Diagnosing prostate cancer

Friday 1 November, 2013

Download PDF Order FREE booklet

On this page:  Prostate specific antigen blood testDigital rectal examinationBiopsyFurther testsGrading prostate cancerStaging prostate cancerPrognosisWhich health professionals will I see?Key points


Your doctor will confirm the diagnosis with a number of tests. You may have some or all of the following tests.

Prostate specific antigen blood test

Prostate specific antigen (PSA) is a protein made by both normal prostate cells and cancerous prostate cells. PSA levels are measured using a blood test. Because PSA levels can be variable, it is common for your doctor to use results from more than one blood test, over time, to help determine your risk of prostate cancer.

Some men with prostate cancer have normal PSA levels, and only one in three men with an elevated PSA level has cancer. Other factors can also increase PSA levels in your blood, including benign prostate enlargement (a non-cancerous condition), recent sexual activity or an infection in the prostate. As it is not a definitive test, a PSA test is normally used with other tests to diagnose prostate cancer.

Digital rectal examination

The digital rectal examination (DRE) is also used to look for prostate cancer and is often performed at the same time as a PSA test. DRE involves a doctor inserting a gloved finger into your rectum to feel the back of the prostate gland. If your doctor feels a hardened area or an odd shape, further tests will be done. The DRE may be uncomfortable but is rarely painful. It is unlikely to pick up a small cancer or one the finger can’t reach. Doing this test together with a PSA test improves the chance of finding early cancer.

Biopsy

A biopsy is when small pieces of tissue are removed from the prostate for examination under a microscope. It is usually done if the PSA test or DRE show abnormalities. The biopsy determines if you have prostate cancer, how much cancer is in the prostate (the volume) and how fast the cancer might grow (the grade).

A biopsy is done with the help of an ulstrasound. A probe called a transrectal ultrasound (TRUS) is inserted into the rectum. The TRUS is about the size of a thumb. It shows the shape and texture of the prostate on a screen. The ultrasound picture helps guide the doctor to insert a small needle from the probe through the rectum into the prostate.

The needle can also be passed through the skin between the anus and the scrotum instead of the rectum (transperineal biopsy). Some studies have shown that this method may allow better sampling of the whole prostate and may reduce the risk of infection.

About 12–18 samples are taken from different parts of the prostate. Most biopsies are done with some form of anaesthetic. It may be uncomfortable and there may be some bleeding. You will be given antibiotics to reduce the possibility of infection. Tell your doctor, before your biopsy, if you are taking any medications, including herbal medicines, as they may interfere with other medications used during your treatment.

Tell your doctor, before your biopsy, if you are taking any medications, including herbal medicines, as they may interfere with other medications used during your treatment.

New diagnosic tests

Tests are emerging to help better identify men who are more likely to have an aggressive underlying prostate cancer. These include blood tests such as the PHI (prostate health index) test, and urine tests such as PCA3. These tests are available in Australia but at the time of publication, are not reimbursed by Medicare. Ask your doctor for more information.

Further tests

If the biopsy shows you have prostate cancer, other tests may be done to work out the stage of the cancer.

Blood tests

Blood samples may be taken regularly to monitor your PSA level, check your general health and see if the prostate cancer has spread.

Bone scan

This scan can show whether the cancer has spread to your bones. A small amount of radioactive material (called technetium) is injected into a vein. Technetium is attracted to newly growing bone cells, which may indicate cancer spread. After 1–2 hours, you will have a body scan. This painless scan will show where the technetium is. It will not make you radioactive.

A bone scan rarely shows cancer spread when the PSA level is less than 20, so doctors may not recommend this test for men with low PSA levels.

MRI scan

The magnetic resonance imaging (MRI) scan uses radio waves and magnetism to build up detailed cross-section pictures of the body. The scan involves lying on an examination table inside a metal cylinder – a large magnet – that is open at both ends. The MRI is sometimes performed using a probe inserted into the rectum.

An MRI can help to see if the cancer is contained within the prostate or if it has spread locally outside the prostate gland. This can help with management and treatment decisions.

CT scan

The CT (computerised tomography) scan uses x-ray beams to take pictures of the inside of your body and can show if cancer has spread to lymph nodes in the pelvis and abdomen.

A dye is injected into a vein, probably in your arm, to help make the scan pictures clearer. This may make you feel hot all over for a few minutes. You will then lie flat on a table that moves in and out of the CT scanner, which is large and round like a doughnut. The test is painless and takes about 10–30 minutes. You may feel slightly confined in the small space while the pictures are being taken. Most men are able to go home when their scan is done.

The dye injected into your vein for a CT or MRI scan, called a contrast solution, may contain iodine. If you are allergic to iodine, fish or dyes, let the person performing the scan know in advance.

Grading prostate cancer

Prostate cancer is given a grade indicating how fast the cancer may grow. A system called the Gleason score is used for grading the tissue taken during a biopsy.

The pathologist obtains the score by giving the two most common tissue types a grade out of 5. These two grades are added together to get a final score out of 10. Most men with prostate cancer will have a Gleason score between 6 and 10.

Gleason score
low score (6) indicates a slow-growing, less aggressive cancer
intermediate score (7) indicates a faster-growing and moderately aggressive cancer
higher score (8-10) indicates a fast-growing, aggressive cancer

Your doctor will also consider how much cancer there is (its volume). For example, if you have one small cancerous spot, your doctor would consider this a low-volume cancer. If you have a low-volume, low-grade cancer, you might choose to have less aggressive management or treatment such as active surveillance.

Staging prostate cancer

Staging means how far cancer has spread, it may be described as one of the following:

  • Localised – the cancer is small and is contained within the prostate gland.
  • Locally advanced – the cancer is larger and has spread outside the prostate to the pelvic region, for example the seminal vesicles, lymph or bladder.
  • Advanced – the cancer has spread beyond the prostate into adjacent organs, such as the bladder, rectum and pelvic wall or to distant areas such as the lymph glands or bones.

The TNM system is used to stage prostate cancer. Each letter is assigned a number that shows how advanced the cancer is. The lower the number, the less advanced the cancer.

TNM system
T (Tumour) 1–4 Refers to the stage of the primary tumour. The higher the number, the less likely the cancer is only contained to the prostate gland.
N (Nodes) 0–3 Shows if the cancer has spread to the regional lymph nodes near the bladder. No nodes affected is 0; increasing node involvement is 1, 2 or 3.
M (Metastasis) 0–1 Cancer has either spread (metastasised) to the bones or other organs (1) or it hasn’t (0).

This information is combined to describe the stage of the cancer from stage 1 to stage 4. Ask your doctor for the exact grade and stage and to explain your test results to you as these can help determine which management or treatment you choose. You can also call Cancer Council on 13 11 20 for more information about staging prostate cancer.

Prognosis

Prognosis means the expected outcome of a disease. You may need to discuss your prognosis with your doctor, but it is not possible for any doctor to predict the exact course of your disease.

Your doctor will consider your test results, the rate and depth of tumour growth and other factors such as your age, fitness and medical history. These factors will also help your doctor give you advice on the best management or treatment options and let you know what to expect.

Prostate cancer usually grows slowly, even fast-growing prostate cancer grows slower than other types of cancer. This means that for many men, the prognosis will be favourable and generally there will be no urgency for treatment.

Most men with prostate cancer usually return to normal or near normal good health after treatment.

Which health professionals will I see?

If your GP suspects that you have prostate cancer (usually based on an abnormal PSA test result or an examination), you may be referred to a urologist. This is a surgeon who specialises in treating and managing diseases of the urinary and reproductive systems.

Health professionals in your MDT
general practitioner (GP)  monitors cancer activity (PSA levels), administers hormone treatment and promotes overall wellbeing  
urologist specialises in treating diseases of the urinary system and male reproductive system
radiation oncologist prescribes and coordinates course/s of radiotherapy
medical oncologist prescribes and coordinates chemotherapy in advanced cases
oncology nurses administer treatments and support and assist you through all stages of your management and/or treatment
cancer nurse coordinator supports patients throughout treatment and liaises with other care providers


The urologist can arrange further tests and advise you about your management or treatment options. Following a diagnosis of prostate cancer, you will be cared for by a range of professionals who specialise in different aspects of your treatment. This multidisciplinary team (MDT) may include:

 
urology care coordinator supports patients that are experiencing bladder and bowel problems after cancer treatment 
continence nurses specialise in helping you manage continence (urinary and bowel) issues
sexual health physician or sex therapist can help you and your partner with sexuality issues before and after treatment
continence physiotherapist provides exercises to help rehabilitate your pelvic floor muscles and improve continence
social worker, occupational therapist, counsellor, psychologist advise you on support services, helps you to get back to normal activities and provide emotional support
dietitian recommends an eating plan to follow while you’re in treatment and recovery

Key points

  • Routine prostate cancer screening is not always advised. A decision to assess your risk of prostate cancer is made after talking with your GP or specialist about the benefits and risks of testing for your individual circumstances.
  • Your doctor may test the level of a protein called prostate specific antigen (PSA) in your blood. Some men with prostate cancer have a higher PSA level, but some do not.
  • The specialist or GP may do a digital rectal examination (DRE). The doctor will insert a gloved finger into your rectum to feel the prostate gland.
  • If a PSA or DRE show abnormalities, some tissue may be removed from the prostate for examination. This is called a biopsy.
  • You may have other tests to determine how much prostate cancer there is. Some men will have a bone scan, MRI scan or CT scan.
  • Diagnostic tests will provide information about the grade and volume of the cancer. The volume is how much cancer is in the prostate. The grade tells how fast the cancer may grow. Your doctor may describe the grade using a number called the Gleason score.
  • A specialist doctor such as a urologist will also assign a stage to the cancer. This describes how advanced the cancer is. The TNM (Tumour, Nodes, Metastasis) system is used for staging. The cancer may also be staged as localised, locally advanced or advanced.
  • Your doctor may talk to you about the expected outcome of the disease, called your prognosis. In most cases, prostate cancer can be cured or controlled for many years.

Reviewed by: A/Prof Declan Murphy, Director of Robotic Surgery, Peter MacCallum Cancer Centre, VIC; Tony Davison, Consumer; Peter Dornan, Consumer; Duane Duncan, Australian Research Centre in Sex, Health and Society (ARCSHS), La Trobe University, VIC; Dr Farshad Foroudi, Radiation Oncologist; Peter MacCallum Cancer Centre, VIC; Virginia Ip, Urology Care Coordinator, Sydney Cancer Centre, Royal Prince Alfred Hospital, NSW; Judy Jeffery, Cancer Connect, Cancer Council NSW; David Smith, Research Fellow, Cancer Council NSW; and Robyn Tucker, Cancer Council Helpine, VIC.
Updated: 01 Nov, 2013