There is no simple test to find prostate cancer. Two commonly used tests are the PSA blood test and the digital rectal examination. These tests, used separately or together, only show changes in the prostate. They do not diagnose prostate cancer. If either test shows an abnormality, you will usually have more tests.
Your guide to best cancer care
A lot can happen in a hurry when you’re diagnosed with cancer. The guide to best cancer care for prostate cancer can help you make sense of what should happen. It will help you with what questions to ask your health professionals to make sure you receive the best care at every step.
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Prostate specific antigen (PSA) blood test
Prostate specific antigen (PSA) is a protein made by both normal prostate cells and cancerous prostate cells. PSA is found in the blood and can be measured with a blood test. The test results will show the level of PSA in your blood as nanograms of PSA per millilitre (ng/mL) of blood.
The PSA test may identify fast-growing cancers that can spread to other parts of the body and would benefit from treatment. It may also find slow-growing cancers that are unlikely to be harmful. Some people without any symptoms of prostate cancer do choose to have regular PSA tests.
Before having a PSA test, it is important to talk to your GP about the benefits and risks in your particular circumstances.
Understanding PSA levels
There is not one normal PSA level for everyone. If your PSA level is above 3 ng/mL (called the threshold), this may be a sign of prostate cancer. Younger people or people with a family history of prostate cancer may have a lower threshold.
PSA levels can vary from day to day. If your PSA is higher than expected, your GP will usually repeat the test to help work out your risk of prostate cancer. Your PSA level can be raised even when you don’t have cancer.
Other common causes of raised PSA levels include benign prostate hyperplasia, recent sexual activity, an infection in the prostate, or a recent digital rectal examination. Some people with prostate cancer have normal PSA levels for their age range.
Current guidelines for PSA tests
Health professionals use Australian clinical guidelines to help decide when to use PSA testing and other early tests for prostate cancer. If you choose to have regular PSA tests, the current guidelines recommend that:
- men with no family history of prostate cancer have PSA testing every two years from the ages of 50–69
- men with a family history of prostate cancer have PSA testing every two years starting from age 40–45, depending on how strong the family history is.
Free PSA or free-to-total test
Your doctor may also suggest that you have a free PSA test. This test measures the ratio of free PSA to total PSA in your blood. Free PSA is PSA that is not attached to other blood proteins.
This test may be suggested if your PSA level is between 4–10 ng/mL and your doctor is not sure whether you need a biopsy. A low free-to-total PSA ratio may be a sign of prostate cancer.
Digital rectal examination (DRE)
To do a digital rectal examination (DRE), the urologist places a finger into your rectum to feel the back of the prostate. They’ll wear gloves and put gel on their finger to make the examination more comfortable.
You may have further tests if the specialist feels a hardened area or an odd shape. These changes do not always mean you have prostate cancer. Having a normal DRE also does not rule out prostate cancer, as the finger can’t reach all of the prostate and the examination is unlikely to pick up a small cancer.
A DRE is no longer recommended as a routine test for GPs to do, but a urologist will use it to help assess the prostate and decide if you need further tests.
An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed pictures of the inside of the body. A specialised type of MRI called mpMRI (multiparametric magnetic resonance imaging) is used to help find prostate cancer. It combines the results of three MRI images to provide a more detailed image.
Your doctor may suggest you have an MRI to help work out if a biopsy is needed or to guide the biopsy needle to a specific area of the prostate. This scan can also be used to show if the cancer has spread from the prostate to nearby areas.
Before the scan, let your medical team know if you have a pacemaker or any other metallic object in your body, as well as if you have any allergies, diabetes, kidney disease or have had a reaction to contrast (dye) during previous scans.
Medicare rebates for MRI scans to detect prostate cancer are only available if the MRI is ordered by a specialist and you meet certain conditions. You may have to also pay a gap fee.
From 1 July 2022, PSMA PET–CT scans have been approved for Medicare rebates in certain circumstances for prostate cancer, but sometimes you will still have to pay the full amount. Ask your doctor or imaging centre what you will have to pay. Call 13 11 20 to get financial support to manage the costs of cancer.
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Depending on the results of the MRI scan, your urologist may recommend you have a biopsy to remove some samples of tissue from the prostate. They will explain the risks and benefits of having a prostate biopsy and give you time to decide if you want to have one.
There are two main ways to perform a prostate biopsy:
- a transperineal (TPUS) biopsy – the needle is inserted through the skin between the anus and the scrotum
- a transrectal (TRUS) biopsy – the needle is inserted through the rectum.
During either procedure, the doctor may take a number of samples from different areas of the prostate and also remove a sample from any suspicious areas seen on the MRI. The samples are sent to a laboratory, where a specialist doctor called a pathologist looks for cancer cells in the tissue.
Depending on the type of biopsy you have, after the procedure you may see a small amount of blood in your urine or bowel motions for a few days, and blood in your semen for a couple of months.
If the biopsy results show prostate cancer, other tests may be done to work out whether the cancer has spread.
This scan can show if prostate cancer has spread to your bones. Before the scan, a tiny amount of radioactive dye is injected into a vein. The dye collects in areas of abnormal bone growth. You will need to wait for a few hours while the substance moves through your bloodstream to your bones.
Your body will be scanned with a machine that detects the dye. A larger amount of dye will usually show up in any areas of bone with cancer cells. The scan is painless and the radioactive substance passes from your body in a few hours.
A CT (computerised tomography) scan uses x-rays to create detailed pictures of the inside of the body. A CT scan of the abdomen can show whether cancer has spread to lymph nodes in that area.
A dye is injected into a vein to help make the scan pictures clearer. You will lie still on a table that moves slowly through the CT scanner, which is large and round like a doughnut. The scan itself takes a few minutes and is painless, but the preparation takes 10–30 minutes.
A PET (positron emission tomography) scan combined with a CT scan is a specialised imaging test. A PET–CT scan may help detect cancer that has spread or come back. For prostate cancer, the scan usually looks for a substance produced by prostate cancer cells called prostate specific membrane antigen (PSMA).
Before the scan you will be injected with a small amount of a radioactive solution that makes PSMA show up on the scan. The cost of this scan is not yet covered by Medicare.
Stage, grade and risk category
Working out the stage, grade and risk category of prostate cancer is complex, so ask your doctor to explain how it applies to you. You can also speak to our trusted cancer nurses on 13 11 20 for support.
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Staging prostate cancer
Tests help your doctors work out if you have prostate cancer and whether it has spread. This is called staging. It helps you and your health care team decide which management or treatment option is best for you.
The most common staging system for prostate cancer is the TNM (Tumour-Nodes-Metastasis) system. In this system, letters and numbers are used to describe the cancer, with higher numbers indicating larger size or spread.
Your doctor may also describe the cancer as:
- localised (early) – the cancer is contained inside the prostate
- locally advanced – the cancer is larger and has spread outside the prostate to nearby tissues or nearby organs such as the bladder, rectum or pelvic wall
- advanced (metastatic) – the cancer has spread to distant parts of the body such as the lymph nodes or bone. This is called prostate cancer even if the tumour is in a different part of the body.
Grading prostate cancer
The biopsy results will show the grade of the cancer. Grading describes how the cancer cells look under a microscope compared to normal cells.
For many years, the Gleason scoring system has been used to grade the tissue taken during a biopsy. If you have prostate cancer, you will have a Gleason score between 6 (slightly abnormal) and 10 (more abnormal).
A newer system has been introduced to simplify the grading and make it easier to understand. Known as the International Society of Urological Pathologists (ISUP) Grade Group system, this grades prostate cancer from 1 (least aggressive) to 5 (most aggressive).
Risk of progression
Based on the size and grade of the tumour, and your PSA level before the biopsy, localised prostate cancer will be classified as:
- low risk – the cancer is slow growing and not aggressive. Gleason score is 6 or less, ISUP Grade Group is 1.
- intermediate risk – the cancer is likely to grow faster and be mildly to moderately aggressive. Gleason score is 7, ISUP Grade Group is 2-3.
- high risk – the cancer is likely to grow quickly and be more aggressive. Gleason score is 8-10, ISUP Grade Group is 4-5.
This is known as the risk of progression. The risk category helps guide management and treatment.
Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease. To work out your prognosis, your doctor will consider:
- test results
- type of prostate cancer
- the stage, grade and risk category
- how well you respond to treatment
- factors such as your age, fitness and medical history.
Prostate cancer often grows slowly, and even the more aggressive cases of prostate cancer tend to grow more slowly than other types of cancer. Some low-risk prostate cancers grow so slowly that they never cause any symptoms or spread, others don’t grow at all.
Compared with other cancers, prostate cancer has one of the highest five-year survival rates if diagnosed early.
Expert content reviewers:
A/Prof Ian Vela, Urologic Oncologist, Princess Alexandra Hospital, Queensland University of Technology, and Urocology, QLD; A/Prof Arun Azad, Medical Oncologist, Urological Cancers, Peter MacCallum Cancer Centre, VIC; A/Prof Nicholas Brook, Consultant Urological Surgeon, Royal Adelaide Hospital and A/Prof Surgery, The University of Adelaide, SA; Peter Greaves, Consumer; Graham Henry, Consumer; Clin Prof Nat Lenzo, Nuclear Physician and Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics, and Notre Dame University Australia, WA; Henry McGregor, Men’s Health Physiotherapist, Adelaide Men’s Health Physio, SA; Jessica Medd, Senior Clinical Psychologist, Department of Urology, Concord Repatriation General Hospital, NSW; Dr Tom Shakespeare, Director, Radiation Oncology, Coffs Harbour, Port Macquarie and Lismore Public Hospitals, NSW; A/Prof David Smith, Senior Research Fellow, Daffodil Centre, Cancer Council NSW; Allison Turner, Prostate Cancer Specialist Nurse (PCFA), Canberra Region Cancer Centre, Canberra Hospital, ACT; Maria Veale, 13 11 20 Consultant, Cancer Council QLD; Michael Walkden, Consumer; Prof Scott Williams, Radiation Oncology Lead, Urology Tumour Stream, Peter MacCallum Cancer Centre, and Professor of Oncology, Sir Peter MacCallum Department of Oncology, The University of Melbourne, VIC.
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The information on this webpage was adapted from Understanding Prostate Cancer - A guide for people with cancer, their families and friends (2022 edition). This webpage was last updated in May 2022.