Prostate Cancer

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Questions to Ask Your Doctor About Prostate Cancer
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Diagnosis

Several tests are used to diagnose prostate cancer.

Digital rectal examination (DRE)

In a DRE, the physician inserts a lubricated, gloved finger into the rectum to feel the surface of the prostate gland. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. However, as many as one-third of patients diagnosed with prostate cancer have a normal DRE.

Transrectal ultrasound (TRUS)
TRUS is used to measure the size of the prostate and visually identify tumors. A probe inserted into the rectum emits ultrasonic impulses against the prostate. The images are projected on a monitor, so the physician can examine the gland and surrounding tissue for tumors.

TRUS and the digital rectal examination are effective prostate-cancer screening tools.

PSA and PAP Tests

Blood tests taken to check the levels of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia help the physician eliminate or confirm a diagnosis of prostate cancer.

Prostate-specific antigen (PSA) is produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce greater amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.

The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). A PSA of 4 ng/mL or lower is considered normal; 4–10 ng/mL, slightly elevated; 10–20, moderately elevated; and 20–35, highly elevated. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer.

The PSA test can produce false results. A false positive result occurs when the PSA level is elevated and there is no cancer. A false negative result occurs when the PSA level is normal and there is cancer. Because of this, a biopsy is usually performed to confirm or rule out cancer when the PSA level is high.

Free and total PSA (also known as PSA II)
PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA is the sum of the levels of both forms; free PSA measures the level of unbound PSA only. Studies suggest that malignant prostate cells produce more bound PSA; therefore, a low level of free PSA in relation to total PSA might indicate a cancerous prostate, and a high level of free PSA compared to total PSA might indicate a normal prostate, BPH, or prostatitis.

Age-specific PSA
Evidence suggests that the PSA level increases with age. A PSA of up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The use of age-specific PSA levels is not endorsed by all medical professionals.

Use the PSA Age/Race Quiz to determine your risk of prostate cancer.

Prostatic acid phosphatase (PAP) test
Prostatic acid phosphatase is an enzyme produced by prostate tissue. The level of PAP increases as prostate disease progresses.

Tumor Biopsy

If a tumor is found, a biopsy is performed to determine the type of cancer, its location, and stage of development.

Before undergoing the biopsy, patients should abstain from alcohol, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen) for 1 week. Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.

They are required to take one Fleet enema the night before the procedure and one 2 hours before the biopsy. An oral antibiotic (usually ciprofloxacin) is prescribed to be taken the day before, the day of, and 2 days after the biopsy.

The biopsy is performed with the patient lying on his side with his knees brought up to his chest. A biopsy needle, similar to one used to draw blood or administer injections, is inserted through the perineum into the tumor. A probe, guided by transrectal ultrasound (TRUS), is inserted into the rectum to help the physician properly place the needle, which is projected through the tip of the probe. A cell sample is extracted from one or several areas of the tumor into the syringe. The sample(s) is analyzed by a pathologist to confirm the diagnosis of a cancerous tumor and determine its type. The results are obtained within 5–10 working days.

Gleason score
The biopsy sample(s) is examined under a microscope for cells or groups of cells that are markedly different from healthy tissue. The greater the disparity between the healthy cells and those that are malignant, the more likely the tumor is aggressive and will spread (metastasize).

The pathologist examines two tissue samples taken from different areas of the tumor and assigns a score of 1 to 5 to each sample. The more abnormal the tissue, the higher the score. The sum of the two produces the Gleason score. Gleason scores of 2 to 4 indicate that the cells are well differentiated, meaning the tissue is not too abnormal; 5 to 7 moderately differentiated; 8 to 10 poorly differentiated. Higher scores suggest aggressive tumors that likely require aggressive treatment.

Complications
After a biopsy, blood in the urine (hematuria) and stool is common and usually diminishes within 1–2 weeks. Patients also experience a dull ache in the perineum for several days. Men are advised to refrain from sexual intercourse for 3–5 days. Blood may appear in the semen.

If the patient develops a large number of blood clots or cannot urinate, the physician should be contacted or the patient should go to the emergency room.

Rarely, biopsy of a cancerous tumor also may cause spreading, or "seeding," of cancer cells along the path of the biopsy needle.

Computed tomography (CT scan)
Computer-assisted tomography (CAT scan or CT scan) is an x-ray procedure that produces three-dimensional images of internal organs and glands. It can be used to detect pelvic lymph nodes enlarged by cancer, but results may be insufficient for diagnosis. CT scans are used only when tumors are large or PSA levels are high.

Bone scan
A bone scan is a nuclear imaging procedure that is used to detect metastasis to bones. It is not used in patients with small cancers and low PSA levels.

Prostate Cancer, Diagnosis reprinted with permission from urologychannel.com
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