When should you be screened for prostate cancer?

Prostate cancer diagnosis may involve PSA tests, digital rectal exams, and biopsies.

Prostate cancer diagnosis may involve PSA tests, digital rectal exams, and biopsies.

Prostate cancer is one of the most common killers of men – it’s the second leading cause of cancer deaths among men in America. It’s largely a disease of men over 40, so it’s around this age doctors recommend the first prostate screening.

Age, ethnicity, family history, nationality, genetic factors, and obesity are all risk factors for prostate cancer, and any one of these is a reason to get checked. The good news is the prognosis for prostate cancer, depending on the stage at which it’s diagnosed, is good compared with some other cancers. Because the condition is so common, there’s a large set of data on what treatments are effective and lots of support for men with the disease

The prostate is a walnut-sized gland in men that wraps around the urethra below the bladder and produces the fluid portion of semen. Early signs of a cancerous prostate are blood in the urine and/or semen and pain or inability to urinate or ejaculate. Prostate cancer commonly metastasizes to lymph nodes in the pelvis and to the bones.

The best treatment results come when prostate cancer is diagnosed early.

The first screening exam is a blood test to determine if there are abnormal Prostate specific antigen (PSA) levels in your blood – PSA is a specific protein produced by the prostate. If the PSA is high, your doctor or specialist will perform a digital rectal exam, during which the doctor feels your prostate from inside your rectum with a gloved finger. Though it’s uncomfortable, a digital rectal exam may be far less uncomfortable and painful than the end result of prostate cancer left undiagnosed.

If the results of the PSA test and rectal exam show abnormalities, your doctor may refer you to a urologist for a biopsy, and you will make treatment decisions with your doctor based on the biopsy results.

This article will discuss this diagnostic process in detail, as well as the how prostate cancer is classified by type (i.e. the Gleason score).

What tests do health care professionals use to diagnose prostate cancer?

The diagnosis of prostate cancer ultimately is based on the pathologist’s review of tissue removed at the time of the prostate biopsy. An abnormal PSA and/or abnormal digital rectal examination often are present and are the indications for the prostate biopsy.

Digital rectal examination (DRE): As part of a physical examination, your doctor inserts a gloved and lubricated finger into your rectum and feels toward the front of your body. The prostate gland is a walnut or larger sized gland immediately in front of the rectum, and beneath your bladder. The back portion of prostate gland can be felt in this manner. Findings on this exam are compared to notes about the patient’s prior digital rectal examinations.

The exam is usually brief, and most find it uncomfortable due to the pressure used to adequately examine the prostate gland. Findings such as abnormal size, lumps, or nodules (hard areas within the prostate) may indicate prostate cancer.

The National Comprehensive Cancer Network (NCCN) notes that a DRE should not be used as a stand-alone test for detection of prostate cancer but should be performed in men with an elevated PSA. The NCCN also notes that DRE may be considered as a baseline test in all patients, as it may help identify high-grade cancers associated with a normal PSA.

Prostate specific antigen (PSA) blood test: The PSA blood test measures the level of a protein found in the blood that is produced by the prostate gland and helps keep semen in liquid form. The PSA test can indicate an increased likelihood of prostate cancer if the PSA is at an increased or elevated level or has changed significantly over time, but it does not provide a definitive diagnosis. Prostate cancer can be found in patients with a low PSA level, but this occurs less than 20% of the time.

If the PSA level is elevated (levels can depend upon your age, on the size of your prostate gland on examination, certain medications you may be taking, or recent sexual activity) or has increased significantly over time, further testing may be needed to rule out prostate cancer.

PSA measurements are often tracked over time to look for evidence of a change. The amount of time it takes for the PSA level to increase is referred to as PSA velocity. The time it takes for the PSA to double, known as the PSA doubling time, can be also tracked. PSA velocity and PSA doubling time can help your doctor determine whether prostate cancer may be present.

The presence of an abnormal result on digital rectal examination, or a new or progressive abnormality in a PSA test may lead to a referral to a physician who specializes in diseases of the urinary system (a urologist) who may perform further testing, such as a biopsy of the prostate gland.

Prostate biopsy: A biopsy refers to a procedure that involves taking of a sample of tissue from an area in the body. Prostate cancer is only definitively diagnosed by finding cancer cells on a biopsy sample taken from the prostate gland.

The urologist may have you stop medications such as blood thinners (for example, warfarin [Coumadin]),Clopidogrel, Xarelto, Eliquis, aspirin, ibuprofen [Advil, Motrin], and certain herbal supplements) before the biopsy. An antibiotic is often prescribed to help prevent an infection related to the procedure. Some urologists may actually place a small swab into your rectum a week or so prior to the procedure to determine the best antibiotic to give you (selective target antibiotic prophylaxis). You may be asked to do a cleansing enema at home before the biopsy appointment and will be instructed to take the antibiotic 30 to 60 minutes prior to the biopsy to prevent an infection. On the day of the biopsy, the doctor will apply a local anesthetic by injection or topically as a gel inside the rectum over the area of prostate gland. You will be asked to lie on your side with your knees pulled up to your chest. Sometimes you may be asked to lie on your stomach. An ultrasound probe is then placed in the rectum. This device uses sound waves to take a picture of the prostate gland and helps guide the biopsy device. The device used is a spring-loaded needle that allows the urologist to remove tiny cores of tissue from the prostate gland. Usually, 12 cores are obtained, six from each side. Two cores are taken from the upper, middle, and lower portions of each side of the prostate gland. The cores are examined under the microscope by a pathologist (a doctor who specializes in examining tissues to make a diagnosis). Results may take several days.

If you do not have an anus (due to previous surgery), then transperineal prostate biopsy is performed. During this procedure, which is often performed under sedation, the biopsy needle is inserted through the perineum (area between the scrotum and the anus) into the prostate.

A biopsy procedure is usually uncomplicated, with just some numbness, pain, or tenderness in the area for a short time afterward. Occasionally, a patient has some blood in the urine, stool, or the ejaculate after the procedure. Rarely, the patient may develop an infection after a biopsy procedure (urinary tract infection, prostate infection, testis infection) or be unable to urinate. If one develops a fever after the procedure, has continued blood in the urine or ejaculate, or has troubles urinating, further evaluation by the performing doctor is needed.