Prostate Cancer Diagnosis

Prostate cancer in its curable state shows no symptoms. There are no abnormalities of urination, no bleeding, no weight loss, or pain. It is only when it becomes symptomatic and in an advanced state that it may become incurable. That’s why it is so important to detect the disease as early as possible.

At Premier Urology, prostate cancer is diagnosed by utilizing five methods:

1. Medical History – This includes analysis of general health, presence or absence of chronic diseases such as diabetes, hypertension, allergies, and high cholesterol. We look at his environmental history in exposure to toxins, his dietary history, and current medications. We conduct generalized review of body systems, previous surgeries, and a urinary history of previous conditions such as prostate trouble, bladder diseases, kidney diseases, and other cancers.

2. Family History – This is extremely important. If first-degree relatives including parents, grandparents, uncles, and cousins have been diagnosed with prostate cancer, then a person may be genetically predisposed to having prostate cancer. A man with a positive family history should begin screening for prostate cancer at age 40. African-American males regardless of family history should also begin screening at age 40.

3. Physical Examination – A general physical examination is mandatory where specifically, a Digital Rectal Exam (DRE) should be performed. This is carried out by by placing a finger in the rectum and palpating the prostate through the rectal wall. Specifically one looks for the presence or absence of tale-tell nodules. An experienced urologist can differentiate between benign and malignant nodules.

4. PSA Test – PSA is a protein made of 6 amino acids secreted by the glandular cells of the prostate. The reason why PSA is elevated in prostate cancer is because prostate cancers contain more glandular cells than a benign gland. Since PSA is produced in equal amounts by both benign and malignant prostate cells,it follows that overall PSA level will be high in prostate cancer because of its increased cellularity. PSA determination should be carried out on an annual basis. If the PSA is greater than 1.0, then PSA tests should be administered every year. If the PSA is less than 1.0, it should be repeated every two years. PSA test is derived from by a simple blood draw. It is important there is no evidence of a urinary tract infection at the time of the PSA test. Urinary or prostate infection will falsely elevate the PSA.

Currently a PSA of 2.5 is benchmark for diagnosing prostate. This is the same PSA level that is the standard for benign prostatic enlargement (BPH). The difference between PSA behavior in prostate cancer and BPH is that because PSA in prostate cancer tends to rise on a regular basis because of the increasing number of prostate cancer cells in an untreated tumor. This phenomenon is called PSA acceleration. In BPH the PSA score remains stable and does not increase at a high rate.

Another PSA factor that is taken into account is the Free PSA ratio. Free measures the PSA circulating freely in the bloodstream vs. PSA attached to serum proteins. In BPH the Free PSA ratio is 25% or greater. In prostate cancer it is often significantly lower.

5. Target Scan Biopsy – A biopsy is precipitated by a clinical the suspicion of a prostate cancer nodule. This impression may be influenced by a DRE which reveals an abnormal feeling prostate, an accelerating PSA. or a low Free PSA. In nearly 40% of all cases where a DRE or PSA was diagnosed as abnormal, a biopsy confirms the presence of prostate cancer.

Conventional biopsies using standard transrectal ultrasound guidance leads to a lower positivity rate. TargetScans are performed using a 3-dimensional ultrasound image of the prostate employing stereotactic methods to biopsy the prostate more thoroughly at computer-determined locations. Thus the TargetScan provides a comprehensive saturation biopsy platform which results in finding cancers that may be missed by using conventional methods.

TargetScan is performed very comfortably using a local anesthesia, which is injected directly into the prostatic nerves, thereby eliminating any pain. Twelve distinct zones of the prostate are identified. The more areas that are found to be cancerous, the greater the concern.

Biopsy Outcomes:

1) Benign Prostatic Hypertrophy – This is the normal benign tissue that makes up the prostate. This finding requires no further evaluation until the next examination.

2) Prostatic Intraepithelial Neoplasm (PIN) – This is a finding that is not cancerous. It can coexist with cancer and some urologists believe that it predisposes to cancer. A recent study reveal that a single focus of PIN has a zero predictive value for the development of cancer. The finding of multiple areas of PIN in a 12-zone biopsy increases the likelihood that prostate cancer will be found in subsequent biopsies over a six-year period.

3) Prostate Cancer – The discovery of prostate cancer in a 12-zone biopsy requires a degree of analysis. It is important to determine the degree of malignancy i.e. the Gleason Grade and the Gleason Score.

In the case of prostate cancer, a Gleason Grade of 1-to-5 is assigned to each area of the biopsy that shows cancer. 1 is the least malignant looking and 5 is the most. The two most prominent grades are added resulting in a Gleason Score between 2 and 10 that correlates to a significant degree of the prognosis with a low score being better than a high score.

The Gleason Score, the volume of tumor, and the extent of tumor throughout the 12 zones of the prostate will predict the type of treatment.