Question: I have a 70 yo friend with a strong fam hx of prostate cancer — his father died of it. Despite a psa of 1.2, he recently had a nodule felt by his family doctor and his urologist on dre, which was followed by a biopsy that was negative — no cancer, and nothing else unusual found. His urologist told him yearly exams were all he needed at this point. Would you be more aggressive? Please explain.
The term “nodule” is used a bit broadly and even I in yesterdays video with Penelope spoke of a nodule in “broad strokes.”
- A true palpable prostatic cancer nodule of the prostate would most commonly show cancer on biopsy.
- It is very common for the prostate to have asymmetry and I am sure the doctor or the patient “mis-communicates” exactly what the exam revealed. I could see me telling a patient that I felt something and the patient in turn inferred “nodule.”
- So..there are nodules or areas of firmness or asymmetry that are not because of cancer. Prostate stones are common and can give the feel of a nodule..but it’s not.
- Chronic prostatitis and the resultant area of induration or fibrosis would feel like a cancer nodule but the biopsy would be negative and with elements of inflammation.
- Granulomatous prostatitis does this and I have examined a gland that I was certain it was cancer only to be inflammatory changes of prostatitis.
- The prostate can have ridges, shelves, prominent ampulla of the vas at the base of the prostate which can all masquerade as prostate cancer.
- Benign enlargement often times is assymetrical…i.e. doesn’t feel normal but may be “physiologically” normal.
So what to do…?
In the above case the likelihood is that the palpable abnormality was something other than cancer and the negative biopsy is very encouraging. Now that we have a normal PSA, a normal biopsy and a slightly atypical exam the goal is to monitor and consider repeating a biopsy if any of the parameters change. Whether this is done on a six month basis or yearly depends on several factors to include the age and health of the patient, the anxiety mentality, and the comfort level of the urologist. In this case the patient could easily ask his family doctor to get a PSA at six months to assure that it is not changing dramatically and to provide comfort that the plan is adequately checking on things.
Remember medicine is an art not a science…so a lot of what we come up with is a blend of medicine and the interaction of the doctor and patient. I.e an anxious patient might request to be seen twice a year, the more laid back guy once a year or even asked to be returned to his family doctor.