Various strategies for lifestyle and dietary modification are used in our clinic. Also, we have been investigating the role of genetics and have an active research program to identify familial genes which predispose to prostate cancer development. New serum markers are used along with prostate specific antigen to assess a man’s risk of having prostate cancer and a need for prostate biopsy. We have available advanced, state of the art color Doppler ultrasonography to help direct prostate biopsy as well as endorectal magnetic resonance imaging.
Prostate cancer is most curable when it is detected early. While some men seek medical attention because they are experiencing symptoms that might indicate prostate cancer (such as frequent urination or an inability to urinate, trouble starting or holding back urine flows, or frequent pain or stiffness in the lower back, hips, or upper thighs), most men experience no such symptoms. Hence, for many men, an abnormal finding during a routine screening examination is the first indication that they might have prostate cancer. An abnormal-feeling prostate or an elevated PSA level are both possible indicators of the disease; however, neither test along (or in combination) can provide a definitive diagnosis of prostate cancer. Physician experience and expertise are required to interpret properly a PSA test. There is no cutoff value considered normal or abnormal and the PSA must be adjusted for patient age, prostate size, and other factors. If either test is abnormal, your physician may suggest you have a biopsy, which can provide much more information and is required before a diagnosis can be made.
The biopsy procedure is routinely performed in the office using a local anesthetic. A transrectal ultrasound (TRUS) probe is used to provide pictures of the prostate and to guide the precise placement of the biopsy needle. The doctor uses the biopsy needle to remove sections of tissue from several different areas of the prostate, and the cells that are collected are then examined under a microscope by a pathologist. The needles are inserted for only a fraction of a second, and the procedure takes about five minutes.
If prostate cancer is diagnosed, the next step is to further characterize the cancer with the use of one or more additional factors. Each prostate cancer is different and unique, and thorough characterization of each person’s cancer will help doctors to suggest the most effective treatment. First, the pathologist who examines the tissue samples will determine the aggressiveness of the cancer, using the Gleason grading system. This system provides an estimate of the cancer’s potential to grow and spread to other parts of the body. In general, a high Gleans grade (greater than or equal to 7) indicates an aggressive prostate tumor that is likely to spread to other areas of the body, while a low Gleason grade indicates a less aggressive cancer that is not likely to spread outside the prostate.
Additional tests may then be done to determine the extent of the tumor in the prostate and also whether the cancer cells have spread from the prostate to surrounding tissues or other parts of the body. This is called “staging,” and is usually accomplished through the use of various imaging techniques. In some cases, and ultrasound image will help the doctor to stage the tumor, although ultrasound is used more often to guide the biopsy needles. A CT scan or radionuclide bone scan also may be used to obtain images of other parts of the body, to see if the disease has spread to lymph nodes, organs, or bones. A magnetic resonance image (MRI) of the prostate is useful in some men and occasionally a scan called ProstaScint is useful.
In making a treatment recommendation, the doctor considers, along other things, the grade and stage of the cancer.
The grade of the cancer is determined by review of the biopsy by an expert pathologist. We obtain the biopsy slides from other hospitals for review by Vanderbilt pathologists for all patients seen in our prostate cancer clinic. The Gleason grade is determined by adding two numbers together and generally can be grouped as follows:
2, 3, 4 Rarely diagnosed in clinical practice
5,6 Most common grade; generally slower growing
7 An intermediate degree of aggressiveness
8, 9, 10 An aggressive type of cancer
Tumor stage is used to describe the extent of cancer and is based upon physical exam findings as well as other staging tests which may be performed.
T1a, b Diagnosed by transurethral resection of the prostate
T1c The most common stage. Diagnosed by a biopsy prompted by an abnormality in PSA. The prostate feels normal to exam.
T2 Abnormal prostate on exam. PSA may or may not be elevated.
T3 Cancer extending in to the tissues surrounding the prostate
T4 Cancer extending to other organs