Medical History And Physical Exam
If your doctor suspects you might have prostate cancer, he or she will ask you about any 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.
Cost And Health Insurance
It is important to know the total costs in advance, including how much your health insurance will cover and what your co-pay and out-of-pocket expenses will be, if you’re enrolled. The test will invariably require insurance pre-authorization, which your healthcare providers office can submit on your behalf.
If you are denied coverage for any reason, ask your insurer for a written reason for the denial. You can then take the letter to your state insurance consumer protection office and ask for help. Your healthcare provider should also intervene and provide additional information to your insurance company as to why the test is essential.
If you are uninsured or underinsured, speak with the lab to see if there are monthly payment options.
Greater Accuracy And Changing Treatment
Approximately 300 men were enrolled in the Australian trial, all with newly diagnosed localized prostate cancer , and all were considered to have high-risk disease. For all men in the trial, the planned treatment was either surgery or radiation therapy to the prostate only.
Half the men were randomly assigned to initially undergo a CT and bone scan, and the other half to PSMA PET-CT.
Based on the imaging, PSMA PET-CT was 27% more accurate than the standard approach at detecting any metastases . Accuracy was determined by combining the scans sensitivity and specificity, measures that show a tests ability to correctly identify when disease is present and not present.
PSMA PET-CT was more accurate for both metastases found in lymph nodes in the pelvis and in more distant parts of the body, including bone. Radiation exposure was also substantially lower with PSMA PET-CT than with the conventional approach.
The trial investigators also tracked how imaging results influenced clinicians treatment choices. Based on imaging findings, the initial treatment plan was changed for 15% of men who underwent conventional imaging compared with 28% of men who underwent PSMA PET-CT.
Another key finding, Dr. Hofman noted, was that PSMA PET-CT was much less likely to produce inconclusive, or equivocal, results .
Thats important, he continued, because if you have a scan with equivocal findings, it often leads to more scans or biopsies or other tests.
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What Are The Risks Of A Bone Scan
The amount of the radionuclide injected into your vein for the procedure issmall enough that there is no need for precautions against radioactiveexposure. The injection of the tracer may cause some slight discomfort.Allergic reactions to the tracer are rare, but may occur.
Patients who are allergic to or sensitive to medications, contrast dyes, orlatex should notify their doctor.
If you are pregnant or suspect that you may be pregnant, you should notifyyour health care provider due to the risk of injury to the fetus from abone scan. If you are lactating, or breastfeeding, you should notify yourhealth care provider due to the risk of contaminating breast milk with thetracer.
There may be other risks depending on your specific medical condition. Besure to discuss any concerns with your doctor prior to the procedure.
About Dr Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
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Who Does A Bone Scan
A specially trained and certified nuclear medicine technologist performs the test. A nuclear medicine physician is a medical doctor who uses tracers to diagnose and treat disease. A radiologist or a nuclear medicine physician oversees the technologist. A radiologist is a medical doctor who uses imaging tests to diagnose disease. One of these doctors will read your scan and decide what it means.
You can have a bone scan done at:
A hospital’s radiology or nuclear medicine department
An outpatient imaging center
Use In Men Who Might Have Prostate Cancer
The PSA blood test is used mainly to screen for prostate cancer in men without symptoms. Its also one of the first tests done in men who have symptoms that might be caused by prostate cancer.
PSA in the blood is measured in units called nanograms per milliliter . The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that can tell for sure if a man does or doesnt have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing, while others might recommend it starting at a lower level, such as 2.5 or 3.
- Most men without prostate cancer have PSA levels under 4 ng/mL of blood. Still, a level below 4 is not a guarantee that a man doesnt have cancer.
- Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer.
- If the PSA is more than 10, the chance of having prostate cancer is over 50%.
If your PSA level is high, you might need further tests to look for prostate cancer.
To learn more about how the PSA test is used to look for cancer, including factors that can affect PSA levels, special types of PSA tests, and what the next steps might be if you have an abnormal PSA level, see Screening Tests for Prostate Cancer.
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When You Need Themand When You Dont
It is normal to want to do everything you can to treat prostate cancer. But its not always a good idea to get all the tests that are available. You may not need them. And the risks from the tests may be greater than the benefits.
The information below explains why cancer experts usually do not recommend certain imaging tests if you are diagnosed with early-stage prostate cancer. You can use this information to talk about your options with your doctor and choose whats best for you.
How is prostate cancer usually found?
Prostate cancer is cancer in the male prostate gland. It usually grows slowly and does not have symptoms until it has spread. Most men are diagnosed in the early stages when their doctor does a rectal exam or a PSA blood test. PSA is a protein made in the prostate. High levels of PSA may indicate cancer in the prostate.
If one of these tests shows that you might have prostate cancer, you will be given more tests. These tests help your doctor find out if you actually have cancer and what stage your cancer is.
What are the stages of prostate cancer?
Prostate cancer is divided into stages one to four . Cancer stages tell how far the cancer has spread.
Stages I and II are considered early-stage prostate cancer. The cancer has not spread outside the prostate. However, stage II cancer may be more likely to spread over time than stage I cancer. In stages III and IV, the cancer has already spread to other parts of the body.
Imaging tests have risks.
Bone Scan And Imaging Studies
The Current Procedural Technology/Healthcare Common Procedure Coding System codes in Medicare data provided information regarding imaging, procedures, and treatments. Bone scans performed after date of diagnosis and before the earlier of 180 days or date of first treatment were considered part of the initial staging workup. Because SEER provides only the month and year of diagnosis, we assigned each patients diagnosis to the first of each month and deemed this reasonable because bone scans are unlikely to be used for purposes other than cancer staging.
For patients who received a bone scan, we then examined uses of additional imaging and procedures: x-ray, CT, and MRI specific to bone evaluation, and bone biopsy. We defined imaging and procedures performed within 90 days after bone scan and before treatment as potential downstream studies to further work-up abnormalities identified on bone scan. A complete list of HCPCS codes is shown in the .
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Preparing For A Bone Scan
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
What Do My Test Results Mean
Your doctor will look at your test results to find out if the cancer has spread and how quickly it might be growing.
How far has my cancer spread?
The stage of your cancer tells you whether it has spread outside the prostate and how far it has spread. You might need scans, such as an MRI, CT or bone scan, to find out the stage of your cancer.
Depending on the results, your cancer may be treated as:
- localised prostate cancer it’s contained inside the prostate
- locally advanced prostate cancer its started to break out of the prostate or has spread to the area just outside it
- advanced prostate cancer its spread from the prostate to other parts of the body.
Is my cancer likely to spread?
Your doctor may talk to you about the risk of your cancer spreading outside the prostate or coming back after treatment.
Your prostate biopsy results will show how aggressive the cancer is in other words, how likely it is to spread outside the prostate. You might hear this called your Gleason grade, Gleason score, or grade group.
Your cancer may be low risk if:
- your PSA level is less than 10 ng/ml, and
- your Gleason score is 6 or less , and
- the stage of your cancer is T1 to T2a.
Your cancer may be medium risk if:
- your PSA level is between 10 and 20 ng/ml, or
- your Gleason score is 7 , or
- the stage of your cancer is T2b.
What happens next?
Tests To Diagnose And Stage Prostate Cancer
Most prostate cancers are first found as a result of screening. Early prostate cancers usually dont cause symptoms, but more advanced cancers are sometimes first found because of symptoms they cause.
If prostate cancer is suspected based on results of screening tests or symptoms, tests will be needed to be sure. If youre seeing your primary care doctor, you might be referred to a urologist, a doctor who treats cancers of the genital and urinary tract, including the prostate.
The actual diagnosis of prostate cancer can only be made with a prostate biopsy .
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Imaging For Metastasis In Prostate Cancer: A Review Of The Literature
- 1Department of Medical Oncology, CHU Lille, Lille, France
- 2Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020 UMR-S 1277 Canther – Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- 3Medical Oncology Department, Centre Oscar Lambret, Lille, France
- 4Nuclear Medicine Department, CHU Lille, Lille, France
- 5Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- 6CRISTAL UMR CNRS 9189, Lille University, Villeneuve-d’Ascq, France
- 7Department of Urology, CHU Lille, Lille, France
- 8Department of Radiology, CHU Lille, Lille, France
Background: Initial staging and assessment of treatment activity in metastatic prostate cancer patients is controversial. Indications for the various available imaging modalities are not well-established due to rapid advancements in imaging and treatment.
Methods: We conducted a critical literature review of the main imaging abnormalities that suggest a diagnosis of metastasis in localized and locally advanced PCa or in cases of biological relapse. We also assessed the role of the various imaging modalities available in routine clinical practice for the detection of metastases and response to treatment in metastatic PCa patients.
In routine clinical practice, conventional imaging still have a role, and communication between imagers and clinicians should be encouraged. Present and future clinical trials should use modern imaging methods to clarify their usage.
Nuclear Bone Scan Procedure
The first step in the procedure is the injection of the tracer material. A technician will do this through a vein in your arm or hand. You might feel a sting from the IV.
Then, you wait for the tracer to travel through your body and bind to your bones. That can take 2 to 4 hours.
Your doctor might order a scan before your body absorbs the tracer for comparison, especially if you could have a bone infection. If youâre having two scans, the first will happen right after the injection.
While your body is absorbing the nuclear material, youâll need to drink 4 to 6 glasses of water to flush extra tracer from your body. Youâll use the restroom before the test so any concentration in your urine doesnât cause a misleading picture.
For the scan itself, youâll lie on a table while a camera takes pictures. Youâll have to remain very still for certain portions of the scan, and you may have to change positions several times. The scanning may take up to an hour. Itâs not painful, but lying on the table may become uncomfortable.
Your doctor may also order a type of test called single-photon emission-computed tomography . The camera rotates around your body to make more detailed images.
Positron Emission Tomography Scan
A PET scan is similar to a bone scan, in that a slightly radioactive substance is injected into the blood, which can then be detected with a special camera. But PET scans use different tracers that collect mainly in cancer cells. The most common tracer for standard PET scans is FDG, which is a type of sugar. Unfortunately, this type of PET scan isnt very useful in finding prostate cancer cells in the body.
However, newer tracers, such as fluciclovine F18, sodium fluoride F18, and choline C11, have been found to be better at detecting prostate cancer cells.
Other newer tracers, such as Ga 68 PSMA-11 and 18F-DCFPyl , attach to prostate-specific membrane antigen , a protein that is often found in large amounts on prostate cancer cells. Tests using these types of tracers are sometimes referred to as PSMA PET scans.
These newer types of PET scans are most often used if its not clear if prostate cancer has spread. For example, one of these tests might be done if the results of a bone scan arent clear, or if a man has a rising PSA level after initial treatment but its not clear where the cancer is in the body.
The pictures from a PET scan arent as detailed as MRI or CT scan images, but they can often show areas of cancer anywhere in the body. Some machines can do a PET scan and either an MRI or a CT scan at the same time, which can give more detail about areas that show up on the PET scan.