Prevention of Prostate Cancer
Well known advice given to our patients include:
- decreased intake of fat and red meat
- maintenance of your recommended body weight
- consuming medications or food that could lower your PSA level
Other possible risks factors include a family history of prostate cancer, obesity, and the known increased incidence of prostate cancer in African Americans.
Prostate Specific Antigens (PSA) tests are used in conjunction with DRE (digital rectal examinations) to evaluate your prostate for any abnormalities. The PSA result is age-specific. Consult your urologist for its correct interpretation.
Essentials of PSA
Your doctor often uses a PSA test to screen for prostate cancer. An elevated PSA by itself does not always mean that cancer is present. It simply alerts your doctor to evaluate your prostate.
There are other medical conditions that can cause your PSA level to increase. These conditions include an enlarged prostate (Benign Prostatic Hyperplasia, or BPH), and inflamed prostate (prostatitis), or a urinary tract infection.
A PSA test should always be combined with DRE to assess prostate health.
In the blood stream, PSA can be either free-floating or attached to other proteins. Men with cancer often have lower levels of free PSA than do those whose elevated PSA has other causes. Free PSA tests have been available for several years and can potentially be used to pinpoint patients who may be harboring cancer.
The introduction of total and free PSA has been extremely helpful. The lower the percent free PSA, the greater the likelihood of prostate cancer. Evaluating the free PSA level is extremely beneficial in men with serum PSA concentrations between 4 and 10 ng/mL, in that 29% of negative biopsies would be spared while retaining a 95% sensitivity.
In younger men with PSA between 2 and 4 ng/mL, a much more aggressive approach is taken in terms of getting an early biopsy. In older patients, 4 ng/ML is recognized as cutoff.
PSA velocity, which measures the rate of rise compared to the previous PSA level, is also taken as an indicator for further diagnostic testing.
If your PSA level is high what should be done next?
Your doctor may repeat the test or perform additional tests to see if there is any reason to suspect cancer of the prostate.
Multiparametric MRI of the prostate is now utilized to define the need for a MRI-guided biopsy of the prostate.
Staging of Prostate Cancer
Staging is one way of organizing the information obtained from the prostate biopsy and staging tests that have been previously described to determine the overall stage of your prostate cancer. Knowing the stage of the cancer helps determine the best treatment option for you. The most commonly used system to describe the extent of cancer spread is the TNM classification system:
T – the extent of the prostate cancer
N – absence or presence of spread of the prostate cancer to lymph nodes
M – absence or presence of distant metastasis
The purpose of staging is to determine the size and location of the tumor, whether it has spread outside of the prostate gland, and the characteristics of the prostate cancer cells. Various tests are available, and your urologist will decide which are needed to appropriately stage your prostate cancer.
A specialized doctor called a pathologist examines prostate cancer cells under a microscope and assigns a number (Grade) depending on how much the cells mimic the patters of normal prostate cells. The Gleason Score is a sum of the grades of the two most common patters seen under the microscope. Gleason scores range from 2 -10.
The higher the score, the more aggressive the prostate cancer is and the more likely it is to grow quickly and spread. Thus, a patient having a Gleason Score of 8 has a significantly more aggressive tumor than somebody having a total score of 6.
Imaging tests are performed if your urologists suspects advanced cancer because of factors such as a markedly high PSA level, a high Gleason Score, and/or large tumor burden. The following tests may be performed:
Bone Scan: Small amounts of radioactive materials are injected into your vein, and special x-rays are taken of the bones to look for any changes.
Computed Tomography (CAT or CT scan): A computerized x-ray machine takes pictures of the inside of the body and looks for the status of pelvic lymph nodes and other soft tissue.
Axumin PET Scan: this scan can achieve early detection of recurrent prostate cancer after surgery or radiation.
PSMA PET/CT Scan: this scan detects lesions between 4 mm and 8 mm and useful in rising PSA after prostatectomy.
Lymph Node Biopsy: Lymph nodes are located throughout the body. They filter out infection and foreign cells. Your lymph nodes may be evaluated to find out whether the prostate cancer has spread to the adjacent lymph nodes. Lymph nodes can be removed using laparoscopy or open surgical methodology prior to open removal of the prostate gland. Your urologist will discuss whether the lymph nodes should be evaluated and the method that he/she is comfortable with.
Patients with a low Gleason score (6 or less) and a low PSA of less than 10 usually do not require any further pre-treatment imaging studies.
High-risk patients are those with high stage, high Gleason score, and high PSA levels. In such patients, a bone scan and/or a CT scan is obtained. Also high-risk patients will greatly benefit from a pelvic lymph node dissection. Occasionally patients with a high Gleason score with low PSA should be staged from the appropriate scan results.