After an abnormal PSA (Recently Diagnosed)
Diagnosis
If Prostate Specific Antigen (PSA) levels are higher than normal or are rising compared to previous PSA, or any abnormalities are detected in the prostate during a Digital Rectal Exam (DRE), your provider may recommend further testing. This often begins with a repeat PSA.
Urine test
Urine may be analyzed for abnormalities that could indicate a problem other than prostate cancer, such as bacterial infection, or to rule out conditions that may cause the same signs and symptoms of prostate cancer, such as prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (enlarged prostate).
Risk stratification
Once prostate cancer is suspected there are multiple ways to determine the risk that it may truly be present. These include additional urine or blood tests to look for genetic evidence of prostate cancer (similar to Cologuard for colon cancer). If the risk stratification tools also suggest that prostate cancer is likely, a prostate MRI is usually done next.
Prostate MRI (magnetic resonance imaging)
Currently, there are only 5 imaging centers in the entire state of Delaware that perform the most up to date type of prostate MRI (see our list of MRI centers under the Resources tab). The initial MRI can be performed as a bi-parametric (without intravenous contrast) study or multi-parametric (with intravenous contrast) study. Even if the study is requested to be done with intravenous contrast, there is usually no need to get lab tests to check such things as BUN or creatinine. Check with the MRI center to be sure. The MRI report from the radiologist will list suspicious areas by a standard classification as PI-RADS 3, 4, or 5. If any of these areas are present they will be targeted on subsequent biopsy by a urologist.
Transrectal Ultrasound (USD)
This procedure uses sound waves to visualize the prostate gland and detect any abnormalities if a patient is not able to undergo an MRI. Ultrasounds may help in treatment planning by measuring prostate gland volume, recognizing varied patterns of cancer, and identifying appropriate sites for biopsy. Ultrasonography alone, however, cannot detect all cancer. If the ultrasound test results indicate the likelihood of prostate cancer, the next step is usually a prostate biopsy.
Prostate biopsy
A biopsy is a procedure in which small tissue samples from the prostate are collected and sent to a pathologist for analysis. Biopsy results are usually reported within 10 days. Two kinds of biopsies can be performed – transrectal or transperineal. An enema and an oral antibiotic are often given prior to the biopsy. Some type of anesthesia will be used. The doctor will insert an ultrasound probe into the rectum. The probe will make images to guide the doctor to abnormal areas of the prostate. From outside the rectum, a handheld device with a spring-loaded, slender needle is positioned and inserted into the abnormal areas to collect tissue samples. If no abnormal areas are detected, various tissue samples are collected from different areas of the prostate. The transperineal procedure is the same as the transrectal procedure, only the needle is inserted through the skin between the rectum and scrotum (perineum). If cancer is present, your urologist will assess the stage of the cancer and how fast it is likely to grow. The doctor may decide to run further imaging tests to determine if the cancer has spread to other tissues in the body.
Other potential further imaging tests may include any of the following;
BONE SCAN
Detects whether the cancer has spread to the bones.
CHEST X-RAY
Shows whether the cancer has spread to the lungs, ribs, or spine (backbone).
COMPUTERIZED TOMOGRAPHY (CT) SCAN
Identifies general signs of disease, such as enlarged lymph nodes or organ abnormalities that may be related to prostate cancer.
POSITRON EMISSION TOMOGRAPHY (PET) SCAN
Detects spread of cancer to lymph nodes, bones and other organs using a combination of CT scan technology and radionuclide substances.
MAGNETIC RESONANCE IMAGING (MRI)
Detects spread of cancer outside of the capsule of the prostate and lymph nodes and bones.
LYMPH NODE BIOPSY
Determines whether the cancer has spread to the lymph nodes. Lymph nodes are small glands located in many parts of the body that help defend against spreading of cancer cells and other harmful foreign particles. Lymph nodes in the pelvic region are usually the first place to which cancer spreads outside the prostate.
Understanding prostate biopsy results
A pathologist will look at the tissue that was taken during the prostate biopsy and will determine; The size of the cancer area (percent of biopsy with cancer), The type of cancer cells. The pathologist will assign a Gleason score from 6 – 10 based on how the cancer cells look under the microscope. This score is an estimate of how fast the cancer is likely to grow and the life expectancy of the patient. In general, the lower the score, the better the prognosis.
GLEASON 6
Indicates tumors with cells that are expected to grow slowly and not spread rapidly.
GLEASON 7
Indicates tumors with cells that are moderately dispersed and are anticipated to grow with moderate aggressiveness.
GLEASON 8 TO 10
Indicates tumors with cells that are more likely to grow rapidly and may metastasize (spread to other parts of the body).
Most of the information listed above will appear on the biopsy report. The biopsy report (also known as the pathology report) typically has a diagram illustrating the prostate. On the diagram, locations where tissue samples were collected will be indicated. These locations will be labeled either “no prostate cancer” or “prostate cancer”. Below the diagram is a table listing more detailed information of each sample collected. The samples are listed in the first column according to their location/site within the prostate. Other columns in the table list the length of the tissue sample collected, whether prostate cancer was found (Yes or No), the percentage of the sample in which prostate cancer exists, and the Gleason score. The Gleason score on the report may consist of two numbers (eg, 3+4). The first number is the grade assigned to the cancer cell type that is most numerous in the tissue sample. The second number is the grade assigned to the cancer cell type that is the second-most numerous. To determine the total Gleason score, these two numbers are added together to give the 6 – 10 range described above.
Prostate Cancer Grade groups
In recent years, healthcare providers have realized that the Gleason score might not always be the best way to grade prostate cancer. For instance, not all cancers with a Gleason score of 7 are the same. Cancers with more grade 3 areas (3 + 4 = 7 Gleason score) are less likely to grow and spread than cancers with more grade 4 areas (4 + 3 = 7 Gleason score). Likewise, Gleason score 8 cancers are less likely to grow and spread than cancers with a Gleason score of 9 or 10. So, 5 grade groups have been developed;
- Grade group 1 = Gleason 6
- Grade group 2 = Gleason 3 + 4 = 7
- Grade group 3 = Gleason 4 + 3 = 7
- Grade group 4 = Gleason 8
- Grade group 5 = Gleason 9 or 10
After all of the tests have been done and the results are available, your doctor will determine the stage of your prostate cancer.
Staging
Staging of cancer is a necessary step to determine the extent of the disease and select the best treatment strategy. Most cancer staging (including prostate) is done using the American Joint Committee on Cancer (AJCC) TNM system. This includes evaluation of tumor size (T), lymph node involvement (N), and metastatic disease (M). For prostate cancer, the PSA level is also considered. For staging details, see Stages of prostate cancer under our Resources tab.
Risk Assessment and Risk Groups
Prostate cancer can either present as a slow growing tumor causing minimal harm or a more aggressive type that may spread quickly. Risk assessment is the critical step of determining the nature of each patient’s disease. Physicians look at clinical and pathology features (PSA, Gleason score, clinical stage, etc) to determine which patients may have aggressive forms of prostate cancer, and which patients do not to determine if treatment is needed or not. New personalized methods of risk assessment using molecular biomarker analysis are available to assess progression risk. The National Comprehensive Cancer Network (NCCN) developed guidelines to categorize prostate cancer into risk groups. They take into account blood tests and exam results, genetic testing results, and family history to help determine the appropriate risk group:
National Comprehensive Cancer Network Foundation. NCCN guidelines for patients: prostate cancer early stage.
- Very low: Includes people in the AJCC T1c stage, Grade Group 1, and who have a PSA of less than 10 ng/mL with PSA density being lower than 0.15 ng/mL, and if the cancer is found in one or two of the biopsies with less than half of all samples showing signs of cancer
- Low: Includes people in the AJCC T1 to T2a stages, Grade Group 1, and a PSA of less than 10 ng/mL
- Intermediate favorable: Includes people with one intermediate-risk factor who are in Grade Group 1 or 2 and have less than half of their biopsies showing cancerous results
- Intermediate unfavorable: Includes people in Grade Group 3 with more than half of their biopsies showing cancer and having two or more intermediate risk factors
- High: Includes people in the AJCC T3a stage or Grade Group 4 or 5 or those who have a PSA of more than 20 ng/mL
- Very high: Includes people in either the AJCC T3b or T4 stage or primary Gleason pattern 5, or those who have more than four biopsies showing cancer or two or three high-risk features
What to Expect
Learning more about prostate cancer and the available treatments is the first step towards improving your or your loved one’s outlook and relieving some of the anxiety and stress caused by diagnosis. Always get a second opinion. Research prostate cancer and treatment options. Read Us TOO’s Pathways for New Prostate Cancer Patients – brochure listing options for the newly diagnosed (zerocancer.org). Request Us TOO’s free kit: Resource Kit for Making Prostate Cancer Decisions – kit of brochures & materials for the newly diagnosed. Visit Us TOO’s Online Communities: Prostate Pointers section for information on prostate cancer and its treatment. Jot down questions for your doctor. Ask about your doctor’s experience in treating prostate cancer. Bring along your companion, a family member, or a friend for support and an objective observer who can help translate what occurred in the doctor’s office. Depending on the stage of the cancer, the doctor will discuss treatment options. Certain treatments for prostate cancer are associated with side effects that can have a profound effect on one’s lifestyle. The important thing to remember as a patient is to keep a diagnosis of prostate cancer and the possible side effects of treatment from interfering with your life or your emotional health. Try to stick to your normal routine. Eat a prostate healthy diet with enough calories to support your ideal weight. For a prostate healthy diet see our Resource tab. Get plenty of rest. Pursue activities that are purposeful and meaningful – go back to work, play with your children or grandchildren. Do things you enjoy – take a trip, go golfing. Exercise regularly – it improves your physical and emotional sense of well-being and has been shown by studies to prolong survival. Anticipate changes in your lifestyle and find ways to accommodate them. Incontinence (loss of urinary control) – sit at the back of the movie theater, sit on the aisle in an airplane. Erectile dysfunction – seek out sexual contact and reestablish intimacy. Seek out support from your family and friends. Join a support group for prostate cancer patients. For information about the Delaware Prostate Cancer Coalition’s support group, see our Support tab.
Questions For Your Doctor About Your Disease and Treatment Options
Treatment options include various types of surgery, radiation, medical (hormone) therapy, and nuclear medicine agents. The following is a list of questions to ask your doctor if you have been diagnosed with prostate cancer. It may be worthwhile to audio record your conversation with your doctor so that you can review his answers to each question and be able to make informed decisions about your treatment options.
After Diagnosis
What additional tests will I need? What is the stage of my cancer? Has my cancer spread and if so, how far? What are the treatment options for this stage of cancer? What are the benefits and risks of the type of therapy you are recommending? What side effects are associated with the type of therapy that you are recommending? What can I do to improve the success of my therapy? Are there other treatment options? Should I consider participating in a clinical trial? Can you refer me/us to a colleague who is not associated with this institution for a second opinion? Where can I find out more about my or my loved one’s treatment options? Where can I find advice about coping with the emotional impact of prostate cancer diagnosis and therapy? Are there any cancer support centers nearby?
Surgery
How many of these operations have you performed? Do you use robotic assistance? If so, what type? What level of success have you had in preserving erectile function and/or urinary continence in your patients following surgery? What can I expect following the surgery in terms of recovery time and short- and long-term side effects? What kind of follow-up can I expect after surgery?
Radiation Therapy
What type of radiation therapy will you be using and why? How old or new is the machine? What level of success have you had in preserving erectile function and/or urinary continence in your patients following this type of radiation therapy? What can I expect following radiation therapy in terms of recovery time and short- and long-term side effects? What kind of follow-up is needed after radiation therapy?
Hormone Therapy
What type of hormone therapy do you recommend and why? What side-effects can I expect from this type of therapy? How long will I need to receive hormone therapy? What are my options in terms of continuous versus intermittent hormone therapy?
Finding Support
While the Internet (Google and other search engines) has become a valuable source of information and support for those dealing with prostate cancer, it is recommended that you verify all information you obtain from the Internet with your doctor. Your doctor is a good resource who can give you information about prostate health and cancer, and who can direct to you other trusted resources of support. Also, visit the American Urological Association’s (AUA) Urology Health website for additional excellent information on adult conditions of the prostate (auanet.org). Find a medical oncologist in your area by consulting the American Society of Clinical Oncology (ASCO). Also, visit ASCO’s website entitled People Living With Cancer for additional excellent information about prostate cancer (asco.org). Find a local Us TOO support group chapter (zerocancer.org). The Us TOO mission is based on the Chinese proverb, “To know the road ahead, ask those coming back.” Talk to other men who have been diagnosed and treated, and/or speak to the wives and companions who are supporting their partners through their diagnosis, treatment, and life after cancer. There are several national and international groups in addition to Us TOO that promote education about prostate cancer and its treatment, provide support, and act as advocates for prostate cancer awareness. See our Support tab for a list of support groups.