Four days before my 66th birthday, the news I received this morning was nowhere near what I wanted to hear. At 8.45 a.m. it was my doctor's voice, mellow but firm: "I'm afraid I have bad news for you: the free psa test you took last week came back with a 5.1% reading......" Of course, after two high total psa test results I'd been pinning my hopes on the free psa % (or % fpsa) to be my deliverance. (If the value came back 25% or more I could justifiaby and rationally forego a biopsy given that 92% of men in that category had BPH or benign prostate hypertrophy - not cancer. To me it was great odds to avoid the possible complications of a biopsy - see below).
It became possible about five years ago to measure the different forms in which PSA is found in the blood, either free (fPSA) or bound to serum proteinase inhibitors (complexed PSA; cPSA). It was observed that these molecular forms occur in different proportions in benign prostatic hypertrophy and prostate cancer. Patients with prostate cancer show a lower proportion of fPSA, while those with BPH have a higher percentage. Assays were developed to measure fPSA, and researchers set up prospective clinical trials. Even before results were in, many predicted that determination of percent fPSA (%fPSA) would add value to PSA screening.
Summing up results of the clinical studies with %f PSA, Milenko Tanasijevic, MD, associate director of Clinical Laboratories, Brigham and Women’s Hospital, Boston, averred, "We believe that there is sufficient evidence showing the clinical usefulness of percent free PSA in clinical practice, especially for patients in whom total PSA is between 4 and 10 and who have a negative DRE."
The relative risks of prostate cancer given by the % fpsa results are well known, and my meager 5.1% (total psa reading of 6.1 at last testing 2 weeks ago) fell into the category of men with more than a 60% probability of having cancer, as opposed to benign prostate hypertrophy.
Anyway as she rambled on, informing what the research showed on cancer probability for my % f psa my mind had by then blanked out. In any case I already knew it and the odds.
By the end of her message she flatly told me there could be no more excuses or other tests, and she was referring me to a urologist for a prostate biopsy. Of course, given the choice between that and two root canals I would likely take the latter any day. A prostate biopsy meanwhile is no sport with more than 12- 80mm long needles inserted one by one at a time into one of the most sensitive regions of the body to snatch (in turns) 1/2" sections from differing positions and then do it again. Some have colorfuly referred to it as "being sodomized by knitting needles".
One Brit who faced it wrote on his blog some years ago:
"All men everywhere should demand sedation during a Prostate Biopsy. Accept no less. Demand sedation -- unless you like knitting needles being inserted where the sun don’t shine -- and 15 samples (or more!) being extracted by a circle of eleven needles, from a place that does not usually have needles pricking it & poking it.
I think what makes me most furious is that in this day & age of instantaneous information available on the internet, the “sedation” option for a Prostrate biopsy is almost not there.
Almost not there? Far into one article the writer says, in a very vague way, “general anesthesia helps….but your insurance company might refuse to pay.’ Saying “general anesthesia helps’ sounds like saying that an aspirin might help a headache. No, no, no. General anesthesia obliterates all pain at time of contact (later you will feel some soreness). General anesthesia doesn’t just help, it annihilates all memory of the pain.
In Modern Times there should be an addition to the Doctor’s Motto: “If at all possible, inflict no pain,” should be added to “Above all do no harm.’
I really am furious at the state of affairs. Everyone needs to know that in the case of a Prostate biopsy (a very-very common procedure for older men), “There is no reason for pain in a modern, well equipped room.’"
I definitely will be taking this guy up on his advice and insisting on sedation, and whoever the urologist is may regard me as "wimp", "wuss" or whatever, but hell - if you're going to have sedation for a colonoscopy why not for something 100 times more invasive!
The pain, of course, is not the worst aspect - another is the possibility of complications which I covered in an earlier blog. SO imagine my freak out when I also pulled up a comprehensive report out of Johns Hopkins Hospital, published in The Journal of Urology in 2011, noting all the hospitalizations for infections (an increase of ~ 7%) reported within 1 month for Medicare patients undergoing biopsy since 2000. (This compares with a hospitalization rate of 0.5% during the same 1 month post -biopsy period in the 90s). You can read much more on their findings here:
"Hopkins researchers have found a significant rise in serious complications requiring hospitalization. The researchers found that this common outpatient procedure, used to diagnose prostate cancer, was associated with a 6.9 percent rate of hospitalization within 30 days of biopsy compared to a 2.9 percent hospitalization rate among a control group of men who did not have a prostate biopsy. The study, which will be published in the November 2011 issue of The Journal of Urology, was posted early online.
The researchers emphasize that this new data should serve as a reminder to physicians to carefully weigh the risks and benefits of biopsy for individual patients and take all precautions to prevent infections and other complications.
The Johns Hopkins team’s findings are the result of the largest analysis ever performed of Medicare records of American men age 65 and older who underwent prostate biopsies in the last two decades. They found that having a prostate biopsy makes patients more than twice as likely to need hospitalization in the immediate post-procedure period. Those hospitalized had a range of complications, such as bleeding and infection, as well as flare-ups of underlying medical conditions, such as heart failure or breathing disorders."
Where will this lead and where will it go? I can't say for now, but will keep blogging as long as I can and keep readers appraised. My first visit with the specialist is unlikely to be before next Wednesday and the biopsy will not likely be before the following week - Wednesday or Thursday. I keep hoping for the best including that no cancer will be found.
Meanwhile, I am weighing treatment options!
Get set for the possibility of another atheist on a cancer ward!