Gerald Hurowitz, M.D.·Published 28 April 2015·10 min read
Key points
At the time of your routine annual physical examination, suspicion was raised either because of an elevation in your serum prostate-specific antigen (PSA) level or an abnormality of the prostate noted by digital rectal examination.
It is well documented that the best outcomes associated with prostate cancer management are related to the qualifications of your treating physicians and medical center.
It is important to know that prostate cancer does not always carry the death sentence that it once did.
In preparing for another consultation, it is important to collect your medical records and other pertinent information to bring with you for your consultation.
A diagnosis of prostate cancer was made. At the time of your routine annual physical examination, suspicion was raised either because of an elevation in your serum prostate-specific antigen (PSA) level or an abnormality of the prostate noted by digital rectal examination. No doubt, this is an emotional shock. At the same time, the diagnosis might not seem all that surprising based on population studies that suggest that the current risk of diagnosis of prostate cancer approximates 1 in 6 men in the United States. Prostate cancer is the most commonly diagnosed malignancy among men in the United States, with approximately 200,000 diagnoses a year and approximately 30,000 deaths annually. The numbers are all the more daunting for black men, who have a 40% higher risk of the disease and twice the rate of death from it. According to current statistics, approximately 1 in 38 men will die from prostate cancer. On a positive note, the mortality rate associated with this disease has declined over the past decade.
The reduced mortality is associated with various factors, including screening efforts leading to earlier detection and advances in life-saving therapeutic approaches.
Multiple controversies surround the diagnosis of prostate cancer. With better detection, the prevalence of prostate cancer has risen, though in up to 50 percent of men, it may not be life threatening and require active treatment. Thus, a logical question is whether all prostate cancer is deadly?
Another is whether active treatment may carry more hazards, such as side effects that hamper quality of life, than the threat of this disease? Today, treatment decisions must take into account a careful understanding of the risk profile of the diagnosis in each man as well as issues regarding his overall health status and life expectancy. A variety of treatments exist, but choice of intervention - from surgery to active surveillance - will differ among patients. Certainly, you may have heard about many of these controversies, which likely adds to your anxiety and fear. The stress may be further heightened because of the idea today that patients should assume a more active role in the decision-making process for managing their disease.
How to select your oncology team and medical center
It is well documented that the best outcomes associated with prostate cancer management are related to the qualifications of your treating physicians and medical center. It makes sense to consider a medical center for your management that has a high level commitment to prostate cancer management and that provides a diversity of personnel and resources dedicated to patients with prostate cancer.
The facility may be a referral center separate from where your prostate cancer diagnosis was made under the care of your original urologist. This facility may include a urologic surgeon with expertise in prostate cancer, radiation oncologist, medical oncologist, prostate pathologist, prostate imaging radiologist, genetics counselors, oncology nurses, and a psychosocial support staff for patients diagnosed with prostate cancer. There should be interaction between all these specialists in the form of interdisciplinary conferences and tumor boards, during which the latest developments in management of both common and complicated cases are discussed. Such a center offers the very latest and best treatments that have been established through rigorous studies as well as the option to be involved in active clinical trials forecasting new therapies.
Written and revised by
Gerald Hurowitz, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
health.am provides general information, not medical advice. Always consult a qualified health professional about your own health.
Learning about your disease before the first visit
It is important to know that prostate cancer does not always carry the death sentence that it once did. Because of the routine use of PSA testing, prostate cancer is often found very early, and it is estimated that many men may have as much as a 10-year advance notice of the disease. To appreciate this concept further, consider that today 1 in 20 men presenting with prostate cancer diagnoses have distant metastases, compared with the rate of 1 in 3 men who presented with the disease in 1982. This "lead time effect" enables early action. Of course, it also raises challenges for considering whether the diagnosis always merits active treatment that may carry risks (see previous discussion).
Nonetheless, having an early start by knowing you have the diagnosis may be the best position to be in so that you and your doctors can plan for the very best outcome.
In preparing for another consultation, it is important to collect your medical records and other pertinent information to bring with you for your consultation. These records should specifically assist in the evaluation of your prostate cancer risk profile. However, other records may also be helpful for the evaluation of your overall health status that may affect the best recommendation. Regarding prostate health records, serial PSA testing over many years may have been done, and results showing the trend in these measurements could be very helpful. The prostate biopsy report detailing specifics about the biopsy findings should be copied and brought. Specific information from the biopsy includes the number of biopsy cores obtained, the locations of biopsy cores containing cancer within the prostate, the percentage of cancer within each biopsy core, and the determination of Gleason score (a grading system that defines the appearance of the cancerous tissue).
For many centers, the actual biopsy slides containing your tissue are requested for first-hand review by pathologists at the medical center to render an independent evaluation of your prostate cancer. Sending these slides in advance for pathologic review or having them on hand with you during the initial consultation can be very helpful to move along the pathologic review process. Additionally, reports of any imaging studies such as bone scan, CAT scan, or MRI may be shown. In the past, these additional imaging studies were frequently ordered, but today they are not commonly done in men with an early diagnosis and evidence of only localized disease. Medical records from your previous urologic consultations can also be very helpful, particularly to review any initial treatments that you may have received. Knowing what has already been done for your prostate cancer may affect further decisions regarding management. Brief summaries of your overall medical conditions are also useful. Your doctors will want to take into account your other health problems so they can recommend the best treatment for your prostate cancer. As stated earlier, the natural history of prostate cancer can be long and drawn out. For many men, their other medical conditions will have a greater effect on their health and longevity than will their prostate cancer diagnosis. In these men, less urgent or aggressive prostate cancer management may be the most appropriate course. It is important to avoid implementing major interventions when they may be unnecessary.
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Cancer Staging
Clinical staging is an important component of the initial evaluation. Clinical stage refers to the extent of the disease and as such influences decision making because it indicates how far the disease has progressed and how likely a treatment may be able to control it. Other components of the initial evaluation include two readily available clinical diagnostic variables: the PSA level and the Gleason score from the prostate biopsy. Often, these variables are combined to give the probability of the progression of disease. Prostate Cancer Staging: How Does it Work?
Staging is a term that is used to determine if a cancer has spread from where it first began. Prostate cancer staging is commonly described as:
Localized prostate cancer: the cancer is contained within the prostate gland and has not spread to nearby tissues or elsewhere in the body. Locally advanced prostate cancer: the cancer has spread outside the prostate gland to surrounding tissue, most often the seminal vesicles. Advanced prostate cancer: the cancer has spread to nearby lymph nodes, bones, or elsewhere in the body.
"They determine the grade by looking under a microscope to see how aggressive the cells look, and depending on the psa (prostate-specific antigen) of the grade, they may or may not do additional tests," Dr. Delworth says. "Those tests are usually either a bone scan or a CT scan - and that's to determine if there's any spread."
Tools used for this purpose include predictive, validated nomograms. Such nomograms provide information regarding the likelihood that the disease is confined to the prostate gland, spread locally beyond the prostate gland, or spread distantly into lymph node tissue or elsewhere in the body. Many patients have a heightened appreciation of their prostate cancer risk profile by accessing nomograms and then entering in their own clinical variables to get a sense of the "big picture."
The most common form of prostate cancer is adenocarcinoma (greater than 95%). This type of prostate cancer is a malignant transformation of the structure of glands and the cells that make up these glands into a random and disorganized architecture. Prostate cancer tissue can be evaluated under the microscope to identify this transformation. The pathologist's microscopic evaluation of the prostate cancer tissue also determines the aggressiveness level, referred to as the Gleason score. The Gleason score represents the sum of two numbers rating the two most common patterns of abnormal glandular architecture based on a graded scale of 1 to 5, with 1 indicating low-grade cancer and 5 indicating high-grade cancer. The first number corresponds with the predominant pattern and the second number relating to the second most common pattern observed in examining the prostate tissue for an individual patient. For example, a Gleason score of 4 + 3 = 7 indicates a predominant pattern of mostly abnormal glands that are not quite the highest grade with a secondary pattern that is somewhat less. In cases where the glands are abnormal but still fairly uniform in appearance, the same number may be repeated.
Tumor aggressiveness increases with the score (e.g., 4 + 4 is more aggressive than 3 + 4).
When doctors refer to cancer staging they are talking about the extent to which the cancer has spread. Both "clinical staging" and "pathological staging" are frequently used, but it is important to recognize the difference between them.
Clinical staging refers to the determination of the extent of disease based on clinical findings prior to any sort of treatment. This primarily involves the findings from the digital rectal examination. Digital rectal examination assesses whether the tumor is palpable and the extent to which this seems to involve the prostate. Because the prostate is a bilobar structure, the examiner can comment on whether the tumor is minimally or extensively palpable, and if it involves one or both sides of the prostate. This palpation involves only the zone of the prostate that borders on the rectal wall, and this side of the prostate is called the peripheral zone.
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Prostate cancer may also arise in areas of the prostate that are not accessible to the examiner's finger. This limitation may account for the difference that may occur between clinical and pathological staging. When they are indicated, imaging studies may provide further information to determine the extent of disease. Bone scan, pelvic CAT scan or MRI may increase the original clinical stage that was determined only by digital rectal examination.
Pathological staging, on the other hand, indicates the extent of cancer that is found in the surgically removed tissue specimens. Pathological staging requires surgery so the pathologist can evaluate the removed prostate to directly assess the extent of cancer spread. Pelvic lymph nodes are also regularly removed during surgery and then assessed for cancer spread.
A review of the various ways that PSA testing aids the clinical evaluation of prostate cancer is helpful. The PSA level itself is helpful, and it is quite readily understood that the higher the number the greater the extent of disease and worse prognosis. But, there are exceptions. Tumors that are poorly differentiated (extremely different from normal biological tissue) may not produce significant amounts of PSA such that the measurement in blood may seem surprisingly low. On the other hand, there are cases in which a more elevated PSA measurement can occur with a large amount of cancerous tissue present within the prostate in locations that may not easily be appreciated on the digital rectal examination, such as the anterior zone (opposite to the peripheral zone).
A complicating issue is that the PSA test is not cancer specific. The test is only prostate specific, and elevations may arise from benign diseases of the prostate such as benign prostatic enlargement and prostatitis. Other forms of PSA measurement have been developed in an attempt to correct for elevations associated with benign conditions of the prostate. These include PSA density, free PSA, and PSA velocity. These are briefly explained as follows. PSA density is a measurement of the PSA level divided by estimation of prostate volume determined by transrectal ultrasonography and simply implies that the PSA value is adjusted for prostate size. A PSA density of less than 0.1 generally implies a low risk situation for prostate cancer. Free PSA refers to a molecular form of PSA that is not bound to a circulating protein in the blood called alpha1 -antichymotrypsin. The free PSA measurement is generally higher in men with benign disease, and a measurement of less than 15% suggests clinically significant or more aggressive disease. PSA velocity refers to the change in PSA over time. The greater the rate of PSA increases over time, the greater the threat of a clinically adverse form of prostate cancer. A PSA change of greater than 2 ng/ml in the year before diagnosis means an increased risk of death from prostate cancer.
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Arthur L. Burnett, MD, MBA, FACS Patrick C. Walsh Professor of Urology, Cellular and Molecular Medicine The James Buchanan Brady Urological Institute The Johns Hopkins Hospital Baltimore, MD
Moffitt researchers work to determine why some prostate cancer patients experience more hot flashes
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