Non Valk health question

[NewValker]

Going to throw this question out there for anyone who has been there...
Readers Digest version,
Been having “plumbing” issues for 3-4 months now, PSA test shows elevated numbers. Dr. wants to do prostate biopsy. With family history & current number, I’m all for it.
Here’s the rub, earliest biopsy appt. is mid March. Wife & kids are egging me on to demand a sooner date. (Hate to be that guy...) Dr. explained cancer doesn’t move that fast down there and she is confident a March appt. will be fine. I am on a call list for any cancellations.
She’s got me on med to relieve the plumbing issues so it’s just waiting now.
So, is waiting until March a bad idea?

Need to fix this problem before InZane that’s for sure!

Thanks for any opinions,
Craig

[Hook#3287]

Hey Craig, sorry to hear of your "plumbing" issues.

I'm lucky to say I've no experience with that, but I'd consider talking to a second professional to confirm your doc's plans.

You could mention how you don't want to mess with your trip in June, but priorities and all.

Let me know if I can help you out.

[NewValker]

Thanks Bill, yes, priorities 
Craig

[Valker]

Did a digital exam (you DID have one?) find anything out of the ordinary? Urologists usually do a better exam, but my GP does a thorough job. 

[Foozle]

Craig:  I have no experience with this particular medical issue, but I have a lifetime of experience working with physicians.  Provided you're seeing someone who is expertly knowledgeable in this area (e.g., a urologist, etc.), you should assume they would not delay a diagnostic test or treatment unless it was clinically acceptable to do so.  If time is of the essence, and a particular doctor simply cannot accommodate you in a timely fashion, the professional onus is on them to refer you to a qualified colleague who can. All of this, of course, presumes a competent, compassionate provider you can trust (which the overwhelming majority are). However, we all know there are rare exceptions.  I hope things work out. Terry

[bassman]

If you can't get the biopsy prior to March you might look into or consider an MRI.  It can be a valuable tool used in conjunction with the biopsy.  The MRI can show areas of specific concern and give the doctor a more exact location of something suspicious to take the biopsy samples from rather than 12 "random" selections which can be a hit or miss procedure.


You might want to get this FREE Patients Guide from the Prostate Cancer Foundation.  It is current, price is right and you can get both an electronic PDF right away and also a booklet in a couple of weeks.  Very informative and can answer a lot of questions as well as make your more informed when you talk to your doctors.

https://www.pcf.org/guide/

Good luck !

[da prez]

  Craig  . If you are a veteran , they can outsource an appointment. If no , the psa test is used by VA as a pre screen. Digital exam is used after the psa test. There is more than one Dr. and I suggest you ask for a referral as you are concerned. The healing process is different with everyone. Be persistent and prevail.           

                                                da prez
                       

[Jess from VA]

I'm not a doctor, but I had a 12 strike Prostate biopsy.

Most (but not all) prostate cancer is very slow growing.  I've read that a decent percentage of old men who died from other causes had it (but it's not discovered from no or routine autopsy, and why bother?).

Presumably you've had the PSA blood test.  There's been a lot of controversy over these tests (for good reason).  It's not specific to actual prostate cancer and often gives false positives, for a number of reasons.  Normal (varies a bit by age) is something like 4 ng/mL to 10 ng/mL.  

I long ago had a high normal (for a mid 50's guy), but on repeat it was normal.  Years later, I had another high normal, and the Urologist wanted to do the biopsy right away.  He didn't even suggest a repeat in a few weeks (which sounded like an economic decision to me, not a medical one).  I asked for one and got one 2 weeks later, and this time the reading went up, barely (tenths).  So I had the biopsy, spent a couple of sleepless weeks, and it came back negative.

Now my dad had prostate cancer (on an off for 30 years, whether cured or in full remission was unknown) (and that wasn't a good sign for me at all), but his PSAs were WAY high compared to my high normals.

The biopsy itself was not that bad.  Like my vasectomy, the worst part was the local anesthetic shot (the poke and the burn).  I spent 20 minutes or so with a large banana up my heiny, with the doc manipulating it like a bike throttle, and he and his nurse watching on an ultrasound TV screen debating exactly where to take the next strike (obviously the goal is to spread them out, so any cancer spot is not missed).  You get to lay on your side (unlike the female OBGYN wide open position).  Postop was pain free and normal, except I passed some bright red blood in my stool for a couple weeks (disturbing to see, but clinically normal).  I could have gone on a long MC ride the next day, no problem at all.

So given the long delay to biopsy, I'm guessing your PSA is not disturbingly high?

A lot of good medical internet reading and perhaps a second opinion seems reasonable.

I wonder what our Bighead has to say.    

[scooperhsd]

Craig - due to the aging of our group, there have been a number of active members with experiance with this as well. The ones who have had such experiance were more than willing to share their experiance so the rest of us could benefit from that.

In any event - let's hope that it isn't anything serious at the moment, but do take the time to get it checked out.

[NewValker]

Did a digital exam (you DID have one?) find anything out of the ordinary? Urologists usually do a better exam, but my GP does a thorough job. 

Yes sir, digital exams by Gp & urologist. Both remarked prostate is somewhat enlarged.

Craig:  I have no experience with this particular medical issue, but I have a lifetime of experience working with physicians.  Provided you're seeing someone who is expertly knowledgeable in this area (e.g., a urologist, etc.), you should assume they would not delay a diagnostic test or treatment unless it was clinically acceptable to do so.  If time is of the essence, and a particular doctor simply cannot accommodate you in a timely fashion, the professional onus is on them to refer you to a qualified colleague who can. All of this, of course, presumes a competent, compassionate provider you can trust (which the overwhelming majority are). However, we all know there are rare exceptions.  I hope things work out. Terry

My urologist came highly recommended by my GP. I like her, very knowledgeable, caring, and I get good vibes from her. She has 2 PSA tests scheduled between now & March so we know what’s happening.

If you can't get the biopsy prior to March you might look into or consider an MRI.  It can be a valuable tool used in conjunction with the biopsy.  The MRI can show areas of specific concern and give the doctor a more exact location of something suspicious to take the biopsy samples from rather than 12 "random" selections which can be a hit or miss procedure.


You might want to get this FREE Patients Guide from the Prostate Cancer Foundation.  It is current, price is right and you can get both an electronic PDF right away and also a booklet in a couple of weeks.  Very informative and can answer a lot of questions as well as make your more informed when you talk to your doctors.

https://www.pcf.org/guide/

Good luck !

I’ll look into an MRI, and thanks for the link to the PCF info.

  Craig  . If you are a veteran , they can outsource an appointment. If no , the psa test is used by VA as a pre screen. Digital exam is used after the psa test. There is more than one Dr. and I suggest you ask for a referral as you are concerned. The healing process is different with everyone. Be persistent and prevail.           

                                                da prez
                       

Ross, I’m not a veteran. Thanks for your thoughts.

I'm not a doctor, but I had a 12 strike Prostate biopsy.

Most (but not all) prostate cancer is very slow growing.  I've read that a decent percentage of old men who died from other causes had it (but it's not discovered from no or routine autopsy, and why bother?).

Presumably you've had the PSA blood test.  There's been a lot of controversy over these tests (for good reason).  It's not specific to actual prostate cancer and often gives false positives, for a number of reasons.  Normal (varies a bit by age) is something like 4 ng/mL to 10 ng/mL. 

I long ago had a high normal (for a mid 50's guy), but on repeat it was normal.  Years later, I had another high normal, and the Urologist wanted to do the biopsy right away.  He didn't even suggest a repeat in a few weeks (which sounded like an economic decision to me, not a medical one).  I asked for one and got one 2 weeks later, and this time the reading went up, barely (tenths).  So I had the biopsy, spent a couple of sleepless weeks, and it came back negative.

Now my dad had prostate cancer (on an off for 30 years, whether cured or in full remission was unknown) (and that wasn't a good sign for me at all), but his PSAs were WAY high compared to my high normals.

The biopsy itself was not that bad.  Like my vasectomy, the worst part was the local anesthetic shot (the poke and the burn).  I spent 20 minutes or so with a large banana up my heiny, with the doc manipulating it like a bike throttle, and he and his nurse watching on an ultrasound TV screen debating exactly where to take the next strike (obviously the goal is to spread them out, so any cancer spot is not missed).  You get to lay on your side (unlike the female OBGYN wide open position).  Postop was pain free and normal, except I passed some bright red blood in my stool for a couple weeks (disturbing to see, but clinically normal).  I could have gone on a long MC ride the next day, no problem at all.

So given the long delay to biopsy, I'm guessing your PSA is not disturbingly high?

A lot of good medical internet reading and perhaps a second opinion seems reasonable.

I wonder what our Bighead has to say.   

Jess,thanks for the info, PSA rose 1.6 in 14 months to 4.6,  set off the red flag.  Yes, way too much info on the google for wandering minds lol.
I too am looking forward to a Bighead response.

Craig - due to the aging of our group, there have been a number of active members with experiance with this as well. The ones who have had such experiance were more than willing to share their experiance so the rest of us could benefit from that.

In any event - let's hope that it isn't anything serious at the moment, but do take the time to get it checked out.

Exactly the reason for this post. I searched their posts but didn’t find what I was looking for so I bit the bullet and started typing.


Thank you all for the responses, my father had prostate cancer, numerous bouts of cancerous pollups, and died of pancreatic cancer. I so don’t want to go down that same road....

Craig

[Bigwolf]

Craig,

I no longer have a prostate.  The following are things that I found to be true during my diagnosis and remedy of that problem.

It isn’t just high PSA numbers that should raise concern.  A sudden increase in those numbers should also get your attention.

With that said, you should be aware that neither PSA tests or the dreaded finger in butt exam are very accurate.  Those are, however, the very best (and only) early warnings we currently have available to us.

  Not just any doctor can determine anything from the digital exam.  This requires a very skilled doctor with experience in that area.  Otherwise, this exam is worthless.

I was often told that prostate cancer was no big cause for concern and that I would probably “die with prostate cancer not from it”.  Now I know that is a very dangerous half truth.  Of course you won’t die from “prostate cancer”.  There is no such thing!  Even if there was, you can live without a prostate, so you will not die from that.  What will kill you is colon cancer, pancreatic cancer, lung cancer, or esophageal cancer and those are technically “adenocarcinoma” which is the very same cancer you can get in your prostate.  Couple that with the fact that there are 12 lymph nodes surrounding the prostate and you can begin to understand my personal concern.

I was lucky, my primary care doctor was concerned about a PSA increase during my annual exam.  He then referred me to a urologist.  The urologist did the digital exam and scheduled me for a biopsy within a few weeks.  The biopsy was positive over a wide spread and was recorded as a 7 on the Gleason scale.  There are other options but I chose robotic surgery to remove it.  I have no regrets.

Hope this helps you to make good healthy decisions.
Best of luck.
Bigwolf

[98valk]

biopsy can and will make things worst.
This is the critical question and yes, there can be risks involved with any biopsy procedure.  Unfortunately, one of the riskiest is the biopsy procedure for prostate cancer, which of course is one of the most common cancers.    For prostate biopsies, an instrument goes up through the rectum and then needle sticks are punched through the colon wall into the prostate gland.  Up to 30 needle sticks may be required and this can cause a potentially lethal blood infection due to the transmission of e-coli or other bacteria.  Though rare, I personally spoke to a man who said he almost died from a routine needle biopsy into the prostate that caused just such an infection.

But even more worrisome, is the risk that any biopsy procedure could potentially spread the cancer.  This is a somewhat controversial issue and most oncologists will probably say there is little risk of spreading, or “seeding” the cancer.   However, one author by the name of Karl Loren, supposedly documented 73 cases of seeding from biopsies that caused metastases.  Apparently, this risk is more well-known than it would seem, since more than half a million American cancer patients are reported to seek medical treatment outside the U.S. simply to avoid having to get a biopsy.  Many of these Americans flee to the Hope4Cancer Institute in Mexico run by Dr. Antonio Jimenez.
https://www.outsmartyourcancer.com/can-biopsies-spread-cancer/

  numbers really mean nothing. https://healthbeatblog.com/2010/03/the-doctor-who-invented-psa-test-calls-it-a-profitdriven-public-health-disaster-why-this-is-good-new/
 for just about all mean the prostate has a low grade infection. research it.
how much high quality zinc do you get every day? most need 50-100mg/day. research it.
stinging nettle root supplement. research it
olive leaf extract. research it

the biopsy itself can generate problems. First, they're very much a hit-or-miss situation; small cancers confined to various areas of the prostate are routinely missed. And in the event that a cancer is present, and the biopsy needle does locate it, individuals are facing a second threat. I've reported on the various studies showing how removing cancerous tissue with biopsies can lead to the spread of cancerous cells into the bloodstream through needle trails or other means. Prostate cancer that stays confined within the prostate is far less of a threat than one that has metastasized or spread to other areas of the body. [Editor's note: For more about the dangers of biopsies of any type, and how to protect yourself, visit the Subscriber Center of the Alternatives website, www.drdavidwilliams.com.]

And when cancer is found, most men proceed to the next step of treatment, regardless of whether the cancer is confined and non-threatening or fast-growing and lethal. PSA testing can't distinguish between the two.

The PSA test measures a protein that the prostate produces when it's inflamed. Although the initial research only suggested that higher PSA levels might be connected to prostate cancer, there is an ever-growing amount of research to suggest that higher PSA levels are more closely linked to an enlarged prostate and the associated inflammation than to prostate cancer. This fact, however, hasn't stopped the unnecessary treatment of hundreds of thousands of men for prostate cancer.
The cancer is often benign

The results of two very recent studies, published in the New England Journal of Medicine, shed more light on what I talked about years ago: Prostate cancer screening with the PSA test has led to some very questionable outcomes and a long list of testing victims.

One of the NEJM studies was actually a review of seven different European studies involving 162,243 men ages 55 to 69. One of the top oncologists in the world, specializing in the study and treatment of prostate cancer for over 20 years, Dr. Otis W. Brawley, said these studies were “some of the most important studies in the history of men's health.”

The review found that, using PSA screening tests, 1,410 men would need to be screened regularly for ten years and 48 additional men would need to undergo totally unnecessary cancer treatment to prevent one death from prostate cancer (N Engl J Med 09;360:1320–1328).

Dr. Brawley, who is currently a director at the National Cancer Institute and the chief medical officer of the American Cancer Society, summed up his feelings about this study by saying, “The test is about 50 times more likely to ruin your life than it is to save your life.”

There's a fortune being made with PSA testing, even though early screenings of this type and early treatment haven't been shown to save lives. This is simply because not all prostate cancers need to be treated. Studies have shown that at least one-third of those men diagnosed with the cancer by PSA and then “cured” by treatment would have never otherwise even known they had the disease, or been affected by it, and would have eventually died of some other cause.
The treatments are seldom benign

The second US study recently published in NEJM involved 76,693 men, roughly half of whom received yearly PSA testing. When the researchers compared the two groups, those who were “diagnosed early” with PSA tests had basically the same rate of death due to prostate cancer as those who had never had the test (N Engl J Med 09;360:1310–1319).

Another very interesting finding from this study wasn't widely reported for some reason.

The treatments being used for prostate cancer involve everything from radiation and administration of hormones to surgical removal of the entire gland. The side effects are far from minor. The long list includes such things as impotency, urinary problems, bowel problems, penile shrinkage, infertility, gynecomastia (breast enlargement), and hot flashes. Any one of these can dramatically lower one's quality of life. The emotional and social aspects alone take a toll on one's personal relationships and severely limit activities. And the treatment itself can be fatal.

Researchers found that, in the PSA screening group, 312 men with prostate cancer died from causes other than the cancer, versus only 225 in the unscreened group. Commenting on the much larger number of deaths in the PSA screening group, the researchers stated it was “possibly” due to the treatment of non-progressive cancer. In other words, it “could” have been the fact that treating cancers that didn't need to be treated killed many of those men.
https://www.faim.org/the-prostate-cancer-machine

[John Schmidt]

I suggest you get an MRI first. A good and up to date facility will enable the urologist to use the MRI to create a 3-D image from the results. Then when they do the biopsy they're not shooting in the dark, they know exactly where to go. It can also give you a bone scan to be sure it hasn't spread to either the bones or surrounding tissue. If the biopsy shows positive, depending on the level of the Gleason score will determine what's next. Good luck, I'd personally get in ASAP.

[Bigwolf]

I suggest you get an MRI first. A good and up to date facility will enable the urologist to use the MRI to create a 3-D image from the results. Then when they do the biopsy they're not shooting in the dark, they know exactly where to go. It can also give you a bone scan to be sure it hasn't spread to either the bones or surrounding tissue. If the biopsy shows positive, depending on the level of the Gleason score will determine what's next. Good luck, I'd personally get in ASAP.

+1 

[RP#62]

Several years ago, my psa was found to be on the high side of normal for my age.  My family doctor said to see a urologist so I did.  The urologist looked at the psa test I showed the family doctor and said I needed a biopsy right away and his office was equipped to do it.  I thought he was a little quick on the trigger so I went to the cancer hospital and saw a doctor that specializes in prostate cancer.  I told him what happened and he said that they never recommend a biopsy based on one psa test.  He recommended I have it checked every couple of months and establish a baseline and see what's normal for me.  Its been  5 or 6 years now and mine fluctuates between the low side of normal to the high side of normal.  Cancer doc said the fluctuations are probably reflective of other, non-related low grade infections that periodically occur that will also influence the psa.  So far so good.  That's been my experience anyway.

-RP

[98valk]

Several years ago, my psa was found to be on the high side of normal for my age.  My family doctor said to see a urologist so I did.  The urologist looked at the psa test I showed the family doctor and said I needed a biopsy right away and his office was equipped to do it.  I thought he was a little quick on the trigger so I went to the cancer hospital and saw a doctor that specializes in prostate cancer.  I told him what happened and he said that they never recommend a biopsy based on one psa test.  He recommended I have it checked every couple of months and establish a baseline and see what's normal for me.  Its been  5 or 6 years now and mine fluctuates between the low side of normal to the high side of normal.  Cancer doc said the fluctuations are probably reflective of other, non-related low grade infections that periodically occur that will also influence the psa.  So far so good.  That's been my experience anyway.

-RP

exactly what the docs I posted have stated.  docs today are too quick to order tests, etc, lots of money there and also to protect themselves from lawsuits.

[NewValker]

Wow, just wow....
I hoped asking this would make my journey easier. Now there’s even more to decipher & decide on.
NOT complaining at all, I really appreciate the first hand stories.

98valk, thanks for the hours of reading!

Pluggy, that’s my biggest fear right there.
On the other hand, I sure don’t need another surgery, especially if its unnecessary or can wait....

Thank you all,
Craig

[Pluggy]

Craig, a December biopsy may tell your medical team you can hold off on treatments until March.  A March biopsy may indicate you should have started treatments in December.  Then it would be.... Oh S---.

I was lucky and blessed.  I had the most aggressive cancer.  The chain of events got my treatments started before it was too late.

[DDT (12)]

Craig, a December biopsy may tell your medical team you can hold off on treatments until March.  A March biopsy may indicate you should have started treatments in December.  Then it would be.... Oh S---.

I was lucky and blessed.  I had the most aggressive cancer.  The chain of events got my treatments started before it was too late.

Craig,

Pretty much all I could contribute, as well... Mine, too, was the 'aggressive type', and I was a bit nervous throughout what seemed to me to be a too long process. I was most fortunate once again, though, by the help I received from this board... you done good there! I was also incredibly fortunate in having BigWolf as a coach throughout the process, as he'd had the same things I experienced a couple of years ahead of me. He was also my host, as he lived fairly near the hospital and surgeon I used, while I lived out of state. I wish you the very best!!!

DDT

[98valk]

Wow, just wow....
I hoped asking this would make my journey easier. Now there’s even more to decipher & decide on.
NOT complaining at all, I really appreciate the first hand stories.

98valk, thanks for the hours of reading!

Pluggy, that’s my biggest fear right there.
On the other hand, I sure don’t need another surgery, especially if its unnecessary or can wait....

Thank you all,
Craig

zinc picolinate is best form to take. 

Ashwagandha is good to take.  https://www.healthline.com/nutrition/12-proven-ashwagandha-benefits#2

avoid all soy products.  it increases bad estrogen levels which attacks the prostate and reduces test levels.   https://www.lifeextension.com/Magazine/2008/11/Dangers-of-Excess-Estrogen-in-the-Aging-Male

fat cells make estrogen, too much body fat on a man increases the estrogen, many studies shown that an overweight man in his 50s has higher estrogen levels than a woman.

avoid synthetic estrogen.  https://mentalhealthdaily.com/2015/04/08/20-foods-high-in-estrogen-phytoestrogens/

avoid xenoestrogens   http://health.in4mnation.com/xenoestrogens-sources-health-effects/

[Big Rig]

Positive waves coming your way for a speedy recovery!

BE THAT GUY!!!!

Your life, go get a second opinion and state that you want to know ASAP! They should accommodate you.

You have to be your own ADVOCATE!!!

Best of luck.

[John Schmidt]

Re. your elevated PSA, to what degree? Mine was similar to RP#62, a little on the high side of normal literally for decades, but was steady. My urologist only saw me once a year until the PSA suddenly jumped a couple points, so he watched it every 2 months for the next six months and saw it moving upward 1-2 points each time. Now it got his attention. The key isn't so much the reading, but how much it increases and how fast, they should never hang their hat on a single PSA. It was then I had an MRI which confirmed his suspicion.

[NewValker]

John, my PSA went from 3.0 to 4.6 in 14 months.
Previous it has been slightly on the high side of normal for my age.
Another PSA scheduled for 12/23.

Thanks all for responses,
Craig

[John Schmidt]

John, my PSA went from 3.0 to 4.6 in 14 months.
Previous it has been slightly on the high side of normal for my age.
Another PSA scheduled for 12/23.

Thanks all for responses,
Craig

That's where mine had been for at least 10 yrs. or more. It never varied more than .1 or .2 +/-. Then it started climbing as much as 2 pts. every couple months, that's when it needs attention.

[The emperor has no clothes]

Craig, I have no advice. Luckily, I've been spared this so far. Just want you to know that we are thinking of you and hoping it's just something minor to deal with.

[NewValker]

Thank you all for checking in on this, really great info to chew on.

Craig, I have no advice. Luckily, I've been spared this so far. Just want you to know that we are thinking of you and hoping it's just something minor to deal with.

Thanks Rob, means a lot! Looking forward to sharing the wind with you again. Hi to Brenda!

Craig

[Hook#3287]

Hey Craig, I see from another post you're down 73 lbs

That's awesome dude

But what's this sober house thing?  That's a thing?

Just kidding, good on you to volunteer to others while you wait out the issue you're going through.

Are you still throwing salt and moving that white stuff?

[NewValker]

Hi Bill, yup still ruining winter riding    and pushing the white stuff makin riding $$$ for next summer!
Gotta keep busy now, when true winter hits it’s just work and sleep.  I’m determined to be fit enough to fight and win if this little issue turns to crap.
Hope you have a nice Christmas, and if InZane is in your plans, and you want company again, count me in,
Craig

[Bighead]

? Is why is she waiting until March.  She cannot be that busy,a prostate biopsy takes literally a few minutes. If she is doing that many biopsies she must be doing 100’s a week.

[JimmyG]

Craig, I know everyone has their opinions, well so do I, so here goes.   If it were me,  after 42 years in the medical imaging profession, doing everything from x-ray to Nuclear medicine to MR to CT to US, including vascular, and also dabbling in therapy, I'd get a prostate ultrasound. I say this for several reasons pertaining to imaging sweet spots. Ultrasound is an excellent way to image the prostate. It is real time imaging, it is easy, no harm procedure, can be done at a very reasonable cost compared to MR, and will probably be the procedure that guides them in a biopsy.  It differentiates tissue very well.  For my money and health, this would be my first step. Of course, state of the art equipment is a must, a qualified ultrasound technologist is second, and a radiologist experience and trained in ultrasound interpretations is third.  Been there done that plus 42 years of watching imaging develop and that's my advice for my body.

Good luck on your journey. Be cautious, Dr's and hospitals kill more people than guns! , but thank God we have them. 

[Fazer]

Craig--Don't know if we have met, but I am on a similar journey.  I had the biopsey last March and got a postive result for cancer in 8 of the twelve cores with a Gleason of 7.  Had a scan that showed it had not spread from the prostate, so I initially elected to wait and watch. 

A couple of weeks ago I started pissing blood, so I contacte my urologist and he strongle disagreed with wait/watch and scheduled a cyscosopy to look at the bladder before doing protstatectomy.  Had it done yesterday and waiting on test result. 

Prostate surgery is scheduled for next month.  Dr. made a good point when he stated I could do something about it now, or in 10-15 years have to live with tubes sticking in me. 

Good to see Big Wolf and DDT have weighed in as well.  Not looking forward to it, but if the drugs they put you to sleep with are as good as I had yesterday, well at least there is that.

Good luck.  Get the biopsey or scan ASAP.

Greg