PSA levels, prostate volume, biopsy results.

[ieshepherd@yahoo.co.uk]

I have a prostate volume of 97and PSA 23 which gives a PSA density of 0.24. My biopsy indicates a Gleason score of 6, one core has 1% and two cores have 5% cancer. DRE is firm and smooth. I am 70 and in good health generally, no symptoms. The MRI scan has no indicators.
I have just had another PSA check, it has gone down to 13.
1. My prostate volume seems very large, but incontinence and urinary problems are minimal. How significant is this figure?
2. Why is the PSA so high and so variable with only a minimal biopsy score?
3. HIFU treatment seems ruled out at present. Is this correct?
4. Radiotherapy seems the best option, but when to start treatment? Are more biopsies needed in the longer term?

Many thanks for your advice.

[Philippa Aslet]

You ask some good questions and ones which I would encourage you to go and discuss in more detail with either or both the Urology Specialist Nurse and Consultant Urologist that you have seen at the hospital.
However in aswer to your questions:
Prostates can grow quite big as yours has but that is not necessarilly related to cancer. Indeed much of the growth is likely to be related to benign or non cancer growth of the prostate which is a normal part of the aging process in men.
PSA is a usefull but imperfect test and many men find themselves in the same position as you. Your PSA is elevated. The limitations of Transrectal biopsies which i assume is the type you have had, is that they can only sample a very small percentage of prostate tissue. The MRI scan sounds reassuring which is good. If you want to adopt Active surveilance as your treatment option, then template prostate biopsies would be able to give you the reassurance that there is not more disease than the initial biopsies have picked up. These biopsies take many more samples of the entire prostate but would require a general aneasthetic.
HIFU with a large Gland is not an appropriate treatment.
Along side active surveilance Radiotherapy and Surgery are good treatments. What is important is that you do not have to rush to a decision. Take your time. Meet the oncologist and the surgeon and discuss the treatments and the side effects. Prostate cancer remains a slow growing slow changing disease in the vast majority of men.
The prostate cancer charity offer an excellant selection of information sheets to help guide you through the decision making process.

[Mr Omer Karim]

This is a good reply by Philipa Aslet.

Your PSA level is very variable because most PSA is produced by the benign component of your prostate (BPH) and you have a good volume prostate. Unfortunately PSA levels are NOT directly related to the amount of cancer in your prostate, hence it is not a perfect test for prostate cancer diagnosis or surveillance. On the face of it you seem a good candidate for "Active Surveillance". I would however agree with Philipa that you should have template biopsies as you could still have a significant TRANSITION zone or anteriorly situated cancer which has been missed by the transrectal biopsies you have had.

You also need to be aware that up to 30% of men who have Gleason 3+3 diagnosed on TRUS biopsy have their cancer upgraded when the prostate is removed.

Looking into the future, you would be at significant risk of needing some sort of surgical treatment for your large prostate even though at present you do not have any subjective symptoms. You should consider having uroflometry and a post void residual urine done by your urologist.

[ieshepherd@yahoo.co.uk]

Many thanks for the helpful and informative posts. Excellent replies.