Prostate Cancer: Screening & Diagnosis

Pictured: Victor Reuter & Karim Touijer Pathologist Victor Reuter (left) discusses a patient’s case with surgeon Karim Touijer. An accurate diagnosis is critical for planning the best treatment approach for prostate cancer.

Increases in screening and the use of sensitive tests have led to an increase in detection of prostate cancer at an early stage, when the disease is more curable. Memorial Sloan Kettering’s Bendheim Prostate Cancer Diagnostic Center offers detection tests that can reveal evidence of disease and whether it has spread from the gland. We also help men to better assess their risk of developing prostate cancer.

Detection Tests

Two tests commonly used to detect prostate cancer are:

Prostate-Specific Antigen (PSA) Test

This blood test measures levels of prostate-specific antigen, a protein made by cells of the prostate gland. Although it is normal for men to have low levels of PSA in their blood, prostate cancer can increase a man’s PSA levels. Men with an elevated PSA level (greater than or equal to 3 ng/mL) or a rising value over time may be referred for a biopsy.

However, an elevated or rising PSA level alone does not always mean that a man has prostate cancer. PSA levels also increase with age, and may be higher in men with a common, noncancerous condition called benign prostatic hyperplasia (BPH), or with a condition called prostatitis, an inflammation of the gland.

Digital Rectal Examination (DRE)

In this detection test, the doctor inserts a gloved finger into the rectum to feel for swelling or inflammation of the prostate or other abnormalities such a hardness or nodule that might suggest the presence of cancer.

Prostate Cancer Screening Guidelines at Memorial Sloan Kettering

Pictured: Andrew Vickers
Video

Memorial Sloan Kettering statistician Andrew Vickers describes a recommended screening strategy to determine men at highest risk for developing an aggressive prostate cancer requiring treatment.

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Doctors at Memorial Sloan Kettering recommend that all men get their first PSA test at age 45. For those with a family history of the disease, and for African American men — who are at a significantly higher risk of developing prostate cancer than are Caucasian men — our recommendation is to have your first PSA test at age 40. The frequency of follow-up PSA testing and whether to have additional testing depend on the results of this test, as well as other factors including your age, whether there is a history of prostate cancer in your family, any future changes in PSA level, and your general health. Learn more about Memorial Sloan Kettering's prostate cancer screening guidelines.

Computer-Assisted Family History Analysis

Memorial Sloan Kettering Cancer Center is one of the few treatment centers to offer computer-assisted family history analysis for men who suspect they might be at a higher risk of developing prostate cancer. If you have a family history of prostate cancer, our genetic counselors can evaluate your risk of developing an inherited form of the disease. Memorial Sloan Kettering also offers genetic counseling to family members of men diagnosed with prostate cancer. Learn more about prostate cancer and heredity.

Getting the Right Diagnosis

A prostate that feels abnormal and an elevated PSA level are both possible indicators of prostate cancer, but neither test — alone or in combination — can provide a definitive diagnosis, which can only be established with a prostate biopsy.

If your detection tests reveal any abnormalities, our doctors will perform a comprehensive examination to determine whether you have prostate cancer. This will include a biopsy, along with an evaluation of risk factors such as a family history of the disease. If your doctor finds that you have the disease, he or she will want to learn more about your tumor and determine whether the cancer is confined to the prostate or has spread to other organs.

One or more of the following tests will be used to make an accurate diagnosis and determine the stage of the disease.

Biopsy

In a prostate biopsy, a urologist removes tissue samples from the prostate using thin needles. You will receive a local anesthetic before the procedure. Ultrasound is used to guide the placement of the needles, to ensure that all suspected abnormalities are sampled. A pathologist then examines the tissue that has been removed under a microscope to look for signs of cancer. Prostate biopsies are usually performed on an outpatient basis.

During a standard biopsy, 12 to 14 tissue samples are removed. If the results of the biopsy indicate prostate cancer, your doctor may perform more tests to further characterize the tumor and determine the most effective course of treatment.

Memorial Sloan Kettering Cancer Center has a team of pathologists whose sole focus is to analyze prostate samples. Their expertise is critical in helping the other members of the prostate care team to determine the most effective treatment for your cancer.

Gleason Grade

Pathologists estimate a prostate cancer's aggressiveness — meaning its potential to grow and metastasize (spread) to other parts of the body — using the Gleason grading system. A Gleason score is actually a sum of two Gleason grade numbers –- each one ranging from 1 to 5 –- that, when added together, make up your final Gleason score. 

The pathologist who examines the biopsied tissue samples determines where the cancer is most prominent (or common) and assigns that the primary grade. He or she then determines where the cancer is next most prominent (or next most common) and assigns that the secondary grade. A score from 1 to 5 is assigned for each area, one for the primary grade and one for the secondary grade based on how aggressive it appears. The higher the score, the more aggressive the cancer. 

The Gleason score is the sum of the primary and secondary grades. A tumor with cells that appear close to normal is assigned a low Gleason score (6 or below). Low-grade tumors are less likely to spread. A tumor whose cells appear markedly different from those of a normal prostate is assigned a high Gleason score (7 or above), and is more likely to spread.

New Diagnostic Techniques

Biomarkers — biological molecules that provide a clear indication of disease — are entering our arsenal of molecular tests for prostate cancer. New biomarkers are enabling us to more precisely detect prostate cancer, guide therapeutic decision making, monitor a patient’s response to treatment, and track the progression of his cancer. At Memorial Sloan Kettering we are working to develop and evaluate the use of biomarkers in clinical practice.

To better detect prostate cancer, our physician-scientists are studying the use of advanced molecular testing for prostate cancer, including a urine test for PCA3 (prostate cancer antigen 3). PCA3 is a gene that is prostate-cancer specific — it is expressed in more than 90 percent of prostate cancer tissue but not in normal prostate tissue — and the test detects its presence in the urine.

For men with advanced disease, our researchers are currently evaluating the effectiveness of a blood test that may be capable of detecting a single prostate cancer cell among a billion or more healthy cells. Interest in these cells, called circulating tumor cells (CTCs), has increased with the availability of new technologies to detect, count, and characterize them. This new “liquid biopsy” may offer a noninvasive, highly accurate way to find cancer cells that cannot easily be detected with current methods.

Diagnostic Imaging

If your biopsy determines that you have prostate cancer, your physician will likely recommend imaging tests to identify the precise location of your tumor and to determine the extent of the disease.

Doctors at Memorial Sloan Kettering usually use magnetic resonance imaging (MRI) and a device called an endorectal coil to determine the volume, location, and stage of prostate tumors. (Stage is the standard term that doctors use to describe the extent to which a cancer has spread to other parts of the body.) A thin wire covered with a balloon is inserted into the rectum to view the prostate and surrounding structures and to gather information about the chemical makeup of prostate cells. Our doctors use information from your MRI to help determine what treatment options will be right for you.

Depending on the findings of the DRE, PSA level, and biopsy, your doctor may also use one or more of the following imaging technologies to fully characterize your disease:

  • MRI to determine the location and extent of the tumor
  • Magnetic resonance spectroscopic imaging (MRSI), which detects levels of proteins and other chemicals associated with prostate cancer, and helps to stage the tumor
  • CT scan to see whether the cancer has spread to lymph nodes  other organs, or bones
  • Radionuclide bone scan to see whether the cancer has spread to the bone
  • PET scan to see whether cancer has spread to other organs of the body

Researchers at Memorial Sloan Kettering are investigating new imaging techniques to improve our ability to characterize an individual's prostate cancer. This approach could help doctors to predict how each person might respond to various treatments, and to evaluate a treatment's effectiveness while it is under way.