How Is Prostate Cancer Diagnosed

Transrectal Ultrasound Scan Guided Biopsy

Your doctor takes a series of small tissue samples from the prostate to examine under a microscope. You have the biopsy through the back passage using a transrectal ultrasound scanner.

A TRUS guided biopsy can be uncomfortable. You usually have a local anaesthetic to numb the area and reduce any pain.

• Find out more about having a TRUS guided biopsy

Surgically Removing The Prostate Gland

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

Like any operation, this surgery carries some risks, such as urinary incontinence and erectile dysfunction.

In extremely rare cases, problems arising after surgery can be fatal.

Itâs possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .

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Getting The Results Of The Biopsy

Your biopsy samples will be sent to a lab, where they will be looked at with a microscope to see if they contain cancer cells. Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer. The results might be reported as:

• Positive for cancer: Cancer cells were seen in the biopsy samples.
• Negative for cancer: No cancer cells were seen in the biopsy samples.
• Suspicious: Something abnormal was seen, but it might not be cancer.

If the biopsy is negative

If the prostate biopsy results are negative , and the chance that you have prostate cancer isnt very high based on your PSA level and other tests, you might not need any more tests, other than repeat PSA tests sometime later.

But even if many samples are taken, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer , your doctor might suggest:

• Getting other lab tests to help get a better idea of whether or not you might have prostate cancer. Examples of such tests include the Prostate Health Index , 4Kscore test, PCA3 tests , and ConfirmMDx. These tests are discussed in Whats New in Prostate Cancer Research?
• Getting a repeat prostate biopsy. This might include getting additional samples of parts of the prostate not biopsied the first time, or using imaging tests such as MRI to look more closely for abnormal areas to target.

Prostate cancer grade

Gleason score

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Imaging Tests For Prostate Cancer

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. One or more imaging tests might be used:

• To look for cancer in the prostate
• To help the doctor see the prostate during certain procedures
• To look for spread of prostate cancer to other parts of the body

Which tests you might need will depend on the situation. For example, a prostate biopsy is typically done with transrectal ultrasound and/or MRI to help guide the biopsy. If you are found to have prostate cancer, you might need imaging tests of other parts of your body to look for possible cancer spread.

The imaging tests used most often to look for prostate cancer spread include:

After A Diagnosis Of Prostate Cancer

After finding out you have prostate cancer, you may feel shocked, upset, anxious or confused. These are normal responses. Talk about your treatment options with your doctor, family and friends. Ask questions and seek as much information as you need. It is up to you as to how involved you want to be in making decisions about your treatment.

After non-melanoma skin cancer, prostate cancer is the most common cancer in Australia. In 2016, 19,305 Australian men were diagnosed with prostate cancer.

Prostate cancer is unusual in that it is slow growing in some men and not a threat, but for others the cancer can be aggressive. Cure rates for prostate cancer are improving, however side-effects of treatment may affect your lifestyle including sexual function and continence.

To ensure that you receive the best care, your specialist will arrange for a team of health professionals based on your needs and preferences

Learn more about the best prostate cancer care for each step of your treatment:

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Medical History And Physical Exam

If your doctor suspects you might have prostate cancer, you will be asked about symptoms you are having, such as any urinary or sexual problems, and how long you have had them. You might also be asked about possible risk factors, including your family history.

Your doctor will also examine you. This might include a digital rectal exam , during which the doctor inserts a gloved, lubricated finger into your rectum to feel for any bumps or hard areas on the prostate that might be cancer. If you do have cancer, the DRE can sometimes help tell if its only on one side of the prostate, if its on both sides, or if its likely to have spread beyond the prostate to nearby tissues. Your doctor may also examine other areas of your body.

After the exam, your doctor might then order some tests.

Further Testing For Advanced Cancer

If there’s a significant chance the cancer has spread from your prostate to other parts of the body, further tests may be recommended.

These include:

• an MRI scan, CT scan or PET scan these scans build a detailed picture of the inside of your body
• an isotope bone scan, which can tell if the cancer has spread to your bones a small amount of radiation dye is injected into the vein and then collects in parts of the bone where there are any abnormalities

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Assessing Your Gleason Score

The Gleason score is a number given by the pathologist who examines the cancerous tissue samples under a microscope. The Gleason score refers to how different the prostate cancer cells/glands appear in comparison to normal prostate cells/glands. The pathologist provides two grades, or numbers, based on the pattern of cancer cells/glands that appear under the microscope. Each grade is based on a scale of 1 to 5. The two grades are added together for your Gleason Score. With today’s biopsy methods/grading recommendations, almost all prostate cancer patients have a Gleason Score of 6 or above. These scores are then rated into low-risk , intermediate and high-risk categories.

Psa Isoforms Psa Density And Velocity

To improve screening and management of PCa, several methods to optimize PSA or PSA derivatives have been used.

3.3.1. PSA aged adjusted

The tPSA value does not account for age-related PSA changes due to prostate volume changes related to the development of BPH. Oesterling et al. were the first to suggest considering age-related reference ranges in order to improve cancer detection rates in young men. They recommended thresholds of 2.5, 3.5, 4.5 and 6.5 ng/mL in men in their 40s, 50s, 60s and 70s, respectively, to improve specificity .

Loeb et al. examined the usefulness of baseline PSA testing in 13 943 men younger than 60 years from a large prospective PCa screening trial in the United States, in which biopsy was performed for a PSA > 2.5 ng/mL or suspicious findings on DRE.

Vickers et al. found that the tPSA value at age 60 years predicts not only a lifetime risk of clinically detected PCa, but also metastases and death from the disease.

Clearly in the discussion with patients about screening, taking into account the results of the Prostate Cancer Intervention versus Observation Trial PIVOT and prostate testing for cancer and treatment trial, the threshold for indicating biopsy should integrate age and life expectancy .

3.3.2. Free PSA

3.3.3. PSA density

PSAd is calculated as tPSA divided by total prostate volume or transitional prostate volume measured on TRUS to avoid unnecessary biopsies.

3.3.4. PSA velocity : PSA doubling time

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Making Sense Of Prostate Biopsy Results

If your biopsy reveals that some cells look abnormal, but may or may not be cancer, your doctor might recommend another biopsy. If your biopsy comes back positive, it means cancer cells were detected.

Your pathology report will include:

• A Gleason score, which helps doctors predict how fast-growing the prostate cancer is
• The number of biopsy samples that contain cancer out of the total number sampled
• A diagnosis of each core or biopsy sample
• The percentage of cancer in each sample
• Whether the cancer is on one or both sides of the prostate gland

When Further Treatment Is Needed

While prostate cancer diagnosis and treatment have improved significantly in recent years, the cancer can still recur. Thatâs why it is essential that you and your doctor continue to monitor your PSA on a quarterly basis for some period of time, no matter how successful your treatment seems to be. Patients usually can consider a number of treatment options to treat or control recurrent cancer. Choosing among them requires a new decision-making process.

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Deaths From Prostate Cancer

Prostate cancer is the second leading cause of cancer death in American men, behind only lung cancer. About 1 man in 41 will die of prostate cancer.

Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 3.1 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

American Cancer Society. Facts & Figures 2022. American Cancer Society. Atlanta, Ga. 2022.

National Cancer Institute. SEER Cancer Stat Facts: Prostate Cancer. Accessed at https://seer.cancer.gov/statfacts/html/prost.html on March 15, 2019.

Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA . SEER Cancer Statistics Review, 1975-2015, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2015/, based on November 2017 SEER data submission, posted to the SEER web site, April 2018.

American Cancer Society. Facts & Figures 2022. American Cancer Society. Atlanta, Ga. 2022.

National Cancer Institute. SEER Cancer Stat Facts: Prostate Cancer. Accessed at https://seer.cancer.gov/statfacts/html/prost.html on March 15, 2019.

Last Revised: January 12, 2022

How Prostate Cancer Is Diagnosed And Staged

Cancer staging helps you and your doctor understand how advanced your cancer is and how much it has spread at the time of diagnosis. Knowing your cancer stage also helps your doctor determine the best treatment options for you and estimate your chance of survival.

The most widely used staging system for cancer is the TNM system that classifies cancer from stage 1 to stage 4.

TNM stands for:

• Tumor: the size and extent of the tumor
• Nodes: the number or extent of nearby lymph node involvement
• Metastasis: whether cancer has spread to distant sites in the body

The TNM scale is used for many types of cancer. When a doctor uses it to determine your prostate cancer stage, theyll consider several other factors as well, including:

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Screening And Early Detection

Screening is performed to detect cancer before it causes symptoms. Catching prostate cancer early can result in a more favorable outlook. Healthcare providers may be able to treat the cancer before it spreads to other places in the body.

Some methods used to screen for prostate cancer include:

• Prostate-specific antigen test: This test measures the level of PSA, a substance made by the prostate, in the blood. Men with prostate cancer may have higher PSA levels than those without. Healthcare providers may recommend a biopsy if a mans PSA is elevated or abnormal.
• Digital rectal examination : During a DRE, healthcare providers insert a lubricated, gloved finger into a mans rectum to feel the prostate to detect any abnormalities.

Recommendations about prostate cancer screening include:

• Men between the ages of 55 and 69 should make an individual decision about being screened with a PSA test.
• Before the screening, men should talk to their healthcare providers about the benefits and risks.
• Men 70 years or older should not be screened for prostate cancer on a routine basis.

Genetic And Genomic Tests For Localized Prostate Cancer

Genetic testing

A man’s inherited genes predict his prostate cancer risk. For a long time, we have known that there is a family risk in prostate cancer. If your father or brother has prostate cancer, or your mother or sister has breast or ovarian cancer, you are at higher risk of being diagnosed with prostate cancer. To partially quantify that genetic risk, a germline test can be performed before a biopsy. This test of DNA from healthy cells can determine whether you have inherited genetic mutations, such as BRCA1 and BRCA2, known to increase prostate cancer risk. If the test shows you’re low risk, you may be able to avoid a biopsy even if you have a slightly elevated PSA, while still being actively monitored for prostate cancer.

Genomic testing

If already diagnosed with prostate cancer, you may undergo another type of test for assessing your genetic risk. A genomic test of tissue from your biopsy or prostatectomy can look for somatic mutations, alterations in the DNA of the cancer cells themselves. Genomic tests measure expression of various genes that relate to how aggressive a cancer is likely to be. They indicate how rapidly cancer cells are growing and how genetically abnormal they are relative to normal cells.

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Is Active Surveillance Right For You

There are some risks associated with active surveillance. They include a low risk of infection with every biopsy and a very low risk of cancer progressing in any one interval of surveillance. Sometimes men choose active surveillance for a period of time and then decide to undergo treatment.

Thousands of UCSF patients have chosen active surveillance to initially manage their prostate cancer. This is one of the largest groups of patients on active surveillance in the world. About one-third of these men receive treatment by five years and 50% by 10 years. The window of opportunity to cure prostate cancer is usually measurable in years or even decades. In fact, treatment results for these men appear to be similar to what would have been expected had they chosen treatment right after their original diagnosis. Based on our experience and those reported from other centers, the risk of significant cancer progression in the short to intermediate term, while not zero, appears to be very low.

Some men with risk factors such as family history, genetic mutations and being African American may still be candidates for active surveillance but need a more careful or intense surveillance regimen to make sure any early signs of progression are identified.

The most common reason for seeking treatment is a biopsy that shows the cancer is growing or becoming more aggressive in appearance . Changes in PSA or cancer stage based on imaging results may also lead to treatment.

Are You At Risk For Prostate Cancer

Any man can get prostate cancer, but these factors increase your risk:

• Age: Your chances of developing prostate cancer go up as you get older. Prostate cancer is rare in men younger than 40. But 6 in 10 men older than 65 have the disease.

• Ethnicity and race: For unknown reasons, Black men and Caribbean men of African ancestry are more likely to get prostate cancer at a young age. This cancer also tends to be more aggressive, which means it may spread to other parts of the body. Asian-American, Hispanic, and Latino men are less likely to get prostate cancer.

• Family history: Having a first-degree relative with prostate cancer doubles your risk of getting the disease. Still, many men with prostate cancer have no family history of the disease.

• Genetic changes: Some men inherit changes in genes linked to prostate cancer. These include mutated breast cancer genes and Lynch syndrome .

• Smoking: Smokers may have double the risk of prostate cancer.

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Prostate Cancer Caregiver Podcast Series

We are proud to announce a new podcast series geared toward helping give support, hope and guidance to prostate cancer caregivers. The goal of this Prostate Cancer Caregiver Podcast Series is to help others connect with a diverse group of people who have felt the impact of prostate cancer in their lives and empower them on their journey.

How To Improve Trus Prostate Biopsy Technique

The gold standard to diagnose PCa with an elevated PSA is the 12 core extended sextant TRUS, the TRUS-guided prostate needle biopsy. However, as show in the figure below, the TRUS non-targeted technique carries a risk of sampling error , of missing an aggressive cancer and of overdiagnosing an indolent cancer . As most lesion are now small and sometime located in regions that are not identifiable by DRE and TRUS, different protocols or strategies to improve the detection of clinically significant cancer were evaluated and published.

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External Beam Radiation Therapy

With EBRT, radiation usually in the form of X-ray photons is focused from a source outside the body onto the prostate and, if needed, surrounding lymph node areas. In preparation for the therapy, internal markers are implanted in the prostate, using a procedure similar to prostate biopsy they’re used to help align and target the prostate with the radiation beam. A planning CT scan is then performed to locate the prostate gland in relation to the surrounding structures and organs. The resulting images are used to make a treatment plan that targets the prostate gland while protecting healthy surrounding tissues .

Most radiation today is given as a type of EBRT known as intensity-modulated radiation therapy , in which the shape and intensity of several fine radiation beams can be varied during treatment to minimize damage to surrounding tissues. At UCSF, patients also benefit from image-guided radiation therapy , where the prostate is imaged immediately before the start of each treatment session to verify and adjust the position of the gland for added accuracy. Stereotactic body radiation therapy, or SBRT , is a special type of IMRT/IGRT in which high doses of radiation are given over a small number of treatments .

The schedule for EBRT treatments varies. Treatment may be delivered in one of the following ways: