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Prostate Cancer

Elevated PSA, decreasing free PSA, neg biopsy

12/29/2008

Question:

Since Oct. 2007 we have been monitoring my husband`s elevated PSA. He`s 49, inital PSA was 5.8. PSA has decreasd slightly after intense antibiotics (in 4/2008 from 5.8 to 5.1) and after anti-imflammatory medicine (in 11/2008 from 6.4 to 5.8). Two biopsies have been negative (11/2007 and 6/2008). Free PSA has recently decreased from 11% in 10/2008 to 9% in 12/2008, and PCA3 test score in 1/2008 was 90. While some of these test scores suggest the presence of cancer, the biopsies don`t prove out. We`ve had two opinions, one of which suggested a saturation biopsy, the other prescribed the anti-inflammatory meds and a 6-month treatment of Avodart. Given his age, should we follow the more aggressive opinion, or if total PSA is not rising should we continue with watchful waiting? Can cancer be present in lymph nodes but be missed in prostate biopsies?

Answer:

I think it would certainly be appropriate to proceed with a saturation biopsy. I'm not sure Avodart and anti-inflammatory meds for 6 months are going to resolve the issue. You must remember if he chooses the Avodart for 6 months you must double his PSA after 6 months to obtain a equivalent value. In my practice I would recommend a saturation biopsy.

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Response by:

Lee E Ponsky, MD Lee E Ponsky, MD
Associate Professor of Urology
School of Medicine
Case Western Reserve University