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Two negative prostate biopsies, taking Proscar and Psa 13. What to do?

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This is a real scenario and shows the complexity of managing certain situations about the prostate. Part of the problem is the common misconceptions about the prostate and prostate  cancer. As well all the things you read in the paper or hear on TV about new studies showing that the PSA is unreliable and is used too often by Urologists and in turn resulting in too many men being biopsied and then subsequently being treated…and subsequently as a result negatively affecting their lives with incontinence and impotence.

So imagine you are in the exam room with your doctor in the above situation and your urologist is walking you through the fine line of doing just the right amount of tests or procedures to determine if you have prostate cancer. The bottom line is that if you have cancer and this is found out a year after your office visit…you’d be quite disappointed and probably mad…probable the word “lawyer” may come to mind.

As Bart Simpson said when asked his thoughts on “why does increasing military might and expenditures on weaponry actually act a deterrent to war?”

Bart had wrongly been put in a genius class because the test scores of a brilliant student had been attributed to him. He said, “Well.. I guess you’re damned if you do and damned if you don’t!”

download-2-bart

So…in the conundrum I’ve described in the title of this post…the issues-

  • The two negative biopsies performed five years ago were negative however that was five years ago and things change. Just because a patient says, “But I have had a biopsy before and it was okay. Isn’t that enough?” Well a lot can happen or change in five years. Yes you didn’t have it then but that was then and this is now.
  • There is the issue of prostate cancer being in unusual places in the prostate that is not a easily sampled on a biopsy. If you look at a picture of a prostate the part that is examined by the urologist  on a rectal exam is the posterior lobe of the prostate. This does not examine the inner or anterior aspect of the prostate. The exam is a good exam and necessary but does not evaluate the “entire gland.”
  • Now you throw in the drug Proscar or generic name Finasteride. Five years ago the biopsies were negative and the PSA then was 15. Now the PSA is 13. The patient concludes that- I have had two negative biopsies and now my PSA is less than five years ago. Well Proscar lowers the PSA by about 50%. So off the Proscar this patient’s PSA could well be 20.
  • The patient stops going to the Urologist because his family doctor is doing the PSA now and it is less than five years ago but the family doctor and the patient are looking at a PSA that hasn’t changed appreciably and “stay the course.”
  • The PSA being the same or lower is not better. The Proscar is “masking” the true value.
  • So the feeling is that all is well with this patient. Well to the urologist who sees this patient…he is concerned. He also has to explain the above and put out there that some other sort of evaluation must be done to be sure the Proscar isn’t deceiving everyone.
  • If the patient for whatever reason  goes back to the urologist, the urologist will note the scenario above and recommend doing something to update the situation and hopefully show that there is indeed no prostate cancer. Again sitting on this situation and the patient is found to have an aggressive form of prostate cancer because it has been allowed to smolder undetected because of the masking effect of the Proscar…well that is a problem for all. I would think the urologist would found potentially at fault.
  • Again remember in the back drop…all the misconceptions that prostate cancer is the slow growing type and that people don’t die of it. And of course the old standby by the male not wanting a rectal exam or another biopsy, “I don’t have any symptoms.”
  • The channel that the male voids through is well away from the posterior aspect of the prostate and so for there to urinary symptoms the cancer would have to be extensive to cause voiding symptoms. In other words when found it is too late.

How about this added to the above scenario? The patient has seen the urologist and has had the two negative biopsies and his PSA is stable on the Proscar (which actually is worrisome..it should be half). The family doctor gets the PSA, and it is unchanged. The family doctor says to the patient, “I’ll leave your prostate exam to your urologist.” The patient however has not seen his urologist for five years. Uh oh! Do you see the perfect storm brewing…yes quite the opportunity for the late diagnosis of prostate cancer due to numerous factors and misconceptions on several layers. Of note in the above situation…the urologist is out of the loop. The patient has stopped going to him and being “checked up” by the family guy.

This is like in baseball the center fielder and the right fielder are both approaching a fly ball. The center fielder yells as they both close in on the ball, one in which it looks like both could catch but both struggling to get there. The center fielder says, “I got it.” The right fielder backs off, the center fielder realizes that he will not be able to get to the ball and then yells, “You take it.” The ball falls safely between the two fielders. Just as too many chefs spoil the soup so too it can be said of doctors “I got it, you take it” type arrangement in which things fall through the proverbial cracks of patient care.

So one day on the blood work of the family doctor the PSA does go up. “Hmmmm, your PSA is going up. Have you been seeing your urologist? You haven’t? Well it may time to go back to him and let him evaluate these numbers.” The doctor then remembers that the patient is on the Proscar. He becomes concerned.

The family doctor remembers the warnings that pop up on his medical record screen regarding patient’s taking Proscar: Proscar does not cause prostate cancer if prostate cancer is found in a patient taking Proscar it is further along and more aggressive, i.e. the “masking effect” in lowering the PSA delays the diagnosis.

The patient is now back with his urologist after five years and the options are discussed.

  • Of course now a rectal exam is done after five years of not checking it.
  • You could do another biopsy
  • You could do a prostate MRI
  • You could do various PSAs that predict the chances of a positive biopsy

If another biopsy is done it may be negative but it may not. And this is not a situation  the patient, the family doctor or the urologist wants to be in.

Summary-Negative biopsies, being on Proscar, reluctant male patients  not wanting to be messed with, misconceptions about prostate cancer, misunderstandings of the family doctor thinking the urologist is more involved in the care of a patient than the urologist actually is-all create a perfect storm of the late diagnosis of prostate cancer.

As my mother would say, “A word to the wise is sufficient”

Tomatoes and prostates? A tomato a day will keep the urologist away.

The apple ain’t got nothing on the tomato!

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Article Reviewed: Lycopene Inhibits Disease Progression in Patients With Benign Prostate Hyperplasia. Schwarz S, Obermuller-Jevic UC, et al: J Nutr; 2008; 138 (January): 49-53.

Lycopene Inhibits Disease Progression in Patients With Benign Prostate Hyperplasia.

Schwarz S, Obermuller-Jevic UC, et al:
J Nutr; 2008; 138 (January): 49-53

Background: Lycopene is a carotenoid found in a variety of healthy foods such as tomatoes, watermelon, and pink grapefruit. It has garnered interest in the area of prostate cancer prevention, but has yet to receive adequate attention in the area of benign prostate hyperplasia (BPH). Objective: To determine the serologic, tissue, and clinical impact of higher plasma lycopene levels in patients with histologically proven BPH. Design/Methods: This was a randomized trial of 40 patients who received 15 mg per day of lycopene from a dietary supplement or a placebo for 6 consecutive months. Patients completed 4 visits at the medical practice during the 6-month period at baseline, after 1 month, after 3 months, and after 6 months. The primary end point was the reduction of increased PSA levels. Results: The mean patient age was 67 years and body mass index was 26 (slightly overweight). PSA levels decreased significantly in the lycopene group after 6 months from 6.6 mcg/L to 5.8 mcg/L, and there was no PSA change in the placebo group. Progression of prostate enlargement did not occur in the lycopene group compared to placebo as assessed by transrectal ultrasonography (TRUS) and digital rectal examination (DRE). Disease symptoms according to the International Prostate Symptom Score questionnaire significantly improved in both groups, but to a greater degree with lycopene. However, the placebo group experienced significantly greater reductions in LDL cholesterol compared to the lycopene group.

Conclusions: Lycopene at a dose of 15 mg/day may inhibit the progression of BPH.

Reviewer’s Comments: Lycopene from diet and supplements has not experienced impressive data as of late in the area of prostate cancer research. Perhaps the earlier use of lycopene in healthy patients with BPH was a more ideal opportunity to test the impact of this supplement. The most impressive finding was not the reduction of PSA by lycopene, but that both groups reduced their intake of overall calories to a large degree during the trial. In the Prostate Cancer Prevention Trial (PCPT), men in the placebo arm that reduced their caloric intake also reduced their PSA velocity. In other words, is the lycopene supplement responsible for the favorable impact in this study, or the fact that men reduced caloric intake, which may have also caused the LDL and PSA reductions? (Reviewer–Mark A. Moyad, MD, MPH).

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Top Tweets for Urology Care Foundation

Urology Care Foundation is funded by the American Urological Association. It is a very useful site both for urologists as well as urological patients. On this site a patient can download infographic posters and subscribe for free for the monthly magazine. Click on the image below to get a taste of the top 5 tweets by UCF for the year and then checkout this informative website-urologyhealth.org.

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Is testosterone replacement safe after you’ve been treated for prostate cancer?

Prostate-Cancer-Symptoms

TRT Requires Close Long-Term Follow-Up

Urology – May 1, 2007 – Vol. 22 – No. 11

Patients with low serum testosterone levels and symptomatic hypogonadism who have undergone treatment for early, localized prostate cancer may be treated with testosterone replacement therapy as long as they are followed closely and remain in remission.

Article Reviewed: Testosterone Replacement for Hypogonadism After Treatment of Early Prostate Cancer With Brachytherapy. Sarosdy MF: Cancer; 2007; 109 (February 1): 536-541.

Testosterone Replacement for Hypogonadism After Treatment of Early Prostate Cancer With Brachytherapy.

Sarosdy MF:
Cancer; 2007; 109 (February 1): 536-541

Read More…

Northeast Georgia Urological Associates-Active Surveillance for Prostate Cancer

If you have been recently diagnosed with prostate cancer you owe it to yourself and your family to watch the following video. Active surveillance should be considered by you to be one of the treatment options for your prostate cancer.

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Contact us 24/7 for an appointment-Leave your number in the form below and we’ll call you the next business day. Our urologists have over thirty years of experience in management and treatment of prostate cancer.

Northeast Georgia Urology-Prostate Screening-A white board animation.

What the newly diagnosed male with prostate cancer thought was a simple disease of older men, becomes much more complicated once the decision process begins. This animation highlights the conundrum that is prostate cancer.