How is prostate cancer diagnosed?

Rectal examination (DRE): the doctor will examine the prostate by inserting two fingers of a gloved hand into the rectum (back passage). This allows the doctor to feel if the prostate is enlarged in size and if it is irregular in shape. If it is, you will be referred for more tests. A rectal examination can be somewhat uncomfortable, but will not be painful.

PSA test: Prostate Specific Antigen (PSA) is a protein produced by the prostate which is released into the blood stream. A PSA test is a simple blood test that measures these levels.

Although a high level of PSA can be an indication of cancer, it can also be an indication of other non-malignant conditions such as enlargement or infection of the prostate. If the PSA levels are raised, you may be referred to a consultant.

A PSA test is not a particularly reliable test to detect prostate cancer. For example, some men with a high level of PSA in the blood have prostate cancer, but others with prostate cancer have a low PSA level.

If the test reveals you have a raised PSA, you will need to undergo more tests to find out if you have prostate cancer. To see if there are abnormal cells, your doctor will take tissue samples (biopsies) from your prostate gland.

Again, many men with raised PSA levels who have biopsies do not have cancer and those who continue to have raised PSA levels need to keep having biopsies, which can be uncomfortable and repeated biopsies can cause complications in some men (see TRUS below).

Rectal ultrasound: you may need to have a rectal ultrasound so your doctor can see the prostate gland. A small ultrasound device is put into your rectum. Before the test you will need to have emptied your bowels. The ultrasound device produces sound waves to create a clear picture of the prostate gland. The test is uncomfortable, but does not take long. The ultrasound test will show the doctor what your prostate gland looks like and if it is enlarged or shows any abnormalities.

Transrectal ultrasound guided prostate biopsy (TRUS): during a TRUS biopsy, small tissue samples are removed (often under a local anaesthetic) for examination under a microscope. Side-effects of the biopsy can include passing blood in the urine and faeces, which can last for two to three days. Results can take up to two weeks to come back. Examination of the tissue samples will show whether they contain cancer. Even if no cancer if discovered, your doctor may want to keep an eye on your condition with further PSA tests and rectal examinations.

If the biopsy confirms cancer, further tests will help your doctor see the size of the cancer and if it has spread. Tests include a CT scan, MRI scan or bone scan.

How is prostate cancer graded?

If the biopsy shows cancer cells, they will be 'Gleason graded'. The Gleason grade tells the doctor how aggressive the cancer is likely to be and how quickly it may spread.

Gleason grading uses a scale from one to 10:

  • Grade one: tissue looks like normal prostate cells
  • Grade two to four: the cancer cells/ tissue is less likely to spread
  • Grade five to seven: the cells look less like normal prostate cells and are more likely to spread
  • Grade eight to ten: the cancer is more aggressive and most likely to spread

In other words, the lower the grade the closer the malignant cells' appearance and function to normal cells. Two samples of abnormal tissue patterns are usually analysed, and their individual score is added together.

The lowest possible Gleason score is two (where both samples are grade one) and the highest score is ten. Higher Gleason scores would normally indicate that the cancer is more active, but this is not always the case.

How will my prostate cancer be treated?

Treatment options for prostate cancer depend on the grade and stage of the cancer (how aggressive it is and whether it has spread), as well as the patient's age and state of health. It is important to discuss them with your doctor.

Active monitoring or watchful waiting: prostate cancer patients are seen on a regular basis for PSA tests, but no other treatment is prescribed unless their condition deteriorates. Watchful waiting may be used for small, slow-growing non-aggressive cancers in elderly men where the cancer will not shorten their life expectancy.

Prostate surgery: A prostatectomy is an operation where the whole prostate is removed. It is only effective in younger men who have aggressive small cancers that have not spread outside the prostate. A prostatectomy is major surgery with side-effects, including mild-to-severe urinary incontinence, difficulty in obtaining or maintaining an erection and infertility.

Cryosurgery or cryoablation: a minimally invasive procedure that destroys cancer cells by rapidly freezing and thawing cancerous tissue in the prostate gland itself. It is normally used to treat the following:

  • Elderly or other patients who cannot tolerate surgery or radiation
  • Patients with prostate-confined tumours
  • Patients who do not respond to radiation

However, there is an 85 per cent (1) chance that freezing will result in nerve damage and cause erectile dysfunction. However, nerve-preserving techniques are in development that will help reduce this type of risk.

Radiotherapy: can be given either externally - through a machine that focuses X-rays into the body - or internally. Internal radiotherapy for prostate cancer is called brachytherapy and is carried out under a general anaesthetic, or sometimes an epidural (spinal anaesthetic). The surgeon will place small radioactive metal seeds into the tumour within the prostate gland. The seeds release small doses of radiation very slowly over a period of time. The seeds are not removed, but stay in the prostate tissue, while the radioactivity fades away gradually over about a year. The radiation affects only the area a few millimetres around the seeds, so does not damage other internal organs.

Hormone therapy: prostate cancer needs the hormones testosterone and androgens (the hormones produced by the testicles) in order to grow. Hormonal therapies reduce the amount of testosterone and androgens in the body. They can be given as injections or tablets, and occasionally an operation (subcapsular orchidectomy) will be done to remove the part of the testicles that produces testosterone.

There are two main types of hormone drugs that reduce testosterone levels:

  • Anti androgens - stop testosterone produced by your testicles from reaching cancer cells so they don’t grow. Anti-androgenic drug names include bicalutamide and flutamide
  • Pituitary down regulators (PDR) - stop the pituitary gland making the hormone that tells the testes to make testosterone. If the message is blocked then the testes will stop making testosterone. PDR drug names include buserilin, goserelin, histrelin and leuprorelin

You can take each drug singly or take a combination of both. If you take both types of drugs together, you will be on what doctors call complete androgen blockage (CAB) or maximal androgen blockade (MAB) therapy.

CAB or MAB can be used to treat advanced prostate cancer to try to slow the growth or spread of the cancer. If you take both types of drug together, there will be side-effects.

Infolinks:

Refs:

  1. Urology Channel | Prostate Cancer Surgical Treatment, Recovery, Complications, Prevention | Accessed Oct 2009 | Last reviewed Oct 2007

All Dr Foster health content is provided for general information only and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional, or relied upon as a source of comprehensive practitioner material.

All Dr Foster health content has been peer reviewed by GPs and is updated anually when necessary.

Dr Foster is not responsible or liable for any diagnosis made or treatment given by a user based on the content of the supplied health content. Dr Foster is not liable for the contents of any external internet sites listed, nor does it endorse any commercial product or service mentioned or advised on any of the sites.

Always consult your own GP if you are concerned about your health.