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Prostate Exam

Old 11-25-18, 07:36 AM
  #26  
Cuyuna
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Originally Posted by OldTryGuy View Post
Not sure if your reply was a , the 3TmpMRI is now considered FAR SUPERIOR to the antiquated TRUS and covered by most insurances. Some require a TRUS first but the issue there is that a TRUS biopsy samples a very little segment of the prostate and many times totally misses the cancer.

If the urologist will not prescribe a 3TmpMRI, bike quickly to another doctor who will. It could mean the difference between death or life.

It's not a matter of finding a doctor to order it...most won't care. The accuracy has been pretty much proven but MRI's value as a prostate cancer screening tool has not been demonstrated yet.

Regardless of the accuracy of the testing, with the vast majority of insurance companies, MRI's and CT's have to be pre-authorized. A doctor can order it but whether or not the patient gets it is entirely up to the insurance carrier. It would be very, very unusual that any insurance company would authorize an MRI of the prostate for screening, and even more rare that they'd authorize it without a DRE and PSA first.

ETA: ....I should add...if/when the screening MRI is denied, the patient has the ability to pay for the MRI himself....somewhere between $500 and $1500, typically. After an insurance company denies it, usually the bottom line appeal would require a peer-to-peer conversation between the ordering physician and a Medical Director at the insurance carrier. Those are hard to schedule and time consuming, and successful about 50% of the time at best. Trying to argue for an MRI for screening will end up being pretty fruitless in most cases and something most doctors are unlikely to be willing to take the time for just because the patient wants it. In the case of Medicare...they don't cover it unless is can be proven to be medically necessary. With Medicare itself...there is no pre-authorization possible...they just deny the charges for it after-the-fact. Since Medicare participants can't bill for the balance, the MRI provider is out the money. Very unlikely that they would provide the screening MRI and take that kind of chance on getting paid.


..

Last edited by Cuyuna; 11-25-18 at 09:08 AM.
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Old 11-25-18, 10:19 AM
  #27  
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Originally Posted by Cuyuna View Post
....... accuracy has been pretty much proven but MRI's value as a prostate cancer screening tool has not been demonstrated yet...................
As I mentioned, a TRUS might be required before approval the MRI and often the TRUS follows a PSA test but not necessarily a DRE since some doctors will biopsy on elevated PSA alone. The use of the 3TmpMRI is becoming the standard since unlike a TRUS, the actual condition of the entire prostate and surrounding areas can be viewed to determine if a biopsy is needed and where sampling must be done. The use of the 3TmpMRI is essential for proper Active Surveillance Treatment.

Online Prostate Cancer Support Community - Ustoo IMO, every man and SO would benefit greatly accessing this site.
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Old 11-25-18, 10:50 AM
  #28  
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Originally Posted by OldTryGuy View Post
As I mentioned, a TRUS might be required before approval the MRI and often the TRUS follows a PSA test but not necessarily a DRE since some doctors will biopsy on elevated PSA alone. The use of the 3TmpMRI is becoming the standard since unlike a TRUS, the actual condition of the entire prostate and surrounding areas can be viewed to determine if a biopsy is needed and where sampling must be done. The use of the 3TmpMRI is essential for proper Active Surveillance Treatment.

Online Prostate Cancer Support Community - Ustoo IMO, every man and SO would benefit greatly accessing this site.
If only somebody would pay for it....
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Old 11-25-18, 11:04 AM
  #29  
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Originally Posted by Cuyuna View Post
If only somebody would pay for it....
Have you been denied??? If so, I am sorry but more approvals are happening. My Axunin PET was at one time denied and is now covered.
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Old 11-25-18, 11:09 AM
  #30  
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Originally Posted by OldTryGuy View Post
Have you been denied??? If so, I am sorry but more approvals are happening. My Axunin PET was at one time denied and is now covered.
I'm a physician. I have intimate knowledge of the pre-authorization process for a variety of medical imaging tests and similar. Prostate MRI looks good from a diagnostic accuracy standpoint and may ultimately become the standard since it's not much more expensive than a screening colonoscopy which IS the standard for colon cancer screening. The difference is that the value of colonoscopy is well documented in addressing colon cancer outcomes. No such data, yet, on how MRI affects survival for prostate cancer.

http://www.diagnosticimaging.com/mri...ly-restrictive

"The results showed that overall, 11.1 percent of payers covered prostate MRI in biopsy-nave patients with suspected prostate cancer; 88.9 percent required a prior negative biopsy. Nearly all payers also require either a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage."


....

Last edited by Cuyuna; 11-25-18 at 11:17 AM.
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Old 11-25-18, 11:43 AM
  #31  
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My doctor said prostate exams are now optional. After some consideration, I opted "no thanks".
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Old 11-25-18, 11:59 AM
  #32  
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Originally Posted by Cuyuna View Post
Appreciate the link. Do you have first hand experience using the 3TmpMRI regarding PCa scanning? At issue is since a urologist can not perform a MRI in her/his office their TRUS services takes precedent. IMO and others, this has to change since the MRI SCAN can show if a biopsy needs to be performed. Those using it are finding missed GL7 and higher after a TRUS has been used. The TRUS found GL9 in my case with Dr. Onik's saturation transperineal 3D Prostate Mapping Biopsy yielding GL10 that was missed by the TRUS. A MRI would have revealed the greater extent of my cancer but of course not the fact that it was GL10. Are not some scanning and treatments being used for years in Europe and proving to be successful finally receiving FDA and insurance approval?
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Old 11-25-18, 12:32 PM
  #33  
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Originally Posted by OldTryGuy View Post
Appreciate the link. Do you have first hand experience using the 3TmpMRI regarding PCa scanning? At issue is since a urologist can not perform a MRI in her/his office their TRUS services takes precedent. IMO and others, this has to change since the MRI SCAN can show if a biopsy needs to be performed. Those using it are finding missed GL7 and higher after a TRUS has been used. The TRUS found GL9 in my case with Dr. Onik's saturation transperineal 3D Prostate Mapping Biopsy yielding GL10 that was missed by the TRUS. A MRI would have revealed the greater extent of my cancer but of course not the fact that it was GL10. Are not some scanning and treatments being used for years in Europe and proving to be successful finally receiving FDA and insurance approval?
I'm not a urologist. I'm aware of the difficulties in pre-authorizing MRI's and CT's, and I know that getting MRI's for prostate just on the basis of DRE and/or a single PSA is a struggle, and is likely to remain so until there's sufficient data to prove that it provides a survival advantage in prostate cancer. Ain't there yet.
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Old 11-25-18, 12:50 PM
  #34  
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Originally Posted by OldTryGuy View Post
Appreciate the link. Do you have first hand experience using the 3TmpMRI regarding PCa scanning? At issue is since a urologist can not perform a MRI in her/his office their TRUS services takes precedent. IMO and others, this has to change since the MRI SCAN can show if a biopsy needs to be performed. Those using it are finding missed GL7 and higher after a TRUS has been used. The TRUS found GL9 in my case with Dr. Onik's saturation transperineal 3D Prostate Mapping Biopsy yielding GL10 that was missed by the TRUS. A MRI would have revealed the greater extent of my cancer but of course not the fact that it was GL10. Are not some scanning and treatments being used for years in Europe and proving to be successful finally receiving FDA and insurance approval?
In my case, the TRUS , 16 sample biopsy, showed Gleason (3+4)=7 and MRI showed the cancer confined to the prostate. I took my time and got three opinions on treatment: the first was IMRT + brachytherapy, the second all kinds of additional pre-tests, which I thought unnecessary and being done only for the money, followed by IMRT and brachytherapy, and the third at Moffitt Cancer Center, where the doc said that subject to his seeing the actual biopsy slides, he would recommend active surveillance. i.e. do nothing other than a PSA every 6 months. However, after Moffitt detected Gleason 5 in the biopsy slides, he told me I should go with the radiation and seeding, but that I would not need all the pre-tests. So I went with the first option and so far, 3 years on, I am very pleased with the result.
So, once diagnosed, I recommend getting at least a second opinion on treatment.
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Old 11-25-18, 01:50 PM
  #35  
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Originally Posted by Cuyuna View Post
................. Ain't there yet.
YUP, but progress is being made.

Thanks for your insight. Very much appreciated from this prostate cancer surviving OldTryGuy.
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Old 11-25-18, 02:09 PM
  #36  
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Originally Posted by Artmo View Post
In my case, the TRUS , 16 sample biopsy, showed Gleason (3+4)=7 and MRI showed the cancer confined to the prostate............. However, after Moffitt detected Gleason 5 in the biopsy slides...............

Don't quite understand what you mean by Gleason 5 since the Gleason Score is based on 2 numbers. I can only assume you mean that the 4 was found to be a 5 appearance because to misinterpret a 5 sample to be a 3 would be an egregious error. HUGE DIFFERENCE between a 5+4 and a 3+4 or 3+5.


Continued good luck.
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Old 11-25-18, 02:29 PM
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Originally Posted by OldTryGuy View Post
Don't quite understand what you mean by Gleason 5 since the Gleason Score is based on 2 numbers. I can only assume you mean that the 4 was found to be a 5 appearance because to misinterpret a 5 sample to be a 3 would be an egregious error. HUGE DIFFERENCE between a 5+4 and a 3+4 or 3+5.


Continued good luck.
You are correct: they said they found a trace of 5, so, although the doc didn't say so, presumably this would then be 3+5?
I omitted to mention, that we also discussed the Oncotype DX Genomic Prostate Score, which, as you probably already know, allows a determination of one's personal risk of the cancer spreading. As we had decided to go with radiation, this was not pursued.
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Old 11-25-18, 06:52 PM
  #38  
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Ugh, I see my doc on Wednesday for an exam. Id forgotten about (or blocked out) the DRE procedure. Oh well, Ive survived it before, Ill survive it again!
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Old 11-27-18, 07:19 AM
  #39  
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Just had my exam last week. Don't be stupid, get the DRE. No, I don't like it either, but it only lasts five seconds and provides the doctor another data point of insight to your health.
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Old 11-27-18, 08:44 AM
  #40  
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Originally Posted by jimincalif View Post
Ugh, I see my doc on Wednesday for an exam. Id forgotten about (or blocked out) the DRE procedure. Oh well, Ive survived it before, Ill survive it again!
As he/she begins, just think, would you rather give it or get it.
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Old 11-27-18, 12:11 PM
  #41  
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Originally Posted by bobwysiwyg View Post
As he/she begins, just think, would you rather give it or get it.
Good point!
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Old 11-27-18, 05:23 PM
  #42  
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Artmo, the doc is a friend of mine. I went to school with him and another doc in the office. Just have a mental block of someone snooping around back there. The doc knows it, and let me slide this time. Next week is colonoscopy time and my guess is they likely do the same thing before shoving the scope in. Getting old ain't easy, and honestly, it sucks.
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Old 11-27-18, 05:25 PM
  #43  
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Originally Posted by TiHabanero View Post
Artmo, the doc is a friend of mine. I went to school with him and another doc in the office. Just have a mental block of someone snooping around back there. The doc knows it, and let me slide this time. Next week is colonoscopy time and my guess is they likely do the same thing before shoving the scope in. Getting old ain't easy, and honestly, it sucks.
DRE is a routine part of a colonoscopy.
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Old 11-27-18, 09:16 PM
  #44  
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Originally Posted by Cuyuna View Post
DRE is a routine part of a colonoscopy.
Really? I did not know this. Just got scoped in January, so maybe wont need the DRE tomorrow.
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Old 11-27-18, 09:43 PM
  #45  
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Originally Posted by jimincalif View Post


Really? I did not know this. Just got scoped in January, so maybe won’t need the DRE tomorrow.
Your doctor tomorrow can check the procedure report from the colonoscopy and see what was found on the DRE.

In the event that the endoscopist didn't do a DRE (shame on him/her), or it it wasn't documented, then you'd be wise to ask your doctor to do it. When you see him.

Last edited by Cuyuna; 11-28-18 at 08:03 AM.
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Old 11-28-18, 05:30 AM
  #46  
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Originally Posted by tyrion View Post
My doctor said prostate exams are now optional. After some consideration, I opted "no thanks".

"If you can't say something nice, keep your mouth closed." Anybody remember those parental words of wisdom? Well, this is a typed response so I am technically abiding by my parents instructions......

IMO, the quoted response is one of ignorance of the lifesaving abilities of a simple procedure that should be included in a man's wellness checkup.

First off, I did not have a PSA performed prior to seeing my PCP, a very good female friend, who I was seeing about some groin swelling. Out of the blue she said, "Haven't done a DRE in a while so take the position." NOT A BIG DEAL I do so and while she is checking she says a lump is felt. Advice is to see the urologist but I have another IRONMAN Florida coming up and didn't want to stop training following a biopsy that I felt would be needed. So I delayed then finally made the appointment some months later and low and behold eventual BIOPSY RESULTS revealed Gleason 10 Prostate Cancer. My cancer is the aggressive PCa cancer that only 8% of the more than 160,000 https://www.cancer.net/cancer-types/...cer/statistics in the USA per year diagnosed will have. My PSA was not extremely high and truth is that the MOST DEADLY/AGGRESSIVE PCa can produce little PSA so we don't rely on those numbers. My cancer was contained within the prostate capsule so a stroke of dumb luck since it hadn't yet metastasized. Treatments done, a return of the cancer, treatment done again and just waiting for another recurrence that will happen and hopefully not in my bones somewhere in my body.

My advice is to have a DRE, it could help save your life.

Last edited by OldTryGuy; 11-28-18 at 05:51 AM.
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Old 11-28-18, 07:54 AM
  #47  
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Originally Posted by canklecat View Post
After my father died from prostate cancer a few years ago, now I wouldn't object to any test the doctor recommended.

Besides, after years in the military, amateur boxing and working in health care, I'd pretty much lost all my shy bones by the time I was 20. For some reason every full and part time job I applied for years ago required a prostate exam despite the low risk for younger men. Covering their insurance bases, I suppose.

I never noticed anything unusual while urinating until this year, but I've begun to do that pee-pause-pee-pause-pee-some-more thing. So while I'm recover from my recent thyroid surgery I'll schedule an appointment to check the prostate. Hadn't had any prostate exam in more than 20 years. I'm 61 now, way overdue.

Prostate cancer is generally considered to be a bit lower in risk for metastasizing but there are no guarantees. Dad spent several years with catheters, even while commuting to work by train in his 70s. I can't imagine how uncomfortable that must have been. And after about 10 years of having it under control it flared up and metastasized, killing him in only a month.

Same reason I wanted to have my thyroid tumor taken care of pronto after it was diagnosed earlier this year. The risk for metastasis is low with thyroid cancer, but I didn't want to take any chances after my dad's experience. Besides, the thyroid was no longer functional and it was so swollen it was interfering with my esophagus and trachea, so it was painful to swallow and occasionally worsened my asthma constriction. It's been less than a week since surgery and it's already easier to swallow.
You're a better man than I. I would have told them go fish. The urine test is about all the invasion of my privacy I can tolerate. Now that marijuana is becoming legal its time for the necessity of that to be reevaluated.
Originally Posted by Biker395 View Post
Yep. The digital exam is a must. They can detect lumps and the like that are a good indication that something is amiss.

I had a female doc do it once. I think she was more embarrassed than I. While she was digging around, she said:

"At least my finger is smaller."

Ah, but those fingernails!
I prefer medical practitioner to keep their comment strictly medical. But that's just my personal conservatism at work.
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Old 11-28-18, 04:29 PM
  #48  
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You can't make an informed decision about your health care without information to guide those decisions. DRE is a simple, minimally invasive procedure to gather information on which to base future health care. It may not be entirely pleasant, but neither is ignorance.
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Old 12-01-18, 07:46 PM
  #49  
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DREs and PSA tests both have their places. In 2011, my PCa was found as a result of my yearly PSA test at age 52.

Historically, my PSA was 1.1 or 1.2 for years and years. Then in just one year, out of the blue, it had doubled to 2.4 -- still at the low-normal range for a person of my age, but that RATE of increase from one year to the next twigged my Primary Care Physician. He suggested a re-test in six weeks to verify that higher number or just a fluke. Retest came back with a PSA of 3.0. Doctor says to me "You! Biopsy, NOW!" So two weeks later, I was at a Urology clinic for the needle biopsy. Yeowch! Thirty 'grabs and sticks' through the intestinal wall into the prostate.

A week goes by, and I get a phone call at work. "Mr Cougrrcj, you have cancer". No 'Please come in so we can discuss your results', no sugar coating. Just a cold, heartless call while I was at work. I called the Wife, and we made an appointment to see the doctor. An aside here. My Wife loves to research things. We showed up for the appointment with a written list of questions for the doctor. Cancer was found in one lobe half of the prostate. When discussing possible avenues of treatment, he was pushing his latest (and somewhat unproven) method of cryo-freezing the prostate. He pushed us to schedule it ASAP -- Then when the wife brought out her list of questions, his attitude was 'Who are you to question my professional opinion?' Not in so many words, but he clearly didn't like to be asked questions. We were not impressed. We decided to get a second opinion.

Wife does more research to find the top doc in Cleveland, and makes an appointment for a consultation. Talk about a 180 from the first doc. 'Any questions, feel free to call at any time. My assisting NP should be able to answer any questions, but if she can't, she will contact me - even if I'm in surgery - and you'll have an answer in less than a half hour'.. We discussed options. Wife and my concern was with the rapid increase in PSA, this might be extremely serious, so we opted for total removal of the prostate. Surgery was scheduled at the first available -- in six weeks!

In that six weeks, when talking to my mother, I discovered that my maternal grandfather died of Prostate Cancer at age 74 in 1962 (before treatment of PCa was widespread), and all of the males on my mother's side of the family (her sister's four boys) ALL have been diagnosed with Prostate Cancer. That's quite a familial connection that I had never known about!

Post surgical biopsy of the prostate revealed that the Cancer had spread to the entire gland, and was on the verge of metastasizing, Gleason score 9. I count myself as lucky to be alive.

A former co-worker of my wife - same age as me - was also diagnosed with PCa at the same time I was - but he was already symptomatic. His had already metastasized, and he developed tumors all along his spinal cord, and finally in the brain. He's been dead for two years now...
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Old 12-29-18, 06:32 PM
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I can relate to this discussion - I'm currently in Active Surveillance for Prostate Cancer after having a 18 needle biopsy last March based on a PSA of 4.1 ng/ml and a DRE where Dr. FingerLove thought he felt something. My most recent PSA in December came back as a 5.0 ng/ml (after a previous PSA of 3.7 in September) so I got a call to come in for a saturation biopsy next month. I had been biking a lot before the PSA, and only took two days off before getting blood drawn. I had taken 7 days off the bike for my PSA in September which had come back as 3.7 (dropping from 4.1), so I told the Urologists PA that I think we should do the PSA again, this time with a 7 day break from biking.

She said that she didn't think the Insurance Company would cover it as I had done one 3 weeks earlier (the one that came back as a 5.0 ng/ml). I then asked why aren't we doing an MRI fused biopsy, and she also thought that Insurance wouldn't cover the MRI portion. I asked her to submit a MRI request anyway, as no way I was doing another biopsy without imaging. I then went to my GP for an unrelated reason this week, told him about my situation, and he did a PSA for me which came back at 3.7! (I was off the bike a week).

Meanwhile, the MRI got approved by the Insurance Company...

So long story short, you can't just blindly go along with what the Urologist's practice thinks may be covered, you really have to advocate for yourself. It will be funny if the Insurance Company denies my 'good' PSA test but spends big bucks on a MRI which may have actually been unnecessary because I had PSA that was bogus.
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