Prostate Cancer and Second Opinions - 047

In early April of 2024, my good friends, a married couple, contacted me about his prostate-specific antigen (PSA) doubling over two years. His wife, who always advocates for him, especially regarding his health issues, texted me his last three PSA levels. He skipped his annual physical exam in 2023, so that’s why there is no PSA for that year.  

• 2021 PSA 1.8

• 2022 PSA 1.96

• 3/28/2024 PSA 3.94

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Age-based PSA

My friend is in his late 50s, and the guidelines say that a PSA greater than 2.5 ng/ml is abnormal for men in their 40s and 50s. The median PSA for this age range is 0.6 to 0.7 ng/ml. His PSA had doubled in two years, so both issues concerned his primary care physician (PCP).

His PCP referred him to a community-based urologist who ordered a multiparametric magnetic resonance imaging (mpMRI) of his prostate.

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The first mpMRI report

6.8 x 4.4 x 5.6 cm prostate with volume 84 cc with benign-appearing hyperplasia of the transitional zone. 

In the right posterolateral midland, a 4mm restricting and early contrast-enhancing lesion touches the capsule without evidence of extracapsular extension.

Impression:

Enlarged prostate with an estimated volume of 84 cc.

Very small, 4 mm PI-RADS 4 lesion centered in the right posterolateral midgland. 

PI-RADS 4. High prostate cancer risk. Clinically significant cancer is likely to be present. 

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Deciding to get a second opinion

His urologist scheduled him for a prostate biopsy. His wife started googling reviews to see what they said about the urologist and his clinic. After reading the reviews, which were less than favorable, she contacted her friend at Mayo Clinic Jacksonville and got him worked into a urologist's schedule in two days.

Of course, the urologist at Mayo Clinic wants to repeat the mpMRI because he knows his equipment and radiologists. He ordered another one.  On July 29, 2024, my friend underwent a second mpMRI, which was compared to the prior mpMRI.

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The second mpMRI report

Prostate:

Volume: 77 cc (PSA density 0.05)

Exam quality: Good

Peripheral zone: A few linear and wedge-shaped areas … consistent with prostatitis changes (PI-RADS 2). No focal finding. 

Impression:

PI-RADS 2 - Low (clinically significant cancer is unlikely to be present). 

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A staff member uploaded his report to the patient portal and notified my friends to read it. His urologist wrote this on the report:

"Mr. [last name], your MRI shows no lesions, so that is actually very good news! We can proceed with a biopsy out of an abundance of caution but it is unlikely we will find any cancer so if you wish to hold off  and simply follow the psa in 6 mos we could also do that."

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Ongoing concerns

My friends sent me his latest mpMRI report to review and asked my opinion because they weren't sure what to do. They still had concerns.

These were my concerns:

1. Is the urologist so busy that he can't call the patient or offer a follow-up appointment to discuss why two mpMRI scans two months apart are so drastically different?

2. Did the urologist factor in that the patient and his wife thought he had prostate cancer and had been trying to digest that terrifying news over the prior two months? If so, doesn't he realize that despite him telling them the current mpMRI indicates "very good news," leaving it up to the patient to decide on moving forward with a prostate biopsy "out of an abundance of caution" is sending mixed messages? Mixed messages, which could tip the scales in the patient choosing to move forward with an inappropriate and sometimes very dangerous prostate biopsy?

3. Why didn't the urologist mention that his PSA density, in combination with his mpMRI results, indicates there is unlikely cancer in his prostate? That kind of information helps patients make a better-informed decision. 

4. Doesn't the urologist know that based on the mpMRI PI-RADS score and the prostate density, present guidelines say there is no reason to do a prostate biopsy? Why didn't he tell them that?

5. Why doesn't the urologist have the guts to say he recommends canceling the prostate biopsy? Is he not confident in his mpMRI scanner and radiologist?

6. Why didn't the urologist address the PSA doubling in two years? Since my friend and his wife had already discussed that concern with him, why wouldn't he feel the need to discuss his enlarged prostate and evidence of prostatitis on his mpMRI as potential causes for the elevated PSA?

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Some of you may wonder why the urologist didn’t put him on an antibiotic since the scan showed prostatitis. The guidelines say that a course of antibiotics is not beneficial for asymptomatic patients with an elevated PSA, even if a mpMRI suggests prostatitis.

Based on all these concerns, and mainly because my friends were shocked at the difference between the two scans, I recommended they schedule an appointment with the urologist to discuss these concerns, give him a chance to improve his communication, and alleviate their fears.

They submitted their concerns and questions to him in the patient portal, and he responded by addressing all of them within thirty minutes. I have to admit that is impressive. 

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Here is part of his response,

"Mr. [last name}, our radiologists are superb as is the equipment. In my experience patients do have outside MRIs showing a lesion and our MRI disagrees and shows nothing of concern so that is not uncommon."

They felt comfortable with his response to their concerns, and the plan is to recheck his PSA in three months.

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Reducing inflammation

In the meantime, I told my friends that an infection can cause prostatitis or be present without infection but representative of whole-body inflammation, like a canary in a coal mine. 

Things that can cause or contribute to inflammation in the body include:

• A diet high in sugar

• A diet high in refined carbohydrates, including processed foods

• A diet high in trans fats

• High alcohol intake, which is like eating refined carbohydrates

• Being overweight

• Physical inactivity

• Uncontrolled stress

• Poor sleep

• Environmental toxins and pollutants

Since the diet is such a significant component, I recommended they consider the Mediterranean diet, which is anti-inflammatory. Research shows that this predominantly plant-based diet, which emphasizes fresh fruits and vegetables, nuts, seeds, healthy fats, whole grains, and limited red meat, may reduce inflammation in the body. 

In addition, a systematic review of intervention and observational studies shows that predominantly plant-based diets can potentially decrease prostate cancer risk and progression.

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After all this, his wife texted me,

2 totally different outcomes.  And 2 months of severe stress and worry to get to it but I suppose I should not complain about that!!!

Definitely wanted a 2nd opinion from a "better" place but the importance of research and picking the best place in the first place is important.  Makes me wonder why the PCP recommended who they did.  Oh well.

They both had every right to complain. To be told that your first scan shows cancer is incredible stress to be under. Then, to be told a follow-up scan two months later shows no cancer without an explanation is frustrating.

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Small-town medicine

Sadly, the scenario they experienced is not uncommon, especially in community-based practices. Some imaging centers are jumping on the bandwagon of the latest and greatest scans without the optimal equipment.

Some don't have adequately trained radiologists who can accurately read complex imaging, such as multiparametric MRIs and prostate-specific membrane antigen (PMSA) PET CT scans. 

I call these types of practices “small-town medicine.” Do we know for sure what happened here? No, but the Mayo Clinic urologist alluded to just that.

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Get a second opinion

If you're dealing with a possible or definitive diagnosis of prostate cancer and the thought crosses your mind about getting a second opinion, do it! If you've been diagnosed with high-risk or advanced prostate cancer, get a second opinion with a prostate cancer center of excellence. 

Prostate cancer is incredibly heterogeneous (diverse) and complicated. In addition, the guidelines for diagnosing, monitoring, and treating it are changing rapidly. You want the best to at least establish your care plan; that type of physician is not typically in a community-based setting. 

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Happy ending

I’m so happy for my friends that this story is turning out to have a happy ending. Their story is a reminder of how important a second opinion can turn out to be. He avoided an uncomfortable, very invasive, and potentially dangerous prostate biopsy.

Until the next one, stay healthy.

Much love,

Keith