Prostate Cancer Treatment Decision Tree

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Engaging in Your Prostate Cancer Care Resource Guide

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Prostate Imaging

This resource was originally published by the Prostate Cancer Research Institute here.


“So your PSA number came back high. What now?”

Let’s say, like many men,  you’ve been getting your PSA checked every year as part of your routine checkup. In the past it has always hovered around 2 or maybe as high as 3.0, and suddenly it’s up to 5! Or maybe this is your first PSA test. Everyone knows that 4.0 is the magic number, anything above that means something is not right with your prostate. Right? Actually, it’s a lot more complicated than that, but for this video we’ll take that as a given. OK, so the number is high, what do you do? Well, if you’re like many men your first instinct might be something like this…

“Aaaah,  I’ve got prostate cancer! Cut the *****ing thing out”!

Unfortunately, there are a bunch of people in the medical community that will support and even encourage that instinct. It’s the wrong instinct.


Slow down.

Take a deep breath.

Now just to be clear, this video is not advocating any sort of wonder-cure and we’re not downplaying how serious prostate cancer can be. Everything we’ll talk about here is backed up by good science, the latest technology, and highly trained medical professionals.

Let’s stop and talk for a second about the prostate. No offense to our creator, or to evolution or whatever you believe about human origins, but you couldn’t find a worse place to situate an organ, especially one that can be prone to problems. It’s…”down there”. And it’s in the middle of everything “down there”. Your urethra, that tube that carries urine out from the bladder, runs right through it… as do a couple of nerve bundles that control your ability to get and maintain an erection. And its located right in there close to the rectum. So, right in the middle of three really important systems.

OK. Back to your story. You’ve got the high PSA number. What’s likely to happen now?

Your general practitioner is probably going to want to refer you to a urologist. The urologist is almost certainly going to want to perform a needle biopsy and usually right away. It’s cancer! There’s urgency! Right?  Ummm. Not really. But we’ll get to that in a future video. For now, just know that for the overwhelming majority of men prostate cancer is very slow growing. You have time.

Here’s your first step in taking control. That’s what this is all about. Taking control of your own healthcare.

Unless your PSA number is crazy high (above 20 for example) or your GP has felt that something is wrong during the Digital Rectal Exam or DRE (that’s the finger up your butt exam that we all adore), you need to tell him or her that you want another PSA test. You see, that test measures a substance in the blood that the prostate gives off when it’s aggravated, and it can be aggravated by quite a few things other than cancer. Sexual activity, inflammation, certain types of heavy lifting, even riding a bike. So you’ll want to wait a few weeks, take it easy for the last few days, refrain from sex for 48 hours (you can do it), and retake the test. If your number has gone back down to near its normal level, you’re done for now. Just make sure to keep getting those yearly PSA tests and DREs.

If it remains high, then its time to move to the next step. Biopsy, right?

Nope. Not if you can help it.

The random needle biopsy, as it’s called, involves sticking a rather large needle into the area just in front of the rectum 12 times to remove samples, called cores, from different areas of the prostate.

It sounds horrible but, to be honest, it’s not terribly painful and it’s usually over in 10 or 15 minutes. A visit to the dental hygienist is probably just as uncomfortable. But it is invasive. Three percent of the men undergoing needle biopsies get infections, some of which are very serious. More importantly though, is the fact that the random needle biopsy is not very accurate. It can miss serious cancer or it can pick up low level, non-aggressive cancers that really don’t require treatment. (We’ll talk about the types of prostate cancer in a future video.)

The doctors who use the random needle biopsies don’t do it because they are mean or ignorant…maybe just a little slow to change. Until the last couple of years the needle biopsy was the best diagnostic tool that we had. Recent advances in MRI imaging have changed everything. The latest generation of MRI machines called 3 Tesla, or 3T machines, scan at a much higher resolution than the earlier machines. They enable radiologists to see all but the tiniest tumors. The tumors that they can’t see almost certainly don’t matter.

What improvements in imaging mean is that biopsies, when they are needed, can be targeted, right to the suspicious area in the prostate. No more random poking.

So, to summarize. If your PSA number comes back high:

Schedule a second PSA test.
Start doing some research. A good place to start is
If the number is still high after that test, find an MRI center that does “Multi-parametric” testing using a 3T scanner. The MRI report will provide two types of important information:

The MRI measures the size of the prostate. The scan report will enable you to determine if your PSA elevation is proportionate to your prostate size. We’ll talk about this more in a future video. As regards cancer,  there are three possible outcomes:

No high-grade cancer. Further monitoring without biopsy is OK.
A high-grade lesion is detected.  Targeted biopsy is needed.
An ambiguous area is detected.  Another MRI in 6 months may be appropriate.

Scanning the prostate in men with PSA elevation is a brand new approach that is more reliable than the old-fashioned method of using 12 random needle sticks. However, this claim is only accurate when using the very latest state-of-the-art MRI technology at approved centers. This technology is so new that finding doctors willing to abandon the old random needle biopsy approach is still a major challenge.  Even so, there is a big payoff, being able to bypass those needles, those infections, and the inaccuracy is worth it.

Screening for Prostate Cancer

This resource was originally published by the Prostate Cancer Foundation here.

Screening for Prostate Cancer

Cancer is a frightening possibility, but today’s medical technology has put some powerful screening tools in our hands, and we know: early detection saves lives. The earlier you find out about cancer, the greater the likelihood that it can be successfully treated. Prostate cancer, in particular, is almost 99% treatable if detected early.

So when do you start screening for prostate cancer? Most guidelines recommend that men practice joint decision-making with their physician to make a screening plan, based on evaluation of multiple risk factors. Over time, as researchers have learned more about the factors that affect your chance of getting prostate cancer, recommendations for when to start screening have started to skew earlier. It’s important for you to take the lead in having a candid discussion with your doctor about your risk factors for prostate cancer.

The following questions can help you decide when to begin this conversation with your doctor.

Do you have a family history of prostate, ovarian, breast, colon, or pancreatic cancers among your male and female relatives? Some families share genetic mutations that make the development of certain cancers more likely. If you know or suspect this is true of your family, begin to discuss screening starting at about 40 years of ageLearn more about genetic factors that affect your risk of developing prostate cancer.

Are you African American? African American men have a greater risk of developing prostate cancer, and of developing aggressive disease, possibly due to as-yet-unknown genetic and socioeconomic factors; unraveling this mystery is an active area of research for the Prostate Cancer Foundation. The National Comprehensive Cancer Network guidelines recommend that you begin joint decision-making with your doctor starting at 40 years of age.

How old are you? The risk of developing prostate cancer in men who do not have other risk factors increases with age. If you don’t have any other risk factors, ask your doctor about screening starting at age 45..

Once you are over about 70 years of age, the US Preventive Services Task Force recommends you stop screening, with the rationale that the potential benefits do not outweigh the harms. Why? Many cases of prostate cancer are very slow-growing, and treatments can be taxing. Statistically, older men are more likely to die of other causes, even when they have prostate cancer. However, if you are a healthy man over 70, the Prostate Cancer Foundation recommends that you continue to discuss screening with your doctor. The decision about whether to screen past age 70 should be made on an individual basis.

The bottom line is that it is never hurts to talk with your doctor about screening. The ultimate goal is to catch active cancer early so it can be successfully treated, to give you the longest, healthiest life possible.

More about genetic factors and their influence on your risk

Genetic screening (called germline genetic testing) can offer powerful insight into your individual risk of developing cancer. Much of the newest research into cancer genetics has focused on identifying germline (ie, inherited) mutations that are positively associated with the development of various types of cancer.

If you have any of the following risk factors, you should discuss them with your doctor and consider genetic screening.

  • A personal history of metastatic prostate cancer
  • A blood relative with a known cancer risk gene mutation, such as a BRCA1/2 mutation or Lynch syndrome
  • Two or more family members with prostate cancer with a Gleason score ≥7
  • One male relative with metastatic prostate cancer and/or one who died of prostate cancer
  • Three or more family members on the same side of the family, with one or more of the following cancers:
    • Breast cancer
    • Ovarian cancer
    • Pancreatic cancer
    • Colon cancer
    • Other cancers, eg, melanoma

If germline genetic screening reveals that you or a member of your family have one of these critical mutations, your genetic counselor may suggest “cascade” screening. This is when many members of a family are screened to determine who else may have the mutation. With more information at hand, each member of the family can better understand their particular cancer risk, options for early detection, and how to reduce their risk for various other forms of cancer. The information you learn could save the lives of your brothers and sisters, parents—and your children.

Prostate Cancer Diagnosis: What’s Involved

This resource was originally published by Everyday Health by Laura Newman, here.

Last Updated: 6/28/2018
A variety of tests are used to help make the diagnosis.
Getty Images

Symptoms are uncommon with early-stage prostate cancer. The majority of men start the diagnostic process for prostate cancer before they become symptomatic. There are several potential tests that may be involved.

Among the most common are:

A Prostate-Specific Antigen (PSA) Test

The prostate-specific antigen (PSA) test is a blood test that may be offered to you as routine screening in the context of a checkup by a primary care physician or urologist.

But using the test for routine screening is controversial. Elevated results on a PSA test may occur for reasons other than cancer, such as an enlarged prostate, benign prostatic hyperplasia (BPH), or an infection in the prostate called prostatitis. Men who receive an elevated result may be referred for further testing. For this reason, the test should only be done after an informed conversation between doctor and patient takes place.

The American Cancer Society uses these parameters to evaluate PSA results:

  • A PSA test result below 4 nanograms per milliliter (ng/ml) means that 85 percent of the time, you won’t have prostate cancer.
  • A PSA between 4 and 10 is associated with a 1 in 4 chance of having prostate cancer.
  • If your PSA is greater than 10, you have a 1 in 2 chance of having prostate cancer.

But doctors have not adopted a uniform system for interpreting PSA. Thresholds for concern and reference ranges vary considerably. (1)

If your PSA test results are elevated you will likely be advised to have more tests.

A Digital Rectal Exam (DRE)

A digital rectal exam (DRE) is a physical exam of your prostate gland administered by a physician in the context of a general checkup or in response to symptoms suggestive of an issue with the prostate gland. During a DRE, a physician places a gloved finger into the rectum and checks for asymmetric areas or nodules and irregularities in the size, shape and texture of the prostate gland, and it may also be used to look for signs suggestive of prostate cancer.

Like the PSA test, suspicious findings on a DRE do not necessarily mean that you have prostate cancer. Rather, the results are considered in combination with PSA test results and symptoms a patient may have.

Concerns have mounted recently about primary care doctors’ ability to use the DRE effectively. A recent study published in the March–April issue of the Annals of Family Medicine found that only one-half of surveyed primary care doctors feel comfortable performing DREs. In fact, the authors of that study recommended against primary care doctors performing them. (2)

Transrectal Ultrasound and Real-Time Biopsy

If you receive an elevated PSA result or have suspicious findings on a DRE, your physician might recommend that you undergo a prostate biopsy. The most common test used for this is a transrectal ultrasound (TRUS), in which an ultrasound probe is inserted into the rectum and sound waves are used to create an image of the prostate gland.

During the ultrasound, biopsy samples are often collected from several areas of the prostate with a hollow needle. This is referred to as a real-time biopsy or a transrectal prostate biopsy. The biopsy samples are then analyzed in a pathology laboratory to see if cancer cells are present.

Important benefits of combining the two procedures include:

  • The ability to better target suspicious areas of high-grade (aggressive areas) and clinically significant tumors.
  • Helping to avoid false-positive diagnoses and overdiagnosis or sampling areas unlikely to contain cancer or aggressive cancer.
  • Getting a high-quality biopsy. (3)

MRI Ultrasound Targeted Prostate Biopsy

Magnetic resonance imaging (MRI) guided biopsies are also being used more frequently, with ultrasound or alone, to help guide a prostate biopsy. MRI scans are capable of revealing potentially cancerous areas in more detail than ultrasound.

Studies have emerged suggesting that fusing the two techniques — using MRI to identify suspicious areas before the transrectal ultrasound and biopsy procedure — might identify cancer more accurately than a TRUS biopsy alone. For example, a landmark study led by researchers at the National Cancer Institute’s urologic oncology branch found that the MRI-fused ultrasound technique detected more aggressive prostate cancer and fewer low-risk prostate cancers.

A joint statement issued by the American Urological Association and Society of Abdominal Radiologists supports fused MRI-ultrasound for men on active surveillance — men who, along with their doctors, have opted to watch a slow-growing cancer rather than treat it aggressively — and for men who have received elevated PSA test result but whose previous biopsies have tested negative for cancer. (4)

Preparing for Your Prostate Biopsy

To prepare you for the test, your urologist should tell you about the risks and benefits of having a biopsy. The most common complications following a prostate biopsy are having blood in the urine, rectum, or semen, a urinary tract infection, and acute urinary retention. These side effects usually pass quickly. Less commonly, erectile dysfunction occurs.

After this discussion with your doctor, you will be asked to sign a consent form. You may also be asked to discontinue some medications, such as anticoagulants, nonsteroidal anti-inflammatory drugs, herbal supplements, and vitamins for one to several days. On the night before the biopsy is scheduled, your doctor may ask you to do an enema at home. Eating lightly the day before is often recommended. You also may be asked to take an antibiotic the day before or on the day of the biopsy. (5)

When you come in for the procedure, you will be asked to lie still on your side with your knees bent. The doctor will insert a small finger-size ultrasound probe into your rectum. The probe lets the doctor see images of your prostate gland and helps determine where to inject a local anesthetic. The images the doctor sees also help guide the biopsy needle. Your doctor will take 10 to 18 tissue samples from the prostate gland, which will then be sent to a pathology lab. The entire procedure takes about 10 minutes. Your doctor will contact you with results usually within about a week.

After the procedure, your rectum may feel sore. You may see small amounts of blood in your stool, urine, or semen that last for several days or weeks. Antibiotics might be prescribed for several days to prevent infection.

Making Sense of Prostate Biopsy Results

If your biopsy reveals that some cells look abnormal, but may or may not be cancer, your doctor might recommend another biopsy. If your biopsy comes back positive, it means cancer cells were detected.

Your pathology report will include:

  • A Gleason score, which helps doctors predict how fast-growing the prostate cancer is
  • The number of biopsy samples that contain cancer out of the total number sampled
  • A diagnosis of each core or biopsy sample
  • The percentage of cancer in each sample
  • Whether the cancer is on one or both sides of the prostate gland (6)

Understanding Your Gleason Score

Your Gleason score is the sum of various “grades” the pathologist has given samples taken from the prostate gland. The more aggressive the cancer looks, the higher the grade. The lowest Gleason score you can receive for prostate cancer is a 6. These cancers are considered low-grade and unlikely to be aggressive. A Gleason score of 8 to 10 is more aggressive and more likely to grow and spread quickly. A cancer with a Gleason score of 9 to 10 is likely to be even more aggressive. (6)