What do you do if your PSA blood test or physical exam is abnormal?

If your primary care physician detects an abnormal PSA or a lump in your prostate during a physical exam, you typically will be referred to a Urologist for evaluation and consideration for a prostate biopsy. This is a simple procedure that can be done in a few minutes in the Urologist’s office. With an ultrasound in the rectum, thin needles can be inserted into the prostate to remove tiny fragments of it for evaluation. Typically at least six biopsies are performed, three from each side of the prostate.

These biopsies are sent to a lab where a physician will determine if cancer is present. If so, they will then determine how aggressive the cancer is. A scoring system, called the Gleason score, assigns the cancer a number from 2 – 10, with 2 being a less aggressive cancer, and 10 being a more aggressive cancer.

Likelihood of Cancer Confined to Prostate *

* Partin et al, JAMA 1997; 277:1445-1451

For truly early-stage disease, you must have a very low risk of cancer being outside of your prostate. This risk can be estimated following a review of your records. Generally speaking, several important criteria must all be met. These include:

• PSA < 10 and
• At most, a small nodule felt in the prostate (stage T1-T2A) and,
• Biopsy showing a Gleason score < 7

The Journal of the American Medical Association recently published a study looking at close to 2,000 men. It showed that for men with low-risk prostate cancer, a prostate seed implant, external radiation, and surgery offered equivalent cure rates. These results typically exceed those found with older technologies such as proton beam radiation.

What is moderate- to high-risk prostate cancer? Although surgery (radical prostatectomy) is an effective treatment option for early stage prostate cancer, it becomes less effective as the risk of cancer having spread beyond the prostate increases. It is difficult for surgeons to completely remove the cancer once it has grown beyond the confines of the prostate gland. Several factors can potentially identify patients who are at a higher risk for having cancer outside the prostate.

These can include any of the following:

• PSA > 10
• A nodule felt to occupy half of the prostate gland or more on physical exam
• A biopsy showing a more aggressive tumor, with a Gleason score > 6
• A biopsy showing cancer invading around the small nerves in the prostate (perineural invasion)
• Multiple positive prostate biopsies

What do you do once diagnosed with prostate cancer? If the biopsy shows the presence of prostate cancer, the next step is to determine how much cancer is present and to make sure that it has not spread. Our prostate cancer experts will expertly review your PSA blood tests, physical exam findings, and biopsy results. Some simple and painless tests such as X-rays of the pelvic structures and bones (CT scan and bone scan) can also help make sure there is no cancer that has spread outside the prostate.

Using the above information, we can then calculate the likelihood of the cancer being completely confined to the prostate, having spread beyond the confines of the prostate, or having spread some distance to the lymph glands in the pelvis.

• This information, as well as an evaluation of your overall medical condition and well-being, is critical in determining which treatment options will offer you the best chance for a cure.