The biopsy that almost always is performed when there is suspicion of cancer, has the risk of spreading the cancer further. What to do is for each person to evaluate themselves, but I can give my story as a potential inspiration.
First visit and MRI
I visited the oncologist after I got a PSA at 124. At the time I did not even know what that meant, if it was bad or just normal. But I had the test done for a reason, so I suspected it could have been better. Quick research and I realized it probably was very bad. So, visit to the oncologist. First action was to be put on a strong antibiotic for 30 days, because maybe it was caused by inflammation. Number dropped in that month from 124 to 97. Obviously not enough, so next visit at the oncologist included a ultrasound scan. It showed I had BPH (benign Prostate Hyperplasia) which also causes elevated PSA numbers. But to get a better understanding of things he wanted me to do biopsy. Fortunately enough I had done some homework and I knew it was the wrong order of things. If biopsy is done before MRI, then I have to wait about 3 months after biopsy before I can have then MRI because the holes poked in the prostate needed to heal first. So I requested an MRI first. I got it, and it showed big anomalies in both sides of my prostate.
Biopsy
Next step now was biopsy to verify if indeed it was cancer, and how aggressive it was. My new oncologist at Srinagarind Hospital in Khon Kaen wanted to take 12 cores minimum. But I was in doubt what to do, because trans rectum, the standard procedure for decades, was with elevated risk of sepsis (infection) so I looked into the option of having it done with trans perineum. It turned out it was not something they did normally, so they did not have the equipment. I also looked at MRI fusion biopsy, where they were guided by MRI to take the samples. In a regular biopsy they just “randomly” poke 6 holes in each side, total of 12, and then they examine the cores. Maybe they miss the tumor, maybe not. MRI fusion they take 12-21 cores, and they know exactly where to poke, much more precise result. But the price was 50.000 baht so I had to think about it for a bit.
After giving et some thought over the next few days I realized I was complicating things. I already had MRI that showed the anomaly, and it was almost 100% in right side and about 50% in the left side. No possible way for him to miss it, so I opted for Trans Rectal biopsy, but requested only doing 6 cores, and in turn reduce the risk of infection AND spread by 50%. Had to fight for it, he wanted all 12 minimum, but my body, my choice, so he finally agreed.
When I came to the hospital I was not given any sedation of any kind. Laid on my left side, he just jammed the “gun” up behind and took the first sample. It hurt like nothing I have tried before. It was unpleasant more than painful, but it was deep in my soul. Next shot, same thing and I got angry. No sedation at all. But I knew I had to bite the bullet so he took yet another sample, but that was enough for me. I told him stop, and hoped he had used his 3 shots wisely, because I was not going to give him anything else. It was, biopsy came back 5+4=9. The second most aggressive version, and being 53 it was even worse. Young is worse than old, because of elevated natural testosterone levels. It also turned out that the doctor was paid by the number of cores he pulled, and the price I was given was 8-10.000 baht. But the price ended at only 3.500 baht total. Biopsy in a private hospital cost 64.000 baht, and the MRI Fusion was 224.000 baht.
CT, Bone or PSMA Pet scans
After the result of the biopsy the oncologist wanted me to have a bone scan and a CT scan done. Bone for bone obviously and CT for soft tissue. I agreed, it was 5000 baht for bone and 17.000 baht for CT. Total 22.000 baht. But I went home and started to look at what it actually was, and realized that while the bone scan is reliable, then the CT scan was outdated. It had an accuracy of 50,7 percent, which in turn means that if it came back negative (no spread), then I could not really trust it, and I would have to do the PSMA Pet scan too. It was 55.000 baht. So I cancelled the bone and CT scan and requested the PSMA Pet. Again I had to fight for it. He did not want to go straight to the PSMA Pet, but my logic prevailed, and I got it my way. Scan was done and it came back with metastasis to lymph node right next to the prostate. When I asked the oncologist if he would have picked up on that on a CT scan, he admitted that the metastasis was too small, it would not have shown. Again I did the right thing.
What would I have done different?
So, this is where I am today, and rewinding, what would I have done different knowing what I know?
First of all I would not have done the biopsy. I am not sure of course, but I suspect the metastasis I got was the result of the biopsy. Very lucky I only had 3 holes poked in the prostate. How big a Gleason Score I have, is merely nice to know information, because going holistic there is no way to tailor a protocol based on aggressiveness of the cancer. So, to date, almost 2 years down the road, I have had zero use of the PSMA Pet result and the biopsy. Do not misunderstand, now I got it ,I am happy because I got a baseline to relate to, if I should do another PSMA Pet scan later. But all scans, CT, MRI, Pet, they all carry the risk of developing secondary cancers, in particular in the lower region of torso. That is bladder cancer and colon cancer. 5% risk studies shows. So, one does not what to contaminate the body more than needed, certainly not for “nice to know” information, it already is working on one problem. If official treatment is contemplated, then I am afraid that there is no way around it, but to do the biopsy. I suspect they do not want to proceed without as many data as possible, but then I would do the MRI as I did, and based on that I would demand to take only the cores needed to get knowledge. Yes, the more cores, the more information, but it comes at a potential high price.
But there are other ways to know if one got cancer, and that is by blood. And in some way it is more important than the biopsy, because it will verify if there is spread, and it can verify what kind of spread there is. Cancer load in the blood stream and the type. PSA test does only test for the most predominant cancer found in prostates, the one that produces Prostate Specific Antigens (PSA). But there are sub strains that does not show in that test, and blood tests will tell. The list of the test worth looking into is below.
Circulating Tumor Markers (Blood-Based):**
Tumor Burden / Subtype Clues:**
Circulating Tumor Cells (CTCs)**
– Identifies active tumor cells in blood; helps assess heterogeneity.
Cell-Free Tumor DNA (cfDNA)**
– Detects mutations from tumors shedding DNA into the bloodstream.
– May identify therapy-resistant clones (e.g., AR-V7, PTEN loss).
Neuron-Specific Enolase (NSE)**
– Marker elevated in **neuroendocrine prostate cancer**.
Chromogranin A**
– Classic **neuroendocrine tumor marker**. Not specific but helpful if rising without PSA changes.
ProGRP (Pro-Gastrin-Releasing Peptide)**
– Also associated with **neuroendocrine differentiation**.
LDH (Lactate Dehydrogenase)**
– General tumor burden and cell turnover marker. Elevated in aggressive variants.
Hormone & Receptor Analysis (Blood):**
– Total & Free Testosterone**
– DHT (Dihydrotestosterone)**
– Luteinizing Hormone (LH) and FSH** – can hint at feedback dysfunction
– Androgen Receptor Activity or Resistance Markers (e.g., AR-V7 via CTCs)**
*Optional / Functional Tests:**
– Galectin-3** – elevated in metastatic, immune-evasive tumors
– Nagalase** – controversial, but some use it as a cancer activity marker
– G6PD** – relevant if using oxidative therapies (e.g., artemisinin, MB)
Personally I have not done any of them to date, but on Wednesday I will have the LDH done. The only one the hospital I visit can help me with, but it is all I need for now.