Waiting by the Phone

The title doesn't really hold up anymore, of course. Nowadays the phone is waiting by me wherever I am. But you can bet I'll answer it quickly. This week would be a telemarketer's dream except that I'm going to have zero patience for calls that aren't about my prostate biopsy results.

I had the biopsy on Thursday and it sounds like it really will be Thursdayish before I get the results.

The biopsy itself wasn't nearly as bad as it could have been. The anesthetic shot hurt a little, but it was more "OW!" pain than the "AHHHHH!!" kind of pain I was expecting. After that, although it was still a humbling procedure, there wasn't any pain. Well, until the anesthetic wore off as I followed Sarah through Ikea. That pain really put a damper on the joy of picking out exactly the right comforter.

An ultrasound probe is used to guide the needle(s) of a biopsy. Prostate cancer can't usually be seen on a regular ultrasound, but the fact that none was seen gives me some comfort. If there was something really advanced and ugly in there it might have shown up. The fact that the prostate looked about normal-sized was mixed news. The good news is I don't have a cancer in there so advanced that it's making the prostate lumpy and misshapen. The bad news is the "normal-sized" observation probably rules out benign prostatic hyperplasia (BPH), which was probably my best bet for explaining the high PSA numbers without cancer. To get my PSA numbers with BPH alone the prostate would have to be considerably enlarged.

We're hoping to get news of a negative result of course. By negative I mean positive news (negative in the cancer world is positive). But that hope is more complex than you might expect. People are sometimes surprised to hear that under some circumstances I'm actually hoping for a positive result for cancer. Here's why.

Prostate cancer can't usually be seen via ultrasound, so taking the core (needle) samples involves a bit of luck. It is possible to have cancer in the prostate but miss the cancer with the needle. Some men will have multiple biopsies before they finally get a positive result. Meanwhile their PSA continues to climb, indicating a worsening cancer. Sometimes the cancer isn't actually found until the PSA has risen to a level that suggests it has spread.

So here's some possibilities of the news we might get, put roughly in order by best news to worse news:

1) Negative biopsy followed by a falling PSA level. If the biopsy is negative we'll probably do my next PSA check in a few months. If that is dropping, or even if it is staying steady over a period of years, we'll be able to relax a lot with the knowledge that it probably isn't cancer. That would be WONDERFUL news.

2) A few of the twelve cores positive for a low-grade cancer. This would allow us to get the thing out. If cancer is in just a few cores and it doesn't appear to be aggressive, the odds of it having spread outside the prostate are low. And if it hasn't even spread much in the prostate itself then odds are good I would be eligible for a "nerve sparing" prostatectomy, which would greatly reduce the odds of the dreaded side-effects of surgery.

3) Negative biopsy followed by PSA tests that show rising PSA. If PSA in the blood rises steadily, or even worse if it doubles every year or so, that is highly suggestive that there is cancer in there. But no surgeon is going to remove a prostate based on PSA scores. You've got to show some cancer to buy yourself a prostatectomy. Some men are stuck in this loop of high PSAs and negative biopsies for years, and because the cancer can hit a critical mass, start growing rapidly, and escape the prostate relatively quickly, the cancer can start to spread before it is found. We really don't want it to spread and don't want to have to worry about it spreading for years.

4) Lots of cores positive for cancer. If it has spread all over the prostate then odds are higher it has spread outside of the prostate. It would also suggest the nerve-sparing surgery would be more difficult (but not impossible) to do.

5) Aggressive cancer in some cores. That would be bad news. No way to tell if it had spread outside the prostate or not.

6) Aggressive cancer in lots or all of the cores. That would be scary news. I really hope that's not the case.

So we're hoping for #1, but of course if the biopsy is negative we won't know for months (at best) if we're in a #1 or #3 situation. If the biopsy is positive we'll have some idea of staging but won't know if it has spread until other tests are done.

Either way, the news this week will be but one step in a longer journey.