, because after re-reading what I have written I see quite a few negative comments about doctors. There are good doc's and bad doc's, and many somewhere in the middle, it is up to us as (potential) patients to become educated about our bodies and try to be aware of changes going on as we age. It ain't as much fun as watching football, but neither is dealing with a major disease. Good luck to you!
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