Getting A Prostate Biopsy
For some men, getting a prostate biopsy might be the best option, especially if the initial PSA level is high. A biopsy is a procedure in which small samples of the prostate are removed and then looked at under a microscope. This test is the only way to know for sure if a man has prostate cancer. If prostate cancer is found on a biopsy, this test can also help tell how likely it is that the cancer will grow and spread quickly.
For more details on the prostate biopsy and how it is done, see Tests to Diagnose and Stage Prostate Cancer.
For more information about the possible results of a prostate biopsy, see the Prostate Pathology section of our website.
Data Extraction And Risk Of Bias Assessment
For each study selected for inclusion, two team members independently extracted data using a previously tested standardised form. Data collected were general study information study population details details of the intervention and comparator and outcomes of interest as listed above. Inconsistencies in extracted data were resolved between the two team members through discussion, with a third team member serving as arbitrator. For the ERSPC study, we focused on the âcoreâ group, which best corresponded to the target population of the accompanying Rapid Recommendation. The ERSPC study recruited men aged 50-74 years, but focused its data analysis on men in the core age group of 55-69 years.
Psa Testing For Detection Of Prostate Cancer
The introduction of prostate-specific antigen testing into clinical practice has greatly increased the detection of localized prostate cancer and, by doing so, has decreased the diagnosis of regional and metastatic disease. PSA testing has had such a profound clinical effect that questions have arisen regarding the significance of the cancers that are being detected.
Stage, grade, tumor volume, and PSA testing are used to determine whether a prostate cancer is clinically significant or insignificant. However, there is no generally accepted precise definition for this distinction.
The goal of early detection of prostate cancer is to identify clinically significant cancers at a time when treatment is most likely to be effective. The risk of death from prostate cancer is significant in those with moderate- to high-grade tumors. This is especially true in younger men. Long-term survival is compromised when the cancer has spread beyond the confines of the prostate, into the regional lymph nodes, and to distant sites.
Several studies have shown that with a PSA cutoff of 4.0 ng/mL, clinically insignificant cancers are detected in fewer than 20% of men, but nearly 50% of all the cancers detected because of an elevated PSA level are localized, and these patients are candidates for potentially curative therapy. Only a small proportion of prostate cancers detected by PSA testing and treated with radical prostatectomy are low-volume and low-grade tumors.
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Is The Psa Test Recommended For Prostate Cancer Screening
Beginning around 2008, as more was learned about both the benefits and harms of prostate cancer screening, a number of professional medical organizations began to caution against routine population screening with the PSA test. Most organizations recommend that individuals who are considering PSA screening first discuss the risks and benefits with their doctors.
Some organizations do recommend that men who are at higher risk of prostate cancer begin PSA screening at age 40 or 45. These include Black men, men with germline variants in BRCA2 , and men whose father or brother had prostate cancer.
In 2018, the United States Preventive Serves Task Force updated its recommendation statement for prostate cancer screening from a D to a C in men ages 55 to 69. The updated recommendation, which applies to the general population as well as those at increased risk due to race/ethnicity or family history, is as follows:
- For individuals ages 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one. Before making the decision, a person should discuss the potential benefits and harms of screening with their clinician and consider these in the context of their own values and preferences.
- PSA-based screening for prostate cancer is not recommended for individuals 70 years and older.
How To Get A Psa Test
Consult with your general practitioner or urologist about receiving a PSA test in their offices. PSA tests are typically covered without co-pay or deductible by Medicare once a year for men 50 years and older. Many states now have laws which require private health insurers to cover the costs for PSA testing. However, additional PSA test costs may need to be covered by the patient.
For those without insurance, or for those with insurance that does not cover PSA testing, free tools are available through advocacy groups, such as ZERO.
Companies such as imawaretm also offer in-home PSA testing kits and telemedicine appointments to discuss your PSA test results with a licensed physician. All imaware test kits are easy to use. After registering the test kit online, results will populate in the secure patient portal within 5-7 business days. You can submit your receipt of this test to insurance for potential reimbursement.
At-Home testing is now at a point where results can be provided accurately and quickly within 5 business days, with real physicians providing telemedicine support through the entire testing process
Dr. Diamandis Lunenfeld-Tanenbaum Research Institute, Sinai Health System
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What’s A Raised Psa Level
The amount of PSA in your blood is measured in nanograms of PSA per millilitre of blood .
If you’re aged 50 to 69, raised PSA is 3ng/ml or higher.
A raised PSA level in your blood may be a sign of prostate cancer, but it can also be a sign of another condition that’s not cancer, such as:
How Is Prostate Cancer Treated
Treatment options for prostate cancer include:
- Surgery to remove the prostate .
- High intensity focused ultrasound .
- Cryotherapy .
- Hormone treatment, also called androgen suppression therapy.
You may continue to have PSA level tests during and after prostate cancer treatment. These tests check that the treatment is working.
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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
Linked Articles In This Bmj Rapid Recommendation Cluster
Tikkinen KAO, Dahm P, Lytvyn L, et al. Prostate cancer screening with prostate-specific antigen test: a clinical practice guideline. BMJ 2018:362:k3581. doi:10.1136/bmj.k3581
Summary of the results from the Rapid Recommendation process
Ilic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen test: a systematic review and meta-analysis. BMJ 2018:362:k3519. doi:10.1136/bmj.k3519
Systematic review and meta-analysis of all available randomised trials that assessed PSA based screening for prostate cancer
Vernooij RWM, Lytvyn L, Pardo-Hernandez H, et al. Values and preferences of men for undergoing prostate-specific antigen screening for prostate cancer: a systematic review. BMJ Open 2018 0:e025470. doi:10.1136/bmjopen-2018-025470
Systematic review of the values and preference of men considering PSA screening
The protocol for this systematic review was registered with PROSPERO .14
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Watchful Waiting Or Active Surveillance
Prostate cancer treatments can have side effects. If youâre worried about these risks, you can decide to hold off on these treatments and see if your tumor grows. Waiting is also an option if youÃ¢re older, your cancer is growing slowly, or you donât have symptoms that bother you.
Waiting does not mean that you do nothing about your cancer. Your doctor will keep a close eye on the tumor and watch for any signs that itÃ¢s getting worse.
Watchful waiting means you and your doctor will look out for symptoms. The doctor may do tests from time to time to make sure the cancer hasnât grown.
Active surveillance means your doctor will do tests, including PSA blood tests and rectal exams, usually about every 3-6 months to check on it. You may also have a biopsy, when a doctor takes a small piece of tissue from your prostate and checks it for cancer.
What Treatments Are Available
If you have advanced prostate cancer, treatment wont cure your cancer. But it can help keep it under control and manage any symptoms.
If youve just been diagnosed with advanced prostate cancer, you may be offered the following treatments:
Research has found that having radiotherapy together with one of the main treatments listed above can help some men with advanced prostate cancer to live longer. But radiotherapy isnt suitable for all men with advanced prostate cancer.
If you live in Scotland, you may also be offered a type of hormone therapy called abiraterone acetate together with standard hormone therapy. In the rest of the UK, abiraterone is currently only given to men with advanced prostate cancer that has stopped responding to other types of hormone therapy. The National Institute for Health and Care Excellence is currently deciding whether to make it available for men who have just been diagnosed with advanced prostate cancer.
Before you start treatment
Before you start any treatment, make sure you have all the information you need. Its important to think about how you would cope with the possible side effects. Speak to your doctor or nurse about this.
It can help to write down any questions you want to ask at your next appointment. It may also help to take someone with you, such as your partner, a family member or friend.
If you have any questions, speak to our Specialist Nurses.
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Psa Levels By Age Chart
The main difference between the PSA scores of prostatitis and an enlarged prostate, compared to prostate cancer, is the ratio of free vs bound PSA within your test sample.
- Prostate Cancer will have a higher bound PSA ratio.
- An enlarged prostate and prostatitis will have a higher free PSA ratio.
- If your free PSA results are less than 25%, your risk for developing prostate cancer is between 10% to 20%.
- If your free PSA results are less than 10%, your risk for developing prostate cancer jumps to around 50%.
The Role Of Psa In Staging
Prostate cancer causes cells to become malignant and multiply uncontrollably. This can lead to overproduction of PSA, and higher levels of PSA in the bloodstream.
However, some men who have prostate cancer do not exhibit elevated PSA levels. And certain noncancerous conditions, like a prostate infection or benign enlargement, can also cause high PSA levels.
PSA levels are just one factor used in determining the stage of prostate cancer. Another diagnostic tool is called the Gleason scale. This rates the extent of abnormality in your prostate cells after biopsy.
At a certain point in prostate cancers late-stage progression, Gleason and PSA become less useful. When a tumor is large enough, doctors no longer need these numbers to predict its growth or malignancy.
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Production In Benign Hyperplasia
The majority of PSA is produced by the glands in the transitional zone of the prostate. This portion of the prostate is associated with benign prostatic hyperplasia . The peripheral zone, where 80% of prostate cancers originate, produces very little PSA.
The Hybritech monoclonal assay produced a measurement of 0.5 Â± 0.4 ng/mL. Using the monoclonal assay, Lee et al calculated a serum PSA elevation of 0.12 ng/mL per gram of benign prostatic tissue.
Definition Of Biochemical Progression
The definition of PSA-only recurrence depends upon the initial treatment modalityprostatectomy or radiation therapy
All prostate tissue is removed during a successful radical prostatectomy. Postoperatively, therefore, detectable serum PSA using standard immunoassays is considered indicative of residual prostatic tissue, presumably representing locoregional or systemic cancer
The definition of biochemical failure is more complicated after radiation therapy than following radical prostatectomy. Some normal prostatic glandular tissue remains and serum PSA levels are unlikely to fall to undetectable levels following a course of RT. The interpretation of serum PSA is also complicated by the use of androgen deprivation, in addition to radiotherapy in some patients with intermediate or high risk disease.
The decline in serum PSA following RT is gradual and the mean time for the PSA to reach its nadir is 18 months or longer .
To standardize serum PSA testing for outcome assessment following RT, a 1996 American Society for Radiation Oncology consensus panel addressed the definition of biochemical recurrence following definitive RT. Biochemical failure was defined as occurring after three consecutive PSA rises following a nadir. The date of biochemical failure was halfway between the nadir and the date of first rise or any rise great enough to provoke the initiation of therapy .
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Addressing All Of Your Healthcare Needs
We understand that a diagnosis of cancer can be challenging for you and your loved ones. Thatâs why we offer psychosocial, nutritional, and other support services for people with urologic cancers. Your team includes palliative care physicians as well, ensuring that your quality of life is the best it can be from the moment of diagnosis and throughout your treatment. As a major medical center, we can also address your other healthcare concerns and connect you with the specialists you need.
Questions To Ask Your Doctor
To help understand the progression of prostate cancer, discuss these questions with your doctors:
- What is my Gleason score?
- Has the cancer spread outside my prostate?
- Whats my prostate cancer stage?
- Are other tests needed to determine my cancer stage?
- What are the treatment options for my stage of cancer?
- Can I avoid treatment right now and go on active surveillance?
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How To Get Tested
Samples used for PSA testing are collected by trained health care professionals at hospitals, labs, and other medical settings. Before getting tested, its best to talk to your doctor about the risks and benefits of PSA testing. You may be able to schedule your own PSA test at a clinic or laboratory without a doctors order. However, you will need a doctor to interpret the results of your test and recommend next steps.
Does The Natural History Of The Disease Justify Screening
The next principle of screening is that the natural history of the disease must be well known, and an asymptomatic phase of sufficient duration must exist to allow detection by screening at reasonable intervals. Autopsy studies and analyses of pathology specimens derived from prostate surgery for apparently benign disease, as well as case series of screening, certainly indicate that asymptomatic prostate cancer exists. However, prostate cancer is not biologically one disease: great variation exists in the aggressiveness of different tumors, with some cancers being quite aggressive and resulting in sickness and death soon after detection and others being indolent. The natural history from the development of prostate cancer to the occurrence of symptoms and, eventually, death is not well known for different types of prostate cancer.
Although prostate cancer likely has a spectrum of aggressiveness, the ends of this spectrum shed light on the unreliability of data suggesting benefits from earlier detection through screening. In the natural history of two biologically different prostate cancers, the time from the development of disease to the onset of symptoms is quite prolonged in indolent prostate cancer but short in aggressive disease. Thus, indolent cancer is likely to be detected by screening before the onset of symptoms, but aggressive cancer may not have an asymptomatic phase long enough to allow detection by screening before symptoms are manifested.
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How Is Prostate Cancer Diagnosed
According to Mayo Clinic, if your test results come back as abnormal, doctors may require further testing. They may do a digital rectal exam, feel or press on the prostate with a gloved finger to check for lumps or hard areas, or do a prostate biopsy.
A prostate biopsy is usually one of the last tests done to rule out prostate cancer after a Urine PCA3 test. This urine test tests for a mix of different genes that show up in nearly 50% of PSA-tested men who have prostate cancer. If you show symptoms of prostate cancer, your doctor may order a PSA test.
If you are diagnosed with prostate cancer, you may have to go through different forms of therapy like radiation or surgery. These all have different side effects.
What Happens If My Cancer Starts To Grow Again
Your first treatment may help keep your cancer under control. But over time, the cancer may change and it may start to grow again.
You will usually stay on your first type of hormone therapy, even if its not working so well. This is because it will still help to keep the amount of testosterone in your body low. But there are other treatments that you can have alongside your usual treatment, to help control the cancer and manage any symptoms. Other treatments include:
Which treatments are suitable for me?
Which treatments are suitable for you will depend on many things, including your general health, how your cancer responds to treatment, and which treatments youve already had. Talk to your doctor or nurse about your own situation, or speak to our Specialist Nurses.
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