Detection & Screening

The purpose of screening for cancer is to detect the cancer at its earliest stages, before any symptoms have developed.

Some men, however, will experience symptoms that might indicate the presence of prostate cancer. Because these symptoms can also indicate the presence of other diseases or disorders (such as BPH or prostatitis), these men will undergo a more thorough work-up. Typically, men whose prostate cancer is detected through screening are found to have very early-stage disease that can be treated most effectively.

Screening for prostate cancer can be performed quickly and easily in a physician’s office using two tests: the PSA (prostate-specific antigen) blood test, and the digital rectal exam (DRE).

The PSA Blood Test
PSA is a protein produced by the prostate and released in very small amounts into the bloodstream. When there’s a problem with the prostate, such as when prostate cancer develops and grows, more and more PSA is released, until it reaches a level where it can be easily detected in the blood.

During a PSA test, a small amount of blood is drawn from the arm, and the level of PSA is measured. PSA levels under 4 ng/mL are usually considered "normal," results over 10 ng/mL are usually considered "high," and results between 4 and 10 ng/mL are usually considered "intermediate."

However, PSA can also be elevated if other prostate problems are present, such as BPH or prostatitis, and some men with prostate cancer have "low" levels of PSA. This is why both the PSA and DRE are used to detect the presence of disease.

The Digital Rectal Exam
During a DRE, the physician inserts a gloved, lubricated finger into the rectum and examines the prostate for any irregularities in size, shape, and texture. Often, the DRE can be used by urologists to help distinguish between prostate cancer and non-cancerous conditions such as BPH.

Should I Be Screened?
The American Cancer Society recommends that both the PSA and DRE should be offered annually, beginning at age 50, to men who have at least a 10-year life expectancy. Men at high risk, such as African American men and men with a strong family history of one or more first-degree relatives diagnosed at an early age, should begin testing at age 45.

However, there is no unanimous opinion in the medical community regarding the benefits of prostate cancer screening. Those who advocate regular screening believe that finding and treating prostate cancer early offers men more treatment options with potentially fewer side effects. Those who recommend against regular screening note that because most prostate cancers grow very slowly, the side effects of treatment would likely outweigh any benefit that might be derived from detecting the cancer at a stage when it is unlikely to cause problems.

Because a decision of whether to be screened for prostate cancer is a personal decision, it's important that each man talk with his doctor about whether prostate cancer screening is right for him.

 

Prostate Cancer Symptoms

For an extensive overview of what can go wrong with the prostate, read Chapter 2 "Little Gland, Big Trouble" from the book Dr. Patrick Walsh's Guide to Surviving Prostate Cancer.

If the cancer is caught at its earliest stages, most men will not experience any symptoms.  Some men, however, will experience symptoms that might indicate the presence of prostate cancer, including:

  • A need to urinate frequently, especially at night;
  • Difficulty starting urination or holding back urine;
  • Weak or interrupted flow of urine;
  • Painful or burning urination;
  • Difficulty in having an erection;
  • Painful ejaculation;
  • Blood in urine or semen; or
  • Frequent pain or stiffness in the lower back, hips, or upper thighs.

Because these symptoms can also indicate the presence of other diseases or disorders, such as BPH or prostatitis, men who experience any of these symptoms will undergo a thorough work-up to determine the underlying cause of the symptoms.

 

Diagnosis

Although the DRE and PSA tests cannot diagnose prostate cancer, they can signal the need for a biopsy to examine the prostate cells and determine whether they are cancerous. In some men, changes in urinary or sexual function lead to a full evaluation by the doctor, and, if prostate cancer is suspected, a biopsy will be performed.

The Biopsy
During a biopsy, needles are inserted into the prostate to take small samples of tissue, often under the guidance of ultrasound imaging. The biopsy procedure may cause some discomfort or pain, but the procedure is short, and can usually be performed without an overnight hospital stay.

Gleason Grading and Gleason Scores
Under normal conditions, prostate cells, just like all other cells in the body, are constantly reproducing and dying, and each new prostate cell has the same shape and appearance as all of the other prostate cells. But cancer cells look different, and the degree to which they look different from normal cells is what determines the cancer grade. "Low-grade" tumor cells tend to look very similar to normal cells, whereas "high-grade" tumor cells have mutated so much that they often barely resemble the normal cells.

The Gleason grading system accounts for the five distinct patterns that prostate tumor cells tend to go through as they change from normal cells. The scale runs from 1 to 5, where 1 represents cells that are very nearly normal, and 5 represents cells that don’t look much like prostate cells at all.

 

Gleason Grade

After examining the cells under a microscope, the pathologist looking at the biopsy sample assigns one Gleason grade to the most common pattern, and a second Gleason grade to the next most common pattern. The two grades are added, and the Gleason score, or sum, is determined.

Generally speaking, the Gleason score tends to predict the aggressiveness of the disease and how it will behave. The higher the Gleason score, the less the cells behave like normal cells, and the more aggressive the tumor tends to be.

Staging the Disease
Staging determines the extent of prostate cancer. Localized prostate cancer means that the cancer is confined within the prostate. Locally advanced prostate cancer means that most of the cancer is confined within the prostate, but some has started to escape to the immediate surrounding tissues. In metastatic disease, the prostate cancer is growing outside the prostate and its immediate environs, possibly to more distant organs.

A number of tests can be used to help determine the stage of disease. For example, cancers growing outside of the prostate can often be detected through traditional imaging studies, such as CT scans, MRIs, or x-rays, or through more specialized imaging tests such as bone scans. Note that because these tests cannot detect very small groups of cancer cells, results of these tests cannot be used alone to determine the stage of the disease, to guide treatment options, or to predict outcomes.

Metastatic disease can also be detected through imaging studies, and often can be detected in the lymph nodes. Cancers that spread to more distant organs tend to travel through the lymph system, a circulatory system similar to the blood stream that carries cells important in fighting infection and disease. During a biopsy, or, more often, during surgery, lymph nodes will be removed and examined for the presence of cancer cells.

Knowing the stage of disease can help to determine how aggressively the disease needs to be treated, and how likely it is to be eradicated by the available treatment options.

 

Treatment

There is no "one size fits all" treatment for prostate cancer, so each man must learn as much as he can about various treatment options and, in conjunction with his physicians, make his own decision about what is best for him. 

For most men, the decision will rest on a combination of clinical and psychological factors. Men diagnosed with localized prostate cancer today will likely live for many years, so any decision that is made now will likely reverberate for a long time. Careful consideration of the different options is an important first step in deciding on the best treatment course.

Consultation with all three types of prostate cancer specialists—a urologist, a radiation oncologist and a medical oncologist—will offer the most comprehensive assessment of the available treatments and expected outcomes.

Click on the following for more information about particular treatment options for prostate cancer: