Prostate biopsy result: a tiny amount of non-aggressive cancer, now under Active Surveillance

Scientist using a microscope, with thanks to the National Cancer Institute for making this photo available freely on Unsplash
"A tiny amount of non-aggressive cancer" is probably the best biopsy result you can get, short of "no sign of any cancer at all." 

And that is why I was so happy to hear those words last week when a urologist gave me the results of the prostate biopsy that I described in some detail here

He delivered this wonderful news as I sat in his office, along with a specialist nurse and an audio recording system. I will come back to the audio recording system in a moment; the make purpose of this blog post is to make the point that not every prostate biopsy brings very bad news. 

Even if you are at elevated risk of prostate cancer—based on family history and/or PSA score—that doesn't mean you're predestined to have a serious case of it. Many men live with a low level of prostate cancer that never produces serious symptoms. So, when a urologist says you should have a prostate biopsy, you probably should, even though a biopsy can be an unpleasant experience. 

(To be honest, the urologist had to talk me into getting the biopsy. I was arguing that "just an MRI" would be enough, and they did do an MRI before the biopsy; but that was mainly to get the lay of the and look for signs that the prostate cancer, if there was any, had spread beyond the prostate itself—in my case, it had not.)

Obviously, what happens after the biopsy will depend on how much cancer is found. If there is no sign of cancer? Great! If there is some cancer? You and your doctors have a sound basis for determining the best course of action. 

In my case, I count myself extremely fortunate to have reached the age of 69 with just a tiny amount of cancer, an amount so small it may never need treatment, although it will be monitored closely (a strategy with a rather cool name: Active Surveillance). 

So, for those readers who've been wondering about the much delayed results of the biopsy that I had in August, there you have it: Stephen Cobb has a tiny amount of non-aggressive cancer. The rest of this article provides more details and context, provided in the hope that it will be helpful for anyone going through the prostate cancer diagnosis process.

More details and context

As readers of my prostate biopsy article may recall, the procedure grabbed 24 tissue samples from my prostate. The urologist said that only one of those samples showed any sign of cancer. Furthermore, that one sample was less than one millimeter in size. 

He went on to say that this finding was consistent with my PSA score, which is not very high, and the results of my MRI, which he described as normal (I will go over those results in a moment). All of that added up to this conclusion: 

"We don’t think this needs treatment at this point [and] it’s very likely you will never need treatment for it." 

This was hugely welcome news for someone who had spent the previous 48 hours reading up on  "treatments for prostate cancer," which can include life-limiting surgery, chemicals, radiation, and more. My brain was working on "to do" list of things like make a will, set up a power of attorney, and find someone to help my partner look after me if I had to undergo one or more of the higher impact treatments.

As I sat in the urology consulting room and let my relatively good news wash away that list and the scary thoughts that went with it, the specialist nurse handed me a small book about prostate cancer. It was opened to the part about how prostate cancer is graded. She had even marked the grade that applied to me; it reads as follows:

Grade Group 1 (Gleason score 6) is the lowest grade and not likely to spread. 

This was a wonderful gift, not least because I immediately realized that I could use the book to reassure my mother, who has already had to live through one of her two children getting treatment for a much higher grade of prostate cancer. 

Although I find this grade group score stuff somewhat confusing, the book had just the right words for my mum: lowest grade and not likely to spread. Which brings me back to the audio recording system, something that has been in use for some years at UHCW (University Hospitals Coventry and Warwickshire). It started with a study by UHCW that found patients receiving a cancer diagnosis had a lot fewer questions afterwards if they were given an audio recorder of the diagnosis delivery meeting. 

So, by the end of my diagnosis delivery meeting I had in my hand a CD of what was said. But that recording and the book were not the only gifts I received. I got a package of prostate cancer coping information plus the contact details and direct line for the designated specialist nurse. I was also registered as a cancer patient and enrolled in  Active Surveillance. That means a PSA test every three months, possibly additional MRIs and biopsies further down the road.

PSA, MRI, and statistics 

Which brings me back to my MRI results. Apparently these did not indicate any signs of cancer. This was supposed to have been conveyed to me back when I had my biopsy. To be honest, I may have been told, but at the time I was very distracted by the messy after-effects of the biopsy. 

What those MRI results indicated to the urologist, in combination with the finding of less than one millimeter of cancer and a series of relatively low PSA numbers, was a low risk of spread. 

You might be wondering what constitutes a relatively low PSA number. That is not an easy question to answer, which is a pity because the process of detecting prostate cancer often starts with a PSA test to measure the level of Prostate-Specific Antigen in your blood. This level is "often elevated in men with prostate cancer" and it makes a lot of sense to check this level if you find out that a close relative has prostate cancer. Here is a chart of the Baseline Age-Adjusted "Normal" PSA Levels (ng/mL).

Studies have shown that if you have a brother who has prostate cancer your chances of getting it are twice as high as someone who doesn't. My brother has prostate cancer and, not long after my biopsy was scheduled, we learned our cousin has it too. Those were decisive factors in the urologist's push to perform a biopsy on me.

When I got my first PSA test at the start of 2021, my level was 5.3. The standard way of presenting the normal PSA range for different age groups goes in bands from 40 to over 70. This is typically presented in the form of a table like so:

   Age           Level 
   40 to 49    0 to 2.5
   50 to 59    0 to 3.5
   60 to 69    0 to 4.5
   70+           0 to 6.5

So, my score of 5.3 at age 68 is above the norm of 4.5 for my age group and thus technically "deranged" as in too high. But this year I turned 69, and I had to ask myself if it really made sense to say that's out of range given that, after my next birthday, a PSA level of 5.3 would suddenly be within the normal range. Clearly there is a steady increase in "normal" over time and that is what I tried to show in the chart above.

As it turned out, I had two more PSA tests before my biopsy and registered 4.2 and 4.3. When I put all this to the urologist as an argument against having a biopsy, his response was very sensible. Although my PSA levels were not badly deranged, and I might have been considered be a borderline candidate for a biopsy based on PSA alone, my family history made doing the biopsy the best course of action. 
I should note that there is disagreement about the value of PSA testing because it is not a foolproof indicator of whether or not someone has prostate cancer, or if they do, how much. For this reason countries like the UK and US don't have universal screening programs for prostate cancer, leaving it to individuals and their doctors to decide whether or not to get tested. 

Personally, I am very glad that I got my PSA tested. Bear in mind that 1 in 8 men do eventually get some level of prostate cancer. Despite that number, and the ones shown on the right, neither my primary care doctor in America, nor my GP in England, recommended that I get a PSA test. 

What happened in my case was this: early in 2020, as my brother's prostate cancer treatment progressed, I began to think about asking for a PSA test. Then Covid happened. I got distracted and medical services got severely disrupted. It was January of 2021 before I requested a test. The result of that test, a PSA level of 5.3, triggered a visit to a urologist in February; but he declared my prostate "normal" based on a Digital Rectal Exam (DRE). However, the experience prompted me to get a follow-up PSA test. I have to admit that I was hoping this second test would show a much lower level and prove the first one a fluke. The level was 4.2 and I was pleased, even hopeful that a biopsy could be avoided. But now, even with the complications that my biopsy produced, I am glad that I took the advice to get the biopsy done and obtain a clear picture of my prostate cancer status, which currently stands at: a tiny amount of non-aggressive cancer, now under Active Surveillance.

At this point, I count myself very lucky; but if that luck changes, and I have to face a more serious situation, I know that I have a brother and a cousin to whom I can turn for advice, and whose bravery in facing far bigger challenges than me, will be a source of inspiration.

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