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.

What are other reasons why PSA levels may have risen?

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DRE

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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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 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.

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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References

1) https://www.cancer.org/cancer/prostate-cancer/early-detection/tests.html

2) https://www.everydayhealth.com/prostate-cancer/non-cancerous-reasons-your-psa-levels-are-high.aspx