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Testing for Prostate Cancer

What Is Prostate Cancer Screening and Why Should You Do It?

With consequences that happen when diagnosed with prostate cancer, catching it early is of the utmost importance. This is where the role of cancer screenings come in. Often, the earliest stages of cancer can present without any symptoms. It is in these early stages that successful treatment against the disease is the most likely, and catching cancer early is crucial. That’s why cancer tests should become a routine part of your health regimen, especially as you age.

Advancements in research and technology have made great strides in the identification of risk factors for cancer. The risk factors present in a particular person can help determine the frequency with which you should be screened and precisely what tests should be performed. Tons of research continues in the field, and the guidelines and accuracy for cancer screenings continue to develop.

When performed routinely, at a prostate cancer clinic, screenings will help catch these symptoms early. Most of the time, the screenings come back clear. Any abnormalities at all will result in further testing. Further testing doesn’t necessarily mean that there is a cancer diagnosis coming, only that more tests need to be performed. There is a wide variety of possible diagnostic tests for prostate cancer.

What are the diagnostic tests for prostate cancer?

Different diagnostic tests are performed based on the result of cancer screenings. A single test may be performed, or there may be a combination of tests:

Prostate Cancer Screening Test  

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DRE or Digital Rectal Exam A lubricated finger is inserted into the rectum to palpate any possible abnormalities. Doctors can use a DRE to actually touch the prostate gland. The gland has a fairly uniform shape, so this exam allows the medical professional to detect any unusual areas or any abnormal sizes. While useful, a DRE is not usually successful at detecting growth that is too small for manual feeling or anything that is deeper in the gland than the digit is inserted.
Prostate Specific Antigen (PSA) Blood is drawn to check for levels of the PSA to ensure they are found within normal levels. In healthy males, the prostate specific antigen levels remain low. When cancer is present, the prostate may secrete higher amounts of this antigen in response to the growth, which is why an elevated PSA level may be an indicator of other issues. On its own, a PSA screening is not conclusive. In some instances, prostate cancer may be present without an elevated PSA level. Also, PSA levels may be elevated by non-cancerous conditions, including prostatitis or another infection.
Prostate Cancer Test After Failed Screening Results  

 

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Percent-free PSA Ratio This is a follow-up blood test to the PSA screening. The test examines the ratio of PSAs found bound with proteins to those found freely flowing in the blood. Doctors hope to see a PSA ratio of 22% or greater. Anything below this threshold is a higher indicator of prostate cancer. This diagnostic test is often ordered if the screening test shows a slightly elevated PSA level. It may even be ordered if the PSA level is on the high side of the normal range.
PCA3Plus Similar to the DRE screening test, a doctor inserts a lubricated finger into the rectum. The finger is used to gently massage the gland to shed cells into the urine, which is then collected and tested. A specific gene called PCA3 can be found in the urine. This gene is often expressed by cancerous cells in the prostate and can be an indicator for prostate cancer. Higher levels of the PCA3 gene indicate a relatively strong likelihood that prostate cancer will be diagnosed via biopsy.
Transrectal Ultrasound A lubricated probe is inserted into the rectum. An ultrasound is then performed to allow the medical professional to see the prostate gland itself. Ultrasound technology allows for the measurement of the prostate gland. This can allow medical professionals to see any abnormal growth patterns in the tissue. Normally performed as the first step of the biopsy process, a TRUS exam may be used to guide the biopsy needles. Usually performed by a urologist in a prostate cancer clinic, biopsy needles will be fed along the path of the probe until tissue samples can be acquired.
Prostate Biopsy Normally performed in conjunction with a TRUS exam, a biopsy involves obtaining samples of tissue from the prostate gland itself. These tissue samples are examined under a microscope to detect any abnormal or cancerous growths. Generally used after other screenings indicate a relatively high likelihood of prostate cancer, biopsies are used to get final confirmation of a diagnosis. Prostate cancer clinics perform the majority of these exams, under the supervision of a urologist.
Prostate Cancer Tests for Intermediate to High Risk Cases  

 

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Bone Scan A radioactive tracer, technetium-99m, is injected into the blood. Nuclear medicine professionals track the flow of this tracer, helping to detect any abnormalities present in the bones. If the technetium-99m uptake rate is higher in particular portions of the bones, it may indicate the presence of cancer. This is an indication that any prostate cancer may have spread to the bones. Patients do not have to deal with a high level of discomfort during the test. Other than the injection of the tracer, the patient just rests on a table while it is passed through a scanner to detect the tracer.
CAT Scan Utilizing a highly detailed version of x-ray technology, this test produces images of soft tissues as well as bones. Examining for the spread of any cancer beyond the prostate gland, the CAT Scan is used to search for any enlarged lymph nodes in the pelvic region. This is test is not invasive for the patient. Similar to the bone scan, the patient lies on a table which is passed through a circular scanner. X-rays are sent through the body to produce images from a variety of angles.
 

 

 

 

 

 

 

 

MRI Scans

Performed with a particularly strong magnet, this scan also utilizes radio waves and a computer to produce details with an extremely high level of detail and clarity. When specifically searching for prostate cancer, the MRI is often performed with the use of an endorectal coil, placed before the scan begins. This coil, inserted directly into the rectum provides a specialized look at the gland and any surrounding tissue. Improved in recent years by advances in contrast materials, an MRI is essential in determining whether or not any cancer has spread, as well as the scope of the spreading. In addition, an MRI may be used to help assist in the biopsy process by guiding needles. Similar to the CAT scan, patients are normally lying on a table for the duration of the exam. The table is put into a tube-shaped scanner, which produces the images. Before the scan is performed, contrast materials may be injected.
Sodium Fluoride PET Scan Similar to the bone scan, this exam uses a tracer to produce images with a high level of detail. The tracer for this scan is 18F-sodium fluoride. Normally used if a bone scan comes back negative, a PET Scan will be done if enough risk factors remain to continue the search for any cancerous tissue. The time taken for a PET scan is shorter than that for a bone scan because the uptake time for the contrast material is also shorter than the technetium used in a bone scan.

The digital rectal exam and the PSA test can be used to screen for prostate cancer even if symptoms are not present, while a biopsy is done when the presence of cancer is suspected.

How reliable are the screening tests for prostate cancer?

Neither the DRE or PSE is a perfect means for identifying prostate cancer. Even during a digital rectal exam,screening tests for prostate cancer abnormalities may be missed by the doctor. A PSA can be difficult to use as a marker because even men without prostate cancer can have elevated PSA levels. That’s why, often, the most accurate results are found by using a combination of the two tests. 

Why is the PSA test performed?

Even though an elevated PSA level does not necessarily indicate the presence of prostate cancer, the FDA still recommends that all men aged 50 years or older receive regular screenings as a method of early detection. The recommended screenings include a digital rectal exam, as well as the PSA screening. By monitoring the PSA level on a regular basis, doctors are able to determine when further screening may be necessary and have a higher success rate of prostate cancer treatment.

There are instances where PSA tests are inaccurate. Conditions like prostatitis and other infections can cause an elevated PSA level, which is completely unrelated to cancer. Also, patients undergoing hormone treatments may show a decreased level of PSAs. In this instance of hormone therapy, it is recommended that PSA treatment is held off until the round of hormones have been completed.

In addition to screening for prostate cancer, PSA tests are utilized as a part of monitoring for recurrence for patients with past instances of prostate cancer. Even with the prior history, an elevated level doesn’t guarantee a cancer diagnosis but can help indicate when further screening may be needed to catch any recurrence early.

Who should have a PSA screening test?

While every doctor and clinic may have their own recommendations, the most common one is that men aged 50 years and up should undergo a regular prostate cancer screening. However, this is far from a universal recommendation. If a patient shows any higher risk factors, it may be advisable to start screenings as early as 40 or even 45. This is best worked out between patients and medical professionals at a prostate cancer clinic, keeping in mind what insurance policies may allow for coverage.

Risk factors that may trigger early screening include family history, particularly if a patient has a father or brother who suffered from the disease, a high animal fat diet, and race. Race is a component because African-American men have shown a higher risk for prostate cancer while other races, like Asians or Native Americans, have shown a lower rate of the disease.

How are PSA test results reported?

As mentioned, PSA screenings test for the levels of prostate-specific antigens found in the blood. The test specifically looks for the number of these antigens in a milliliter of blood, measured in nanograms. Thus, the final test result shows that the number of nanograms per milliliter abbreviated ng/ml. The most used scale is as follows:

0 to 2.5 ng/ml – considered low level

2.6 to 10 ng/ml – slightly to moderately elevated level

10 to 19.9 ng/ml – a moderately elevated level

20 ng/ml or more – considered to be a significantly elevated level

It’s worth noting that no part of this scale is labeled “normal.” Every man will have their own usual level of PSAs found in the blood. This speaks to the importance of regular screenings at a prostate cancer clinic. Establishing a baseline makes it easier for doctors to see a pattern that might require prostate cancer treatment earlier rather than later.

What are some of the limitations of the PSA test?

While certainly effective in assisting the doctor in determining when further screenings are necessary, PSA tests are far from perfect. There are a few instances where the results can be misleading:

Low PSA Levels: There are instances where a PSA screening test will show a PSA count that isn’t elevated, even in the presence of prostate cancer. This can occur, for example, due to hormone therapy. In addition, prostate cancer is one of the slower moving cancers. and a tumor may take extended time before any symptoms, including elevated PSA level, can be detected. In addition, some tumors remain small enough to never elevate the PSA levels.

High PSA Levels: Since there are a plethora of reasons why the PSA levels may be elevated even without cancer, there can be a relatively high rate of so-called false positives. However, it is always better to be cautious with such a serious disease, and further screenings will always be taken with a high PSA level, even though it can cause some anxiety. It is worth noting that only 30% of men who underwent a biopsy due to higher PSA levels was diagnosed with prostate cancer, in a recent study.

What if the test results show an elevated PSA level?

Even though there are plenty of ways that a PSA screening may not be guaranteed accurate, it is still a vital part of any health regimen. Elevated PSA level should not be ignored by any patient or doctor. An elevated test may very well mean a host of other benign causes, but getting to the bottom of the cause will be helpful.

If an elevated PSA level is the only present symptoms, a doctor may recommend more frequent monitoring, including more regular PSA tests and digital rectal exams. In addition, it may be recommended to undergo testing for other causes of an elevated PSA level. These may include urine tests, x-rays, ultrasounds, or any other tests that may indicate an enlarged prostate or infection, but not necessarily cancer.

If any of the other screening tests indicate a cause for concern, a biopsy will likely be ordered to check if any other prostate cancer treatment is necessary.

The controversy of the PSA test

The general consensus is that screening tests should be done when they can routinely catch the disease early and save lives. Some medical professionals feel that PSA screening tests do not meet this standard. The concerns that these doctors have is that PSA levels can be elevated for a variety of reasons, and the follow-up testing can have substantial side effects as well as cause anxiety in the patient. In fact, many cancerous regions of the prostate gland may remain so small as to never present any health risk.

Furthermore, the concern is that many of the follow-up tests can be considered relatively invasive, with their own levels of complications. One example is that the process of getting a biopsy can cause bleeding and increase the potential for an infection. Also, if prostate cancer treatment is performed on a small case that presents no health risk, the side effects can be incredibly negative, including erectile dysfunction and incontinence, among other symptoms.

With these drawbacks in mind, there is continuous work being done to improve the accuracy of the tests to ensure that patients are consistently getting the maximum benefit from these tests. However, for now, the FDA still recommends yearly screenings for PSA levels at a prostate cancer clinic.

Should I seek a second opinion?

With a disease as serious as prostate cancer, it may always be wise to seek out a second opinion. This is even more so if the initial testing was done with a general practitioner. Following up at a dedicated prostate cancer clinic for a second opinion can be a very wise choice.

The best time to seek out this opinion is after all of the initial testing has been done, and a treatment plan is in place. At this point, it is wise to seek out a second opinion to ensure the plan set forth is in your best interests. It can be a good time to ask questions that you may not have thought about at your initial appointment – if you are looking for a selection of questions, we have some recommended ones here.

In addition to second opinions, this stage might also be a good time to seek out any support groups or have discussions with other men who have had prostate cancer. The support can be incredibly helpful for mental health during any stage of prostate cancer treatment. On top of this support, talking to fellow patients can help mentally prepare you for any upcoming procedures from a patient’s perspective and ensure that you are able to cope with any of the negative parts of treatment as best as possible. These groups and a second medical opinion should not be neglected as a part of a prostate cancer treatment plan.