How do doctors diagnose prosate cancer
How do doctors diagnose prostate cancer?
BMJ Group, Monday 13 October 2008
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If you are worried that you may have something wrong with your prostate, you are likely to go to your GP first.
Questions your doctor may ask you
Your doctor may ask you some of the following questions.
Do you have trouble urinating?
Do you find it hard to go to the toilet, 'dribble', or just stop and start?
How often do you have to get up in the night to urinate?
Is there any blood in your urine?
Is urinating painful?
Do you have pain anywhere else?
How long have you had your symptoms?
Digital rectal examination
If your tumour is bigger than half an inch (around 1.5 centimetres), your doctor may be able to feel it through the wall of your rectum. Wearing a medical glove and using a lubricating gel to make the examination more comfortable, your doctor will put a finger into your rectum to feel for a lump. This is called a digital rectal examination (DRE). It doesn't hurt, but some men find it embarrassing.
PSA test
The PSA blood test can help to diagnose prostate cancer. The PSA test measures the amount of a substance called prostate-specific antigen (or PSA) in your blood. PSA is a substance that is made naturally by your prostate. It helps to keep your semen healthy. But if there is a cancer in the prostate, more PSA can seep from your prostate into your blood. So high levels of PSA in your blood may be a sign of cancer.
Bear in mind that a PSA test on its own cannot tell you for certain if you have prostate cancer. It can only tell you what your chance of having prostate cancer is.
Your test result will show the level of PSA in a measurement of nanograms (ng) per millilitre (ml) of blood. If your level of PSA is between 4 ng/ml and 10 ng/ml, you have a 20 percent to 50 percent chance of having cancer. If your PSA level is above 10 ng/ml, it is highly likely that you have cancer. If you do have cancer, then the higher your level of PSA, the larger your tumour and the more likely it is to have spread.
If you've had treatment for your cancer, your doctor may recommend that you have regular PSA tests to check that the cancer has not come back or grown.
If, after getting the results of your tests, your GP thinks you may have prostate cancer, he or she should talk to you about seeing a specialist. What you decide to do may depend partly on how old you are and how well you are. If you and your GP decide that you should see a specialist urgently, you should get an appointment within two weeks.[1]
If your PSA test results show that you have borderline level of PSA and you have no other symptoms of prostate cancer, your GP should repeat the test one to three months later. If the results of this second test show that your PSA has gone up, your doctor should refer you to see a specialist urgently.[1] This means you should get an appointment within two weeks.
Should I have a regular PSA test?
In some countries, such as the US, this test is offered as part of a routine health check. This is called screening for prostate cancer. Some people in the UK argue that it should be offered to men routinely, in order to pick up early cancers. But at present British doctors do not advise men to have it unless they have symptoms of prostate cancer. This is because:[2] [3]
There is no definite evidence that detecting and treating prostate cancer early will improve your chances of surviving the disease
Most prostate cancers grow slowly and don't spread, so they may never need treatment
Not all prostate cancers are picked up by a PSA test
PSA levels can be high for other reasons. It's not only prostate cancer that can make them high.
Doctors have also reviewed the research on screening and found two studies that have looked at whether it can save lives. These studies have found that men who are not screened are no more likely to die from prostate cancer than those who are screened. But these studies did not look at whether the men who were screened were able to lead more normal lives. Also, the doctors who looked at this research were not certain that the studies were reliable. They decided that, until better studies are organised, they can't say whether men should or shouldn't be screened for prostate cancer.
If you wish to consider having the test because you are worried about prostate cancer, your GP should explain the pros and cons to you. If you decide to go ahead, your GP will arrange it.
Referral to a specialist
If your GP refers you to a specialist, usually called a urologist, the specialist will probably repeat some of the things that your GP did, as well as doing a biopsy. If necessary, he or she will check how far the cancer has spread and grade it.
Biopsy
A biopsy is the main test doctors use to find out for certain if you have cancer. The doctor uses a special needle to remove a very small piece of tissue from your prostate to look at under a microscope. The needle is either gently pushed through the wall of your rectum into the prostate or it is inserted into the skin between your scrotum (the sac that holds your testicles) and your anus (the opening through which you empty your bowels). The needle is guided by a special device called an ultrasound probe.
A biopsy is not usually painful, but you may feel a sharp scratch, even if you are given a local anaesthetic (painkiller) to numb the area.
The more abnormal the cancer cells look compared with healthy prostate cells, the more likely it is that the cancer is fast-growing (aggressive) and able to spread.
How doctors know how far the cancer has spread
Most of the time, doctors will know if your cancer has spread by looking at a combination of your PSA level and your biopsy results. If they need more information about your cancer, doctors can use special techniques to look at other parts of your body, including your lymph nodes and your bones. They may use ultrasound scans, X-rays or body scans (computed tomography and magnetic resonance imaging) to check whether cancer is anywhere else in your body.
From the results of your tests, you doctor will be able to tell you:
How big your prostate cancer is
How likely it is that your prostate cancer has spread to your lymph nodes
Whether your prostate cancer has spread to other parts of your body
What type of prostate cancer cells you have and how fast they are likely to grow and spread.
How doctors classify your cancer
Doctors use number and letter classification systems to describe how far your cancer has spread. This is called staging. There are several systems, but the most common is called the TNM system. See our explanation of the TNM system to find out what the different classifications mean.
How doctors grade your cancer
Doctors use something called the Gleason score to describe how your cancer looks under a microscope. This is called your cancer grade. A tumour that has a low-grade score is likely to be growing slowly, while one with a high-grade score is more aggressive and likely to spread. If your cancer has been given a grade, use our explanation of the Gleason score to learn more about what it means.
How doctors describe the overall stage of your cancer
Your doctor may combine your TNM classification and Gleason score to tell you the overall stage of your cancer. Knowing this stage can help you and your doctor consider what may happen to you, and it can help you decide on the best course of treatment.
There are four stages of prostate cancer: 1, 2, 3 and 4. Stage 1 is the earliest, and stage 4 is the most advanced.[3]
For more information, see Staging your prostate cancer.
References
National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. June 2005. Clinical guideline 27. Available at http://www.nice.org.uk/cg027 (accessed on 27 September 2007).
Mazdar D, Waxman J. Prostate cancer. Postgraduate Medical Journal. 2002; 78: 590-595.
Horwich A, Parker CC, Huddart RA, et al. Management of early prostate cancer. Annals of Oncology. 2002; 13 (supplement 4): 83-87.
Glossary
rectum
The rectum is the last 15 to 20 centimetres (six to eight inches) of the large intestine, ending with the anus (where you empty your bowels from).
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