The Clinton Herald, Clinton, Iowa

August 27, 2013

Can reader forgo biopsy for prostate cancer?

By Keith Roach
The Clinton Herald

---- — DEAR DR. ROACH: I’m 77, and my doctor tells me I’m in very good health. My PSA level is high. The level has gone from 11 last June to 17 in December, and now 21. I don’t have any symptoms. The doctor wants me to have a biopsy. What do you think? I don’t want one. — T.M.

ANSWER: Your doctor knows you better than I do. That being said, your PSA level means you are more likely than not to have prostate cancer. I can’t be sure; only a biopsy will answer the question. However, I can tell you that looking at many people in a situation similar to yours, after prostate cancer was diagnosed by PSA, early treatment with surgery did not lead to improvement in survival. It is likely that if the diagnosis were cancer, you would be offered “watchful waiting,” which means that you would be treated only when symptoms develop.

Many people feel strongly that they would want to know if they had prostate cancer. Only by having that information can you make a truly informed decision. The risk from a biopsy is small, but there is a risk of infection. On the other hand, if you are sure you wouldn’t want treatment even if the result were cancer, it’s reasonable to forgo biopsy.

The choice is yours. Many (or even most) men want to find out what is going on, and most of those choose to undergo treatment, whether it is surgery, radiation or medication. Men older than 75 are likely to see less benefit from treatment than younger men.

DEAR DR. ROACH: I am 73 years old and in good health. In June 2012, I discovered a red growth about the size of a large grape just inside my vaginal area. My primary doctor referred me to a urologist, who said it was a caruncle and prescribed Estrace cream. It reduced the size but did not make it go away. The urologist said she could do surgery to remove it, or I could just continue to use the cream and watch it, since it doesn’t bother me. I am concerned about the continued use of hormones, and I worry about the link to cancer. — J.F.

ANSWER: A caruncle is a benign, fleshy growth at the end of the urethra, the tube that carries urine from the bladder to the genitals for removal. Nobody really understands why they occur, but they definitely occur more in women who are postmenopausal and who have low estrogen levels. Treatment with topical estrogen usually is effective at reducing the size. It can be removed surgically if it is bothersome, but since yours isn’t, I wouldn’t recommend surgery. Both urologists and gynecologists treat caruncles.

As far as your concerns about cancer from topical estrogen, the risk is very, very small. In someone with a history of breast cancer, I would consult an oncologist, but absorption of topical estrogen is low. Many authorities recommend using twice-weekly estrogen cream to prevent recurrence, but if you were to stop the estrogen cream, you could restart it if the caruncle started bothering you.