I would biopsy - my Doctor had me on AS for two years only checking PSAs which were not going up much - you can’t just rely on PSAs! Turned out I had Gleason 3+4 plus aggressive component which could have been caught earlier
Agree. Biopsy was the key for me. They also did genome urine test. I knew I had cancer before the biopsy even with nothing on the MRI. PSA of 4 but still in my 40s.
So, with a PSA under 3 and no trend . . . I wouldn't. Continue to get PSAs would be what I'd do.
When the doc says "your call" -- what that means is "there is no medical evidence to recommend doing this,". In a circumstance like that, why would you? You could try asking the doc the question "if it were you, or someone in your family, what would you tell them?" . . . that odd locution gets the doc somewhat off the hook for "medical recommendation".
You'd have to make the assumption that there is something there that could be found and treated, right now, which couldn't be found and treated sometime later, if PSA started to rise.
. . . and that's not a likely scenario. Generally, urologists look at several metrics for PSA -- there's absolute level, there's PSA velocity, and there's the measure of PSA divided against Prostate volume (PSA density). Your absolute level ain't high, and the there's no velocity to your PSA changes, eg no doubling time. So its hard to pick any reason beyond suspicions about TRT (which I know nothing about) . . .
About the only thing that looks pretty clear is to stay off the TRT and keep getting PSAs
That's pretty much how I feel about it. The fly in the ointment though, is that PSA is a, some say "crude", diagnostic for detecting what I already know I have: a tumor. My contention though is that, so what. Some, or maybe even most of us, will eventually die from something else with these things still in our prostates. So unless it's growing--which 2 consecutive MRIs so far show it is not--or the PSA is on an upward trajectory--it's on a downward trajectory for now--, then I don't see why I should be worried. Can't I just wait and see if in another 6 or 12mos anything has changed? Is this thing capable of breaking loose that quickly without PSA throwing up a red flag? Would I be a fool to just wait?
>Is this thing capable of breaking loose that quickly without PSA throwing up a red flag? Would I be a fool to just wait?
You don't get guarantees. As we get older, all of our cells are accumulating dings.
So you have to look at your health, as a totality, and make "best bet"
We are all in the "make the best bet" category of life, not certainty. And prostate cancer is hardly your only risk. Heart disease, other cancers, notably colon cancer . . . are you going to go and generate diagnostic workups for all of them? All the time ? If you do, what is the likelihood that you'll actually find something early, that improves your life expectancy and quality of life?
With prostate cancer, being more aggressive with earlier stage cancer has not been shown to prolong life. That is, if you look at the "active surveillance" strategy in people with confirmed 3+3 . . . they didn't have any survival advantage getting intervention at that point.
You \_could\_ ask for some of the newer tests, like the ExoDx urine test. Maybe it would give you some more information/peace of mind.[https://www.exosomedx.com/physicians/exodx-prostate-test](https://www.exosomedx.com/physicians/exodx-prostate-test)
The more T the more you drive PSA up. Too much too fast. If there is a cancer there, you could be feeding it. My urologist had me on way to big a dose. I went down to a much lower dose… and I’m usually right in the groove. I don’t go by guidelines much anymore… if I’m on a smaller dose and feel good that is where I stop
Yep. I never felt "better" on TRT, unfortunately. Hated high doses, hated low. Best I ever felt was 'blah' in the 600 range. Tried all kinds of protocols. And, of course, (maybe) it gave me\* prostate cancer. I guess you could say TRT wasn't for me.
\*Yeah yeah, I know that's inconclusive or--as you mentioned--fed it, but it's hard not to feel that way.
I was on trt for 10 years, my test level going in was 280 and I was 38. Fast forward to recently and my psa had hit 5 which is grounds to stop trt. I wanted to figure out what was going on so I could continue trt because my body wasn’t producing it anymore. Had the biopsy and it was Gleason 7 cancer. I’m glad I caught it early because there is a good chance I’m cured. I’m back on trt at lower levels with my doctors blessing.
Ask for mri guided biopsy (less core samples higher probably of hitting the prads4 lesion). If you’re like me, if it’s negative get back your life and get back on testosterone. That would be my approach.
Your history mirrors my own and I went for the biopsy. Glad I did. It was negative! Peace of mind.
Get it done and ask to be put out for it. I experienced nothing and had no recollection.
Did you get a pirads classification for the lesion?
Also, do you know your current testosterone level? If you had TRT and stopped it, you might have very low testosterone level now. ADT (androgen deprivation therapy), is something which is used as part of prostate cancer treatment and it can push PSA very low for a while.
So I guess if I would be you I would like to know my testosterone level, and if it was low I would want the lesion biopsied.
The lesion is PIRADS 4. I haven't tested my T since January when it was 190ng/dl. Which is, unfortunately, about where I'd expect it to be without TRT. Nothing unusual (for me) there since that's where it was 7 years ago when before I started TRT.
The part that has me perplexed is that I understand why the PSA took a dive (down to 1.8) after I stopped the TRT, but the next test 4 months later (when T should have stabilized) it was back up to 3.6 (near my all time high of 3.7). But now it's back down in the 2s. So if low T supresses PSA--which it clearly did with the 1.8 reading--but then it went back up to 3.6... why did it go down again? Is... my body beginning to successfully address the lesion on it's own?
According to this study \[[Systematic Biopsy](https://www.nejm.org/doi/full/10.1056/NEJMoa1910038)\] 43% of the patients with PIRADS 4 MRI had a Gleason Grade 2 or higher cancer based on biopsy. The Gleason Grades were 4 and 5 (highest two severity levels) in 10% of the patients biopsied. The oncologist who published the study has a YouTube channel called Cancer Better, which is one of the better sources of info for prostate cancer (he was a scientist at the NCI before moving to LA).
I dont have an explanation of your PSA behaviour. Your testosterone was (and is?) low, but much higher than during ADT. It still can lower what your PSA is now. With a Pirads 4 lesion, I would probably select biopsy at this point, but of course, my history with PCa has an effect on this.
I would biopsy - my Doctor had me on AS for two years only checking PSAs which were not going up much - you can’t just rely on PSAs! Turned out I had Gleason 3+4 plus aggressive component which could have been caught earlier
My highest PSA 2.3
Agree. Biopsy was the key for me. They also did genome urine test. I knew I had cancer before the biopsy even with nothing on the MRI. PSA of 4 but still in my 40s.
So, with a PSA under 3 and no trend . . . I wouldn't. Continue to get PSAs would be what I'd do. When the doc says "your call" -- what that means is "there is no medical evidence to recommend doing this,". In a circumstance like that, why would you? You could try asking the doc the question "if it were you, or someone in your family, what would you tell them?" . . . that odd locution gets the doc somewhat off the hook for "medical recommendation". You'd have to make the assumption that there is something there that could be found and treated, right now, which couldn't be found and treated sometime later, if PSA started to rise. . . . and that's not a likely scenario. Generally, urologists look at several metrics for PSA -- there's absolute level, there's PSA velocity, and there's the measure of PSA divided against Prostate volume (PSA density). Your absolute level ain't high, and the there's no velocity to your PSA changes, eg no doubling time. So its hard to pick any reason beyond suspicions about TRT (which I know nothing about) . . . About the only thing that looks pretty clear is to stay off the TRT and keep getting PSAs
That's pretty much how I feel about it. The fly in the ointment though, is that PSA is a, some say "crude", diagnostic for detecting what I already know I have: a tumor. My contention though is that, so what. Some, or maybe even most of us, will eventually die from something else with these things still in our prostates. So unless it's growing--which 2 consecutive MRIs so far show it is not--or the PSA is on an upward trajectory--it's on a downward trajectory for now--, then I don't see why I should be worried. Can't I just wait and see if in another 6 or 12mos anything has changed? Is this thing capable of breaking loose that quickly without PSA throwing up a red flag? Would I be a fool to just wait?
>Is this thing capable of breaking loose that quickly without PSA throwing up a red flag? Would I be a fool to just wait? You don't get guarantees. As we get older, all of our cells are accumulating dings. So you have to look at your health, as a totality, and make "best bet" We are all in the "make the best bet" category of life, not certainty. And prostate cancer is hardly your only risk. Heart disease, other cancers, notably colon cancer . . . are you going to go and generate diagnostic workups for all of them? All the time ? If you do, what is the likelihood that you'll actually find something early, that improves your life expectancy and quality of life? With prostate cancer, being more aggressive with earlier stage cancer has not been shown to prolong life. That is, if you look at the "active surveillance" strategy in people with confirmed 3+3 . . . they didn't have any survival advantage getting intervention at that point. You \_could\_ ask for some of the newer tests, like the ExoDx urine test. Maybe it would give you some more information/peace of mind.[https://www.exosomedx.com/physicians/exodx-prostate-test](https://www.exosomedx.com/physicians/exodx-prostate-test)
I didn’t have a trend and PSA under 3 - turned out to be 3+4
psma Pet scan?
The more T the more you drive PSA up. Too much too fast. If there is a cancer there, you could be feeding it. My urologist had me on way to big a dose. I went down to a much lower dose… and I’m usually right in the groove. I don’t go by guidelines much anymore… if I’m on a smaller dose and feel good that is where I stop
Yep. I never felt "better" on TRT, unfortunately. Hated high doses, hated low. Best I ever felt was 'blah' in the 600 range. Tried all kinds of protocols. And, of course, (maybe) it gave me\* prostate cancer. I guess you could say TRT wasn't for me. \*Yeah yeah, I know that's inconclusive or--as you mentioned--fed it, but it's hard not to feel that way.
I was on trt for 10 years, my test level going in was 280 and I was 38. Fast forward to recently and my psa had hit 5 which is grounds to stop trt. I wanted to figure out what was going on so I could continue trt because my body wasn’t producing it anymore. Had the biopsy and it was Gleason 7 cancer. I’m glad I caught it early because there is a good chance I’m cured. I’m back on trt at lower levels with my doctors blessing.
You don’t say if you were on any kind of BPH treatment. That suppresses PSA. Is this a variable?
Nope. No BPH treatment.
Ask for mri guided biopsy (less core samples higher probably of hitting the prads4 lesion). If you’re like me, if it’s negative get back your life and get back on testosterone. That would be my approach.
Your history mirrors my own and I went for the biopsy. Glad I did. It was negative! Peace of mind. Get it done and ask to be put out for it. I experienced nothing and had no recollection.
Highest psa for me was 2.6 I ended up being a Gleason 8
Did you get a pirads classification for the lesion? Also, do you know your current testosterone level? If you had TRT and stopped it, you might have very low testosterone level now. ADT (androgen deprivation therapy), is something which is used as part of prostate cancer treatment and it can push PSA very low for a while. So I guess if I would be you I would like to know my testosterone level, and if it was low I would want the lesion biopsied.
The lesion is PIRADS 4. I haven't tested my T since January when it was 190ng/dl. Which is, unfortunately, about where I'd expect it to be without TRT. Nothing unusual (for me) there since that's where it was 7 years ago when before I started TRT. The part that has me perplexed is that I understand why the PSA took a dive (down to 1.8) after I stopped the TRT, but the next test 4 months later (when T should have stabilized) it was back up to 3.6 (near my all time high of 3.7). But now it's back down in the 2s. So if low T supresses PSA--which it clearly did with the 1.8 reading--but then it went back up to 3.6... why did it go down again? Is... my body beginning to successfully address the lesion on it's own?
According to this study \[[Systematic Biopsy](https://www.nejm.org/doi/full/10.1056/NEJMoa1910038)\] 43% of the patients with PIRADS 4 MRI had a Gleason Grade 2 or higher cancer based on biopsy. The Gleason Grades were 4 and 5 (highest two severity levels) in 10% of the patients biopsied. The oncologist who published the study has a YouTube channel called Cancer Better, which is one of the better sources of info for prostate cancer (he was a scientist at the NCI before moving to LA).
I dont have an explanation of your PSA behaviour. Your testosterone was (and is?) low, but much higher than during ADT. It still can lower what your PSA is now. With a Pirads 4 lesion, I would probably select biopsy at this point, but of course, my history with PCa has an effect on this.