Imaging Tests For Prostate Cancer
Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. One or more imaging tests might be used:
- To look for cancer in the prostate
- To help the doctor see the prostate during certain procedures
- To look for spread of prostate cancer to other parts of the body
Which tests you might need will depend on the situation. For example, a prostate biopsy is typically done with transrectal ultrasound and/or MRI to help guide the biopsy. If you are found to have prostate cancer, you might need imaging tests of other parts of your body to look for possible cancer spread.
The imaging tests used most often to look for prostate cancer spread include:
Prostate Cancer Screening Ages 40 To 54
The PSA test is a blood test that measures how much of a particular protein is in your blood. Its been the standardfor prostate cancer screening for 30 years.
Your doctor will consider many factors before suggesting when to startprostate cancer screening. But hell probably start by recommending the PSAtest.
While the general guidelines recommend starting at age 55, you may need PSAscreening between the ages of 40 and 54 if you:
- Have at least one first-degree relative who has had prostate cancer
- Have at least two extended family members who have had prostate cancer
- Are African-American, an ethnicity that has a higher risk of developing more aggressive cancers
The Test Is Often Not Needed
Most men with high PSAs dont have prostate cancer. Their high PSAs might be due to:
- An enlarged prostate gland.
- Recent sexual activity.
- A recent, long bike ride.
Up to 25% of men with high PSAs may have prostate cancer, depending on age and PSA level. But most of these cancers do not cause problems. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. They are not likely to spread beyond the prostate. They usually dont cause symptoms, or death.
Studies show that routine PSA tests of 1,000 men ages 55 to 69 prevent one prostate cancer death. But the PSA also has risks.
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What Have Randomized Trials Of Prostate Cancer Screening Found
Several large, randomized trials of prostate cancer screening have been carried out. One of the largest is the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which NCI conducted to determine whether certain screening tests can help reduce the numbers of deaths from several common cancers. In the prostate portion of the trial, the PSA test and digital rectal exam were evaluated for their ability to decrease a mans chances of dying from prostate cancer.
The PLCO investigators found that men who underwent annual prostate cancer screening had a higher incidence of prostate cancer than men in the control group but had about the same rate of deaths from the disease . Overall, the results suggest that many men were treated for prostate cancers that would not have been detected in their lifetime without screening. Consequently, these men were exposed unnecessarily to the potential harms of treatment.
A second large trial, the European Randomized Study of Screening for Prostate Cancer , compared prostate cancer deaths in men randomly assigned to PSA-based screening or no screening. As in the PLCO, men in ERSPC who were screened for prostate cancer had a higher incidence of the disease than control men. In contrast to the PLCO, however, men who were screened had a lower rate of death from prostate cancer .
The United States Preventive Services Task Force has estimated that, for every 1,000 men ages 55 to 69 years who are screened for 13 years :
Specialist Referral And Biopsy
Your doctor will discuss your prostate check results with you. If the PSA and DRC results suggest you have a high risk for prostate cancer, your doctor will refer you to a urologist .
The specialist will discuss having a prostate biopsy, in which a small sample of your prostate gland cells are taken for examination.
The aim of the biopsy is to confirm whether or not you have prostate cancer and, if so, whether it needs treatment. The treatment options will then be discussed with you.
If the biopsy shows no evidence of cancer, you may be advised to attend future check-ups.
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What Is Done If A Screening Test Shows An Elevated Psa Level
If someone who has no symptoms of prostate cancer chooses to undergo prostate cancer screening and is found to have an elevated PSA level, the doctor may recommend another PSA test to confirm the original finding. If the PSA level is still high, the doctor may recommend that the person continue with PSA tests and digital rectal exams at regular intervals to watch for any changes over time .
If the PSA level continues to rise or a suspicious lump is detected during a DRE, the doctor may recommend additional tests to determine the nature of the problem. These may include imaging tests, such as magnetic resonance imaging or high-resolution micro-ultrasound.
Alternatively, the doctor may recommend a prostate biopsy. During this procedure, multiple samples of prostate tissue are collected by inserting hollow needles into the prostate and then withdrawing them. The biopsy needle may be inserted through the wall of the rectum or through the perineum . A pathologist then examines the collected tissue under a microscope. Although both biopsy techniques are guided by ultrasound imaging so the doctor can view the prostate during the biopsy procedure, ultrasound cannot be used alone to diagnose prostate cancer. An MRI-guided biopsy may be performed for patients with suspicious areas seen on MRI.
Special Types Of Psa Tests
The PSA level from a screening test is sometimes referred to as total PSA, because it includes the different forms of PSA . If you decide to get a PSA screening test and the result isnt normal, some doctors might consider using different types of PSA tests to help decide if you need a prostate biopsy, although not all doctors agree on how to use these tests. If your PSA test result isnt normal, ask your doctor to discuss your cancer risk and your need for further tests.
Percent-free PSA: PSA occurs in 2 major forms in the blood. One form is attached to blood proteins, while the other circulates free . The percent-free PSA is the ratio of how much PSA circulates free compared to the total PSA level. The percentage of free PSA is lower in men who have prostate cancer than in men who do not.
If your PSA test result is in the borderline range , the percent-free PSA might be used to help decide if you should have a prostate biopsy. A lower percent-free PSA means that your chance of having prostate cancer is higher and you should probably have a biopsy.
Many doctors recommend a prostate biopsy for men whose percent-free PSA is 10% or less, and advise that men consider a biopsy if it is between 10% and 25%. Using these cutoffs detects most cancers and helps some men avoid unnecessary biopsies. This test is widely used, but not all doctors agree that 25% is the best cutoff point to decide on a biopsy, and the cutoff may change depending on the overall PSA level.
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What Other Test Are Available For Men At Risk For Prostate Cancer
While traditionally, the options available to men at risk for prostate cancer were limited to PSA blood test and a prostate exam , a number of exciting innovative options are now available.
PSA is still a useful test but is being supplanted by more informative tests such as 4KScore and PHI , both of which incorporate the traditional PSA test as well. Thus, the report will list both the traditional PSA test and the 4KScore or PHI score respectively.
PHI is a new test that provides an incremental improvement over the PSA test alone when it comes to predicting the risk of prostate cancer. It can be used to reduce the need for unnecessary biopsies in some men.
Effectiveness Of Early Detection
Potential Benefits of Screening
To understand the potential benefits of PSA-based screening for prostate cancer, the USPSTF examined the results of the ERSPC, PLCO, and CAP trials and site-specific reports from 4 ERSPC trial sites. To understand the effectiveness of treatment of screen-detected, early-stage prostate cancer, the USPSTF also examined the results of 3 randomized trials and 9 cohort studies.3
The ERSPC trial randomly assigned a core group of more than 160,000 men aged 55 to 69 years from 7 European countries to PSA-based screening vs usual care.8 Four ERSPC sites reported on the cumulative incidence of metastatic prostate cancer. After a median follow-up of 12 years, the risk of developing metastatic prostate cancer was 30% lower among men randomized to screening compared with usual care . The absolute reduction in long-term risk of metastatic prostate cancer associated with screening was 3.1 cases per 1000 men.11 After a median follow-up of 13 years, the prostate cancer mortality rate among men aged 55 to 69 years was 4.3 deaths per 10,000 person-years in the screening group and 5.4 deaths per 10,000 person-years in the usual care group .8 The ERSPC trial did not find a reduction in all-cause mortality.8
Neither the ERSPC, PLCO, or CAP trials, nor any of the ERSPC site-specific analyses, found an overall all-cause mortality benefit from screening for prostate cancer.
Potential Benefits of Treatment
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An Abnormal Psa Test: What Comes Next
If your PSA score is in the abnormal range, your doctor may recommend yourepeat the PSA test. If your levels are still high, your doctor mightrecommend one of the newer prostate cancer screening tests available today.
These tests can help better assess your risk for prostate cancer anddetermine whether a biopsy is necessary. Only a prostate biopsy candefinitively diagnose prostate cancer.
For individualized recommendations that suit you, ask your doctor about:
- What age you should start prostate cancer screening
- New blood, urine and imaging tests that are available
- Improved biopsy techniques, if applicable
Potential Harms Of Screening And Treatment
Potential Harms of Screening and Diagnosis
In addition to the ERSPC and PLCO trials, the USPSTF examined the results of a good-quality cohort study embedded within the ProtecT trial , a fair-quality cohort study conducted in the US Department of Veterans Affairs health system, as well as a report on complications of prostate biopsy from the ERSPC Rotterdam site to understand the potential harms of screening and diagnosis.3
In the large RCTs, one-fourth to one-third of men offered PSA-based screening had at least 1 positive screening test result. In the PLCO trial, 13% of men had undergone at least 1 biopsy. In the ERSPC trial, nearly 28 biopsies were performed for every 100 men randomized to screening.3 In the ProbE trial, 7.3% of men reported moderate or greater pain, 5.5% reported moderate to severe fever, and 26.6% reported troublesome hematospermia within the 35 days after biopsy.28 Complications from transrectal prostate biopsy resulted in 1.3% of men in the UK cohort, 1.6% of men in the VA cohort, and 0.5% of men in the Rotterdam cohort requiring hospitalization.30-32 In these studies, two-thirds to three-fourths of biopsies demonstrated that the PSA screening test was a false positive.3
Potential Harms of Treatment
In several studies, men older than 70 years had a significantly increased risk of medical complications and perioperative mortality after radical prostatectomy compared with younger men.3
Recent Advances Can Help Men With A Worrisome Psa Result Avoid Immediate Biopsy
Prostate-specific antigen blood testing receives high marks as an effective way to monitor disease activity in men diagnosed with prostate cancer. Yet, as a screening tool for prostate cancer, PSA testing is problematic.
PSA naturally tends to increase as men get older, but levels that get too high may suggest prostate cancer. A PSA level of less than 4 nanograms per milliliter is often reassuring, unless there has been a sudden jump from a much lower number. Many doctors consider a total PSA level higher than 10 ng/mL as the threshold for getting a biopsy to check for cancer.
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How Are Researchers Trying To Improve The Psa Test
Scientists are investigating ways to improve the PSA test to give doctors the ability to better distinguish cancerous from benign conditions and slow-growing cancers from fast-growing, potentially lethal cancers. And other potential biomarkers of prostate cancer are being investigated. None of these tests has been proven to decrease the risk of death from prostate cancer. Some of the methods being studied include
Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter. New England Journal of Medicine 2004 350:22392246.
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Enabling Precision Medicine In Oncology
What is precision medicine in cancer?
Precision medicine in oncology aims to identify an individualized treatment plan based on genomic aberrations in a patients tumor. In other words, precision medicine in cancer uses biomarker testing to help oncologists select the most beneficial therapy for an individual patient. Treatments, therefore, are genomically informed and individualized, based on the patients own genetics, their metabolic profile, environment, and habits.
A key effort in precision medicine is to try to identify who will respond and who will not respond to treatment. Each patient is different, and each type of cancer is also different, and there are even differences in the same cancer type across patients.
The future of precision medicine in Oncology
Our vision for precision medicine in Oncology includes the wide spread adoption of CGP in routine testing and the application of whole exome sequencing . In addition, our vision also includes the expansion to whole-genome sequencing , whole-transcriptome and epigenomic analyses, as well as combining data sets for a multi-omics approach.
Advantages of precision oncology
Conventional test versus advanced technologies
Benefits Of Early Detection And Treatment
The goal of screening for prostate cancer is to identify high-risk, localized prostate cancer that can be successfully treated, thereby preventing the morbidity and mortality associated with advanced or metastatic prostate cancer.
Adequate evidence from randomized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened.3, 4 Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened.3 Current results from screening trials show no reductions in all-cause mortality from screening. There is inadequate evidence to assess whether the benefits for African American men and men with a family history of prostate cancer aged 55 to 69 years are different than the benefits for the average-risk population. There is also inadequate evidence to assess whether there are benefits to starting screening in these high-risk groups before age 55 years.
Adequate evidence from RCTs is consistent with no benefit of PSA-based screening for prostate cancer on prostate cancer mortality in men 70 years and older.
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What Is Cancer Screening
Screening means testing people for early stages of a cancer, or for early changes that could develop into cancer if left untreated. For screening to be useful the tests:
- need to be reliable at picking up cancers that need treatment
- overall must do more good than harm to people taking part
- must be something that people are willing to do
Screening tests are not perfect and have some risks. The screening programme should also be good value for money for the NHS.
What To Do If You Are Worried About Prostate Cancer
Talk to your GP if you’re worried about prostate cancer. Or if you have urinary symptoms such as difficulty passing urine. The symptoms don’t mean that you have prostate cancer, but it is important to get them checked.
Adult screening programme Prostate cancerUK National Screening Committee, Last accessed March 20222
Screening for prostate cancer. External review against programme appraisal criteria for the UK National Screening CommitteeUK National Screening Committee, October 2020
Prostate cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow upC Parker and others
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New Blood Test Improves Prostate Cancer Screening
- Karolinska Institutet
- Researchers recently reported that magnetic resonance imaging could reduce overdiagnoses and thereby improve prostate cancer screening. Now, the same research group shows that the addition of a novel blood test, the Stockholm3 test, can reduce the number of MRIs performed by a third while further preventing the detection of minor, low-risk tumors.
Researchers at Karolinska Institutet in Sweden recently reported that magnetic resonance imaging could reduce overdiagnoses and thereby improve prostate cancer screening. Now, the same research group has published a study in The Lancet Oncology, which shows that the addition of a novel blood test, the Stockholm3 test, can reduce the number of MRIs performed by a third while further preventing the detection of minor, low-risk tumours.
“Overall, our studies show that we have identified the tools needed to be able to carry out effective and safe screening for prostate cancer. After many years of debate and research, it feels fantastic to be able to present knowledge that can improve healthcare for men,” says Tobias Nordström, associate professor of urology at the Department of Clinical Sciences, Danderyd Hospital at Karolinska Institutet, who is responsible for the STHLM3MRI study.
Henrik Grönberg, Martin Eklund and Tobias Nordström are partners of the company A3P Biomedical AB, which holds the development rights of the Stockholm3 test.