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High PSA, Three Negative Biopsies. Now what?

I'm 58, healthy.

From July 2016 to today my PSA has gone from 6 to 14. Can't remember my 4K score from 2020, but it was high enough that he ordered an MRI -- which was clean -- but urologist wasn't freaked out. MRI was followed up with a negative biopsy. PSA kept rising so I had another MRI in Feb 2022. Everything normal except this from path report:

"Mostly encapsulated 13mm T2 hypointensenodule in the left paramedian anterior transitional zone at themid gland demonstrates
associated diffusion restriction. PI-RADS 3 - Indeterminate."

Urologist said to test PSA again in a few months. It went up again so he ordered a fusion MRI biopsy (no fun at all!), which was also negative.

He wants to keep monitoring PSA. He said he has a few patients that just run high.

I like him well enough, but I was disappointed/annoyed that no one shared the biopsy results with me before my follow-up appoint two plus weeks later, especially since they were negative. Also, I was looking at my records in the patient portal and one of the visits has his notes from a different patient. It's a big, busy practice. I get it. But after my first biopsy with an older uro, he called me the day he got the report.

Do I get another opinion? Another doctor? I'm in Phoenix and we have Mayo, which seems to do a lot of cutting edge stuff. Or if anyone has any other ideas. Thanks!

  1. Hi . Your concerns are certainly understandable and I'm never one to shy away from a second opinion. That said, a key word in the "PI-RADS 3 - Indeterminate" finding is indeterminate. I want to share this article looking exactly at managing indeterminate or equivocal PI-RADS 3 lesions: It acknowledges that active surveillance protocol is "where the balance between the individual risk of missing csPCa and the constant process of repeating prostate biopsies is crucial." Perhaps something like urinary biomarker testing could be added, some of which test not only for the presence of cancer, but also the grade. Your doctor or another if you seek a second opinion should be able to offer more information. Wishing you the best. Richard ( Team)

    1. Thank you for the thoughtful reply.

      1. Hi . I had a very similar experience to yours, ex the dissatisfaction with the oncologist.

        I’m 53 and my PSA began rising. It reached 4.4, and with a family history of cancer and results from a Nuvoscan which showed a prostate lesion, I did an mpMRI. I was also PIRADS3. Followed up with 4K and ExoDex urine test. Both showed elevated risk of csPCA

        Did a TRUS biopsy. 18 cores were taken, all benign. I have some inflammation and prostatitis. My prostate is small, so urologist said risk of having missed cancer is low. 18 cores is a near saturation biopsy, to my understanding.

        Will check PSA again next year. I was certainly relieved, but if PSA continues rising, I’m sure we will do another mpMRI and start the dance all over again!

        I can’t say emphatically enough how important it is to go to a tier one hospital if it’s close to you. I live in SF, and UCSF is superb. Docs and standard of care are top notch. Gotta think Mayo is on the same level

        1. Hi . First, great to hear that your biopsy was negative. Second, also like that you were able to get the ExoDX test. It is one of the urinary biomarker tests I wrote about in the article I posted for . While you biopsy was negative, it sounds like it did its job in guiding you in the decision making process. I know a lot of the top research I've seen on PCa has come out of UCSF - you are in good hands. Best, Richard ( Team)

        2. Thank you for the reply. Sounds like we are in the same boat! My next PSA check will be part of my yearly physical from my primary care doc in December. If there are any red flags I'll follow up with a Mayo doc. I was so relieved after my first negative biopsy. Little did I know that there would be (at least!) two more. Good luck to us! May there be no more prostate biopsies in our future!

      2. UPDATE: My PSA test from the summer was 14. Sometime in August I watched a youtube video about flaxseed and prostate health.

        (The video is from an MD's channel called Nutrition Facts. The episode is called Flaxseed vs. Prostate Cancer. Link:

        After watching the video I started making overnight oats with a 1/2 cup of oats and a 1/4 cup of ground flaxseed. Also use two scoops of plant-based protein powder and water. I just had a physical and my PSA dropped from 14 to 8.5. Not sure if the flaxseed is responsible, but I'm not changing my breakfast any time soon!

        1. Hi . Glad to hear about the drop. I like how you put it, you can't be positive about what was responsible, but you are going to keep doing the things you have been. There is a surprising amount of research finding positive effects of flaxseed on the prostate health. Here is one article discussing some of the research: Wishing you the best. Richard ( Team)

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