Understanding PSA and Other Prostate Cancer Screenings

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PSA

What is PSA?

PSA is a protein (called prostate specific antigen) produced by cells that line the small glands inside the prostate. When a man has prostate cancer, his PSA levels tend to increase which is why a PSA test is often used by physicians to screen for prostate cancer.

What is a PSA Test?

To conduct a PSA test, a physician will take a blood sample and send it to a laboratory for analysis. A PSA test result is an important factor when determining prostate cancer diagnosis, plan, and treatment. However, an elevated PSA does not always mean a man has prostate cancer.  Additionally, a low PSA does not mean that cancer is not present.

When should I start PSA Screenings?

Doctors often recommend PSA testing in men 55 and older. However, your doctor may recommend testing your levels at an earlier age if you have known risk factors for prostate cancer, including family history of the disease or the know presence of a germline mutation.

Understanding your PSA results

In general, doctors often consider PSA levels of 3.9 ng/mL and lower to be normal depending on your age. It is also important for your doctor to track any increases in your PSA levels as these increases may suggest the presence of cancer even if your PSA is in the normal range.

According to American Cancer Society, men with a PSA level between 4.0 and 10.0 ng/mL have a 25% chance of having prostate cancer. Men with a PSA level greater than 10.0 ng/mL, their chance of prostate cancer is over 50%1

Consult with your physician regarding PSA results and PSA ranges.

As mentioned above a high PSA doesn’t always mean a man has prostate cancer. PSA levels can be elevated because of several benign conditions.

What are other reasons why PSA levels may have risen?

  • 1. Age
    • It is normal for PSA levels to increase gradually with age.
  • 2. Men Over 50: BPH
    • Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland, but it is not prostate cancer. BPH is another common prostate problem in men over age 501. It may not need to be treated unless it causes frequent, difficult urination or other urinary symptoms.Your primary care doctor may be able to tell the difference between BPH and prostate cancer by doing a digital rectal exam (DRE), but commonly this will require evaluation by a urologist and further testing, such as a biopsy or imaging studies.2
  • 3. Prostatitis: A Common Problem in Men Under 50
    • Prostatitis is the most common prostate problem for men younger than 50.2Prostatitis caused by bacteria is treated with antibiotics. Another, more common type of prostatitis, called nonbacterial prostatitis, can be harder to treat and may last a long time.2
  • 4. Medical Procedures
    • Any of the following medical procedures could potentially lead to a rise in PSA:
      • Prostate Biopsy
      • Transurethral Resection of the Prostate (TURP)
      • Urethral Catheter
      • Cystoscopy
      • Or any other procedure that involves the prostateIf you have had any of the above medical procedures or conditions, you should consult your physician to see if you should wait before having your PSA test.
  • 5. A Digital Rectal Exam (DRE)
    • To avoid this type of elevation, doctors will usually draw blood for a person’s PSA level prior to conducting a rectal exam.
  • 6. Urinary Tract Infection
    • If you have been diagnosed with a urinary tract infection, this could irritate or inflame the prostate cells that could lead to a result of a falsely elevated PSA.Be sure to wait until after the infection has cleared up before getting a PSA test. In men, most urinary tract infections are caused by bacteria and respond well to antibiotics.
  • 7. Sexual Activity
    • Participating in a sexual activity that involved ejaculation within about 48 hours before testing can affect PSA results.
  • 8. Certain Medications and Supplements
    • Medications such as aspirin, statins, nonsteroidal anti-inflammatory drugs, or medication for urinary problems have the potential to affect PSA levels.Sport or nutritional supplements such as testosterone can cause PSA levels to rise.
  • 9. Riding a Bicycle
    • There have been studies that suggest cycling may raise PSA. The studies mention the rise may be due to the seat putting pressure on the prostate. It should be made of note that not all studies have found this to be true.
  • 10. Prostate Cancer
    • Having a high PSA result when paired with other screening tests,  including DRE, can be an indication you may be at risk for prostate cancer, which can result in your doctor recommending a biopsy to confirm a prostate cancer diagnosis.

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Digital Rectal Exam

Digital Rectal Exam (DRE)

Doctors use a Digital Rectal Exam (DRE) to screen for cancer. This procedure is completed to examine the health of the prostate gland and to check for abnormalities and prostate cancer. The prostate can be felt through the side of the rectal wall. Please note that not all parts of the prostate can be felt on this exam.

What can you expect with a DRE?

A DRE is an in-office examination where your doctor or nurse use gently insert a lubricated, gloved finger into the anus to estimate the size of the prostate and feel for lumps or other abnormalities.

Due to the additional pressure on the prostate, some men may feel discomfort or the urge to urinate during the exam.

If the PSA or DRE tests are suspicious for prostate cancer, your doctor will likely request further testing such as prostate biopsy and/or imaging.

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Prostate Biopsy

Prostate Biopsy

As mentioned, rising PSA levels and an abnormal DRE may suggest cancer is present. To confirm the presence of prostate cancer, your doctor will order a prostate biopsy. The biopsy is the small samples of tissues from the prostate to be reviewed by a pathologist to determine if cancer is present. An urologist often completes this process.

What can you expect before and during a biopsy?

To prepare for the biopsy, the doctor may do the following:

  • Ask you to stop taking certain medications.
  • Prescribe antibiotics to prevent infection
  • Order an at home enema
  • Have a clear liquid diet in the days leading to the procedure

Please talk with your doctor about their full list of instructions before your biopsy.

During the biopsy procedure, the doctor will use TRUS, mentioned below, during the biopsy to guide a thin hollow needle through the rectal wall into the prostate.  In some instances, the doctor will order an MRI before the biopsy to locate abnormalities within the prostate that may represent prostate cancer. The needle retrieves several thin cylindrical sections, or cores, of prostate tissue. Most urologists take 6-12 core samples in total from different areas of the prostate.

Some doctors may recommend imaging guidance during the prostate biopsy procedure to help ensure that the best samples are being removed. Transrectual Ultrasound (TRUS) is a form of imaging guidance.

What is a Transrectal Ultrasound (TRUS)?

A small probe, about the width of a finger, is inserted into your rectum. The probe emits soundwaves that enter the prostate and create echoes. Those echoes are picked up by the probe and sent to a computer that turns them into an image of the prostate.  This procedure often takes less than 10 minutes and is done in a doctor’s office or outpatient clinic.

What happens after the biopsy is performed?

Biopsy samples will be sent to a lab examined by a pathologist for cancer cells. If the pathologist can see cancer, a grade will be assigned. This grade is called the Gleason grade. Prostate cancer Gleason grades range from 1 to 5. Higher Gleason grades usually represent more aggressive prostate cancer. The Gleason grades will be available on the pathology report.

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Gleason Scoring

What is Gleason Scoring?

Pathologists review biopsy tissue and assign it a Gleason grade based on the appearance of the cells. If cancer is present, it will be assigned two Gleason grades ranging from 1 to 5. The primary grade, or first number shown, is the most common Gleason pattern (grade) found in the biopsy. The second number is the second most common Gleason pattern (grade).  These two numbers are added together for a Gleason score. Gleason scores range from 2 to 10 with most prostate cancer ranging from 6 to 10. An example Gleason score is 3+4=7. In this example, 3 is the primary pattern, and 4 is the secondary. When added together they equal 7.

Another term you may hear regarding Gleason scores is Grade Groups. Gleason scores have been divided into groups ranging from 1 to 5. Gleason score and Gleason grades determine the Gleason group.

Gleason Group Break Down

Grade group 1: Gleason score = 6 (or less) and Gleason pattern = 3+3

Grade group 2: Gleason score = 7 and Gleason pattern = 3+4

Grade group 3: Gleason score = 7 and Gleason pattern = 4+3

Grade group 4: Gleason score = 8 and Gleason pattern = 4+4, 3+5, 5+3

Grade group 5: Gleason score = 9 or 10 and Gleason pattern = 4+5, 5+4, 5+5

Limitations of Gleason Scoring:

Gleason scores play a vital role in determining treatment decisions. First developed in the 1970s, Gleason scores have been used to assess the aggressiveness of patient’s prostate cancer.  Unfortunately, errors when determining biopsy Gleason score are common. Gleason grading and scoring are largely subjective, and not all pathologists may agree on a Gleason grade, especially on small tissue samples obtained at biopsy. Therefore variation between pathologists does occur.

Additional testing can be done to get a more accurate assessment of your cancer aggressiveness. The Prolaris test is one such test that combines clinical and pathologic features (findings on DRE, PSA and Gleason score) with a tumor molecular measure derived from your biopsy tissue to deliver a unique view into how fast cancer cells are dividing and cancer aggressiveness. A Prolaris Score can help you, and your doctor move forward with confidence to make the best treatment decision.

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