Prostate Cancer

[Guest]

I am a healthy 42 year old physician. I have a rising psa over past two years ( 1.2 at age 40 to 3 six months later at age 40.5 later(4 on recheck one month later) and the final value after 2years is 6(with free/total psa<.04; free/total psa percent of less than 4%).No symptoms or family history.DRE negative. First biopsy at 40.5 showed atypical small acinar proliferation on a color doppler study done at a great oncology hospital. Three more biopsies(some with 12 cores) done at this top quality hospital were all negative. Please listen: I do not have BPH(prostate volume is 23), and I do not have prostatitis(no symptoms: pain, frequency,dysuria,tenderness; and I have had 4 courses of 4 days of cipro with each biopsy. Please listen: If I don't have prostatitis(which I am sure about!) have you had any experience with a story similar to this that might explain the lab values. Please listen: I would welcome any comments and I doubt there is anything you could say that would frighten me( as I feel I either have prostatic carcinoma now (false negative rate on biopsy is 20%) or I will get cancer in the future. I know I need to be followed carefully with PSA's and biopsies. Please respond. Again I do not have prostatitis and I have complete faith in the competence of the hospital both with the color doppler as well as the pathology report- Matt [moderator note: e-mail address has been removed]

[Guest]

A lab test is simply a lab test and, as such, they have unexplained false positives. PSA is no different, and a frequent offender in this regard. I believe your case falls into that category.
[quote] I am a healthy 42 year old physicianI have a rising psa over past two years ( 1.2 at age 40 to 3 six months later at age 40.5 later(4 on recheck one month later) and the final value after 2years is 6(with free/total psa<.04; free/total psa percent of less than 4%).No symptoms or family history.DRE negative... [/quote]

[Guest]

Thank you for writing back.
I am really confused.
I believe that I am at really high risk for prostatic cancer.
I am not sure, but I think the tone of your letter tells me that I have no need to be worried ie: false positives happen all the time,perhaps you have had many patients like this. The question is " Did your letter imply that I don't need to worry as this is likely just a false positive?
This is important because i am really worried and concerned when in fact I shouldn't be.
[quote] A lab test is simply a lab test and, as such, they have unexplained false positives. PSA is no different, and a frequent offender in this regard... [/quote]

[Guest]

Many things are possible. It is possible you are at high risk, and it is possible that the test is simply a false positive. If you do not have a family tree consistent with hereditary prostate carcinoma, and have had multiple cores biopsies without any carcinoma, the data suggest the latter is a good bet. There are mathematical models published re the likelihood of multiple biopsies missing a clinically significant cancer. My recollection of that work is something like 22 negative biopsies renders a 95% + chance there is not a 5% cancer (by volume) present. Obviously, the greater the number of negative biopsies, the less the likelihood of a clinically significant cancer being missed.
[quote] Thank you for writing back.
I am really confused... [/quote]

[Guest]

I thank you again for writing back.
Your response is quite clear and easy to understand in that if I have a lot of normal biopsies, then this is a favorable sign.
However, this is the conflicting info I have found.
-someone has informed me that for each biopsy there is a 20% false negative rate.
-an source from another site (?prostate pointers or p2p) website, said that we they looked at a urology textbook/article (?name unknown as i write this, but I do remember the date was 1996), informed me that for a 42 year old, with a PSA of 6 and a free/total psa of less than 4%,my chance of having cancer is 87%.I can find the name of the article if you like.
-with regards to family history, I know that family history is important, and that it may indicate genetic vulnerability or susceptability, isn't true that a positive family history doesn't really color the picture when my blood values are essentially worrisome,ie there is very little contribution of family history in these calculations of risk when I assess my own risk
-I thank you again,Matt [moderator note: e-mail address has been removed]

Many things are possible. It is possible you are at high risk, and it is possible that the test is simply a false positive...

[Guest]

You can read an enormous amount of material on PSA, and worry yourself sick. Your math suggests a 13% false positive rate (rather high for a test that cascades into progressively invasive testing and extreme anxiety). If it were me, I would simply add up the total number of core biopsies I had, and figure the probability of harboring a clinically significant cancer. My guess is the math suggests that probability is quite low.
[quote] I thank you again for writing back.
Your response is quite clear and easy to understand in that if I have a lot of normal biopsies, then this is a favorable sign... [/quote]

[Guest]

-Thanks again. I agree if you read a lot on PSA it is not in your best interest and you will worry a lot and it will interfere with your ability to enjoy life today.
-You think like a surgeon (this is a sincere compliment).Although you are not doubt bright, successful, and I sense personable and direct with your patients, is it not possible that you have reduced the clinical picture to something which is inappropiately simple? ie: I am young(42). The psa jump/acceleration has been very recent(1 year) and perhaps if there is a cancer, it would be easily missed on biopsy(false negative rates may be in the range of 20%).
In other words,my PSA has taken off over the last year and it is likely that some malignancy is growing larger every month (free/total percentage is less than 4%- this might indicate a extremely aggressive cancer in a young male).
I do believe that if the next 2 biopsies if done at 6 month intervals show nothing(including no more small acinar proliferation) and my PSA's drop,I will be more reassured that it is nothing. This follows your premise that the more normal core biopsies you have, the less likely you are to have it or perhaps even develop it in the future.
I must admit I will be curious if my next PSA in July will be. If it takes off incredibly and goes over 10, and my free/total PSA percentage is less than 4%, I will be very worried and all the normal previous core biopsies over the last year will not reassure me.
Anyways, this is how my fears have changed my life:
1. I have rewritten my will.This is a good thing.
2.I plan to take a lot more holidays and see all sorts of marvelous places. This is also a good thing.
3.I do not plan to save any more money, and especially no more money for my retirement--at least for the next two year period. This may be a maladaptive thing, but if you are going to die young, I think most people would go for the gusto!
4. I am terrified that I will suffer some horrible side effect from the surgery, chemotherapy or radiation specifically impotence or erectile dysfunction/or loss of libido or enlarged painful breasts. I am terrified that I may die young. The results of this is that I have been very,very sexually active-nothing unsafe, but certainly impulsive and promiscuous.Even though I know I am responsible for my actions, these intense chaotic feelings and behaviours have been in part very enjoyable but perhaps speak of how incredibly desperate and tortured I feel.
I thank you for writing.
I respect you and I hope this letter doesn't sound disrespectful.
Best wishes-Matt
[quote] You can read an enormous amount of material on PSA, and worry yourself sick. Your math suggests a 13% false positive rate (rather high for a test that cascades into progressively invasive testing and extreme anxiety)... [/quote]

[Mark R.]

I'd like to hear how the doctor is doing seven years later. Where ya at Doc?