Cancer care pathways
For an overview of what to expect during all stages of your cancer care, read or download the What To Expect guide for prostate cancer (also available in Arabic, Chinese, Greek, Hindi, Italian, Tagalog and Vietnamese – see details on the site). The What To Expect guide is a short guide to what is recommended for the best cancer care across Australia, from diagnosis to treatment and beyond.
There is no single, simple test to detect prostate cancer. Two commonly used tests are the PSA blood test by your GP and the digital rectal examination by a urologist. 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 be referred to a urologist for further evaluation.
Health professionals use Australian clinical guidelines to help decide when to use PSA testing and other early tests for prostate cancer. (The Clinical practice guidelines PSA testing ... have been developed by the Prostate Cancer Foundation of Australia and Cancer Council Australia, and have been approved by the National Health and Medical Research Council.)
Prostate specific antigen (PSA) 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. The results are given as nanograms of PSA per millilitre (ng/mL) of blood. The PSA test does not specifically test for cancer.
If the PSA result is higher than the typical range for your age (for example, above 3 ng/mL for people aged 50–59) or is rising quickly, this may indicate the possibility of prostate cancer. But the amount of PSA in the blood can be raised even when you do not have cancer. Other factors that can increase 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.
Because your PSA levels can vary from day to day, your doctor will usually repeat the test to help work out your risk of prostate cancer.
You doctor may suggest other blood tests:
- free PSA or free-to-total test
- prostate health index (PHI).
Free PSA test
This measures the PSA molecules in your blood that are not attached to other blood proteins (free PSA). This test may be suggested if your PSA score is above 3 ng/mL and your doctor is not sure whether you need a biopsy. The free PSA test measures the ratio of free PSA to total PSA. A low level of free PSA compared to total PSA may be a sign of prostate cancer.
Prostate health index (PHI)
This measures three different forms of the PSA protein. PHI is not widely used in Australia and is not covered by Medicare.
Digital rectal examination (DRE)
To do a digital rectal examination (DRE), the doctor slides a finger into your bottom to feel the back of the prostate. They’ll wear gloves and put gel on their finger to make the examination more comfortable. If the specialist feels a hardened area or an odd shape, further tests may be done.
These changes do not always mean you have prostate cancer. On the other hand, a normal DRE does not rule out prostate cancer, as the examination is unlikely to pick up a small cancer or one the finger can’t reach.
A DRE is no longer recommended as a routine test for people who do not have symptoms of prostate cancer, but it may be used to check for any changes in the prostate before doing a biopsy.
An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed pictures of the inside of the body. Your doctor may suggest this scan to help work out if a biopsy is needed. An MRI can be used to show whether the cancer has spread from the prostate to nearby areas. It can also help guide the biopsy needle.
A specialised type of MRI called mpMRI (multi-parametric magnetic resonance imaging) is used for people suspected of having prostate cancer. This combines the results of three MRI images to provide a more detailed image.
Before an MRI scan, a dye may be injected into a vein to make the pictures clearer. You will lie on an examination table that slides into the scanner, a large metal cylinder open at both ends. The scan is painless but can be noisy and may take 30–40 minutes.
There are some things to be aware of when you are going to have an MRI:
- Some people feel claustrophobic in the cylinder. Talk to your doctor or nurse before the scan if you feel anxious in confined spaces.
- The magnet can interfere with some pacemakers but newer pacemakers are MRI-compatible. Let your doctor or nurse know if you have a pacemaker or any other metallic object in your body.
- The dye used can cause allergies. If you have had a reaction to dyes during a previous scan or if you have diabetes or kidney disease, tell your medical team beforehand.
Medicare provides a rebate for MRI scans, but there may be a gap fee. Ask your doctor what you may need to pay.
You may have a biopsy after an MRI scan. Your specialist should explain the risks and benefits of having a prostate biopsy and give you time to decide if you want to have a biopsy.
During a biopsy, small amounts of tissue are taken from the prostate using a special needle. The samples are sent to a laboratory, where a
specialist doctor called a pathologist looks for cancer cells in the tissue.
There are two main types of prostate biopsy:
- In a transperineal (TPUS) biopsy, the needle is inserted through the skin between the anus and the scrotum.
- In a transrectal (TRUS) biopsy the needle is inserted through the rectum.
A transperineal biopsy is more common.
A biopsy can be uncomfortable. After the procedure, there may be a small amount of blood in your wee or poo for a few days, and you may see blood in your semen for a couple of months.
It usually takes one to two weeks for the biopsy results to come back.
If the biopsy results show prostate cancer, other tests may be done to work out whether the cancer has spread. You may also have regular tests to check PSA levels, prostate cancer activity and general health.
This scan can show whether the prostate cancer has spread to your bones.
A tiny amount of radioactive substance will be injected into a vein. You will need to wait for one to two hours while the substance moves through your bloodstream to your bones.
Your whole body will then be scanned with a machine that detects radioactivity. A larger amount of radioactivity will 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-ray beams 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. The dye can cause allergies. If you have had a reaction to dyes during a previous scan or if you have diabetes or kidney disease, tell your medical team beforehand.
You will lie still on a table that moves slowly through the CT scanner, which is shaped like a large doughnut.
The scan itself takes a few minutes and is painless, but the preparation takes 10 to 30 minutes.
A PET (positron emission tomography) scan may help detect cancer that has spread or come back.
A PET scan involves injecting a small amount of a radioactive solution. Cancer cells take up more of this solution and show up more brightly on the scan. For prostate cancer, the scan usually uses gallium to show prostate-specific membrane antantigen (PSMA).
There is no Medicare rebate for PET scans for prostate cancer. Ask your doctor what you may need to pay.
The tests described above help your doctors work out whether you have prostate cancer and whether it has spread. This process is called staging. It helps you and your healthcare team decide which management or treatment option is best for you.
The TNM system
The most common staging system for prostate cancer is the TNM system. This system uses letters and numbers to describe the cancer:
- T is used to show the size of the tumour
- N is used to show whether the cancer has spread to nearby lymph nodes
- M is used to show whether the cancer has spread to the bones or other organs – whether it has metastasised.
The TNM scores are combined to work out the overall stage of the cancer, with higher numbers indicating larger size or spread.
| Staging prostate cancer
||The cancer is contained inside the prostate.
||The cancer is larger and has spread outside the prostate to nearby tissues or nearby organs such as the bladder, rectum or pelvic wall.
||The cancer has spread to distant parts of the body such as the lymph glands or bone. This is called prostate cancer even if the tumour is in a different part of the body.
Grade and risk category
The biopsy results will show the grade of the cancer. This is a score that describes how quickly the cancer may grow or spread.
For many years, the Gleason scoring system has been used to grade the tissue taken during a biopsy. If you have prostate cancer, you’ll have a Gleason score between 6 and 10. A new system has been introduced to replace the Gleason system. 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 stage, grade and your PSA level before the biopsy, localised prostate cancer will be classified as having a low, intermediate or high risk of growing and spreading. This is known as the risk of progression. The risk category helps guide management and treatment.
| Grading prostate cancer
||6 or less
||Low risk. The cancer is slow growing and not aggressive.
||Intermediate risk. The cancer is likely to grow faster and be mildly to moderately aggressive.
||High risk. The cancer is likely to grow quickly and be most aggressive.
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, the type of prostate cancer, the stage, grade and risk category, how well you respond to treatment and 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. Compared with other cancers, prostate cancer has one of the highest five-year survival rates if diagnosed early. Some low-risk prostate cancers grow so slowly that they never cause any symptoms or spread.
What to expect
To help people with prostate cancer receive the best care possible, we have developed an optimal cancer care pathway. View the guide to make sure you get the best care and support at each stage.
- A blood test measures the level of a protein called prostate specific antigen (PSA). A raised PSA level may suggest a problem with your prostate, but not necessarily cancer.
- A digital rectal examination (DRE) is when a doctor slides a gloved finger into your rectum to feel for any hard areas in the prostate.
- An mpMRI scan may help work out if you need a biopsy. It may also help guide the biopsy needle to the abnormal area seen in the prostate.
- If tests show abnormalities, some tissue may be removed from the prostate for examination in a laboratory. This is called a biopsy.
- You may have other tests to check the extent of the prostate cancer, including a bone scan, CT scan or PSMA PET scan.
Staging and prognosis
- The stage shows how far the cancer has spread. The TNM (tumour–nodes–metastasis) system is used to give an overall stage of 1–4. The cancer may also be described as localised (early), locally advanced or advanced (metastatic).
- The grade tells how fast the cancer may grow. Your specialist will describe the grade using the Gleason or ISUP Grade Group score.
- Localised prostate cancer is also categorised as having a low, intermediate or high risk of progression. This risk category helps your health professionals decide on treatment.
- For information about the expected outcome of the disease (prognosis), talk to your specialist.
Expert content reviewers:
Dr Amy Hayden, Radiation Oncologist, Westmead and Blacktown Hospitals, and Chair, Faculty of Radiation Genito-Urinary Group (FROGG), The Royal Australian and New Zealand College of Radiologists, NSW; Prof Shomik Sengupta, Professor of Surgery and Deputy Head, Eastern Health Clinical School, Monash University, and Visiting Urologist and Uro-Oncology Lead, Urology Department, Eastern Health, Victoria; Assoc. Prof. Arun Azad, Medical Oncologist, Urological and Prostate Cancers, Peter MacCallum Cancer Centre, Victoria; Ken Bezant, consumer; Dr Marcus Dreosti, Radiation Oncologist, GenesisCare, and Clinical Strategy Lead, Oncology Australia, SA; Assoc. Prof. Nat Lenzo, Nuclear Physician, Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics and the University of Western Australia, WA; Jessica Medd, Senior Clinical Psychologist, Department of Urology, Concord Repatriation General Hospital, and HeadwayHealth Clinical and Consulting Psychology Services, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council Western Australia; Graham Rees, consumer; Kerry Santoro, Prostate Cancer Specialist Nurse, Southern Adelaide Local Health Network, SA; Assoc. Prof. David Smith, Senior Research Fellow, Cancer Research Division, Cancer Council NSW; Matthew Starr, consumer