The Big Picture | What Is It? | Diagnosis | Understanding Risk  | Treatment Options | Prostate Cancer Results Study Group

Diagnosis and Staging

Early detection is the key to curing prostate cancer. See our recommendation on the home page for screening for prostate cancer using the  Prostate Specific Antigen (PSA) blood test and digital rectal exam (DRE). The risk of developing prostate cancer before age 50 is low, however we recommend that African-American men and men with a family history of the disease should begin as early as 40.  See the recommended screening schedules and discuss with your physician.

PSA

A PSA (Prostate Specific Antigen) blood test and digital rectal exam (DRE) are the two standard screening tests for prostate cancer. PSA is an enzyme produced exclusively by the prostate. PSA is produced by both normal and prostate cancer cells. Small amounts of this enzyme in the bloodstream are normal. Note that an elevated PSA alone does not necessarily indicate cancer. Normal levels are between 0-2.5 ng/ml. Levels higher than this should be evaluated. Benign elevations of PSA can be caused by an enlarged prostate, prostate inflammation, infection or trauma. Often, the DRE does not reveal any abnormalities that the doctor can feel. Occasionally, the PSA will be less than 2.5 ng/ml, but the DRE will be abnormal. For this reason, the PSA blood test together with the DRE is important for early detection. Almost all normal prostate cells and prostate cancer cells make PSA even if they are outside the gland. The PSA is used not only for detection but for monitoring results after treatment. If prostate cancer cells have spread to the bone or lymph nodes, these cells will make PSA. After surgery, the PSA is likely to drop quickly. After any form of radiation (Seeds, IMRT, etc.) the PSA drops more slowly as the cells die off slowly over time. Thus, it may take several years to reach the lowest post-treatment PSA level (nadir) after any form of radiation treatment.

Biopsy

Trans-rectal Biopsy A trans-rectal biopsy using an ultrasound guided approach is the standard approach for biopsying the prostate. This is usually performed under local anesthesia in the urologist’s office. The standard is 6-12 cores. The pathologist will grade the cancer using the Gleason Scoring* system and likely will state how much of the core is involved with cancer.  Note that while this percentage of the core involved with cancer is  reported on the pathology it does not typically weigh into a treatment decision.. The number of cores involved, however, can influence the treatment recommendations.

Transperineal Biopsy This is a very precise form of biopsy in which the biopsy is directed through the skin beneath the scrotum to defined targets in the prostate . It is used  in our center in special situations in which the trans-rectal biopsy is unable to reach the suspected area of concern . The multiparametric MRI which almost all of our patients receive  has sometimes identified areas which require further biopsies. For example we did this type of biopsy on a gentleman who have 5 previously negative biopsies. We were able to find and positively identify the cancer using this new technique.

Staging

Staging prostate cancer is based on the physical exam and any diagnostic studies performed. Since most patients do not require bone scans, CTs and other imaging tools, the digital rectal exam provides this staging information. If there is no palpable nodule in the gland, the Stage is T1. T1 means there is no palpable disease and is divided into 3 categories based on how it was diagnosed. T1a and T1b are reserved for patients in which the cancer was found after a procedure to help them urinate , called a TURP (transurethral resection of the prostate)**. T1c is usually detected by an elevated PSA. Note that even if the pathology shows disease on both sides of the gland, this does not affect the stage. Many patients and physicians get confused on this point and improperly label someone as stage T2c when biopsies are positive on both sides of the prostate, but no disease is palpable on the DRE; patients such as these are more properly defined as stage T1c.

T2a refers to a small nodule on one side of the gland, T2b means that the nodule occupies most of one lobe, and T2c means that the nodule occupies parts of both lobes. T3 is quite rare and means that the nodule extends outside the gland.

Risk Grouping

Every patient at PCCS is evaluated for Stage, Grade and PSA but more importantly into a risk group . Studies have demonstrated that patients  with only slightly different characteristics can be grouped into risk groups that have similar outcomes. These risk groups can be useful for evaluating results of various treatments and to make treatment decisions. The risk groupings currently being adopted by most major centers are Low, Intermediate and High Risk. It is valuable for you to determine in which group you fall so that you can discuss it with your physician. Here are the risk groups most commonly used. See Understanding Risk Groups for a more complete description.

* Gleason Score (GS): A method for categorizing cancerous tissues from least aggressive to most aggressive. It is prostate cancer specific. Prostate tumors sometimes are made of patterns ofof two or more grades of cells. Each of the patterns of cells are graded from 1-5;. The two numbers are added together to give the Gleason score. For example Gleason score 7/10 refers to a pattern of Gleason grade 3 cells and Gleason grade 4 cells. The most common cell pattern is recorded first. A Gleason 4+3=7 means that most of the cancer was Gleason pattern grade 4 and less was grade 3. A Gleason 4+3=7 is typically more aggressive than a Gleason 3+4=7. If all the cells are the same such as Gleason 3 then cancer becomes a Gleason score 6 (3 plus 3) Most cancers are Gleason score 6 or 7. GS 2-4 are very rare, and tend to come from the central aspect of the prostate that is removed at time of TURP. Over the years Gleason scores have evolved. In the late 1980’s and early 1990’s cancers were often called Gleason score 2-4. Those same biopsies reviewed today would typically be called Gleason score 6 or 7. This is another reason one cannot accurately compare results of patients treated from an older era to modern era patients.
** TUIP:  Transurethral incision of the prostate; a procedure that can be done to is to relieve urinary obstruction; less traumatic to the prostate than a TURP.