Diagnosis and Treatment
Other than skin cancer, prostate cancer is the most common cancer in American men
Early prostate cancer generally has no symptoms. That’s why discussing with your doctor when to begin and how often to have a digital rectal exam and a prostate-specific antigen (PSA) blood test is so important. By the time symptoms are noticeable, like blood in the urine, pain, problems passing urine or even loss of bladder or bowel control, the cancer is in an advanced stage making treatment outcomes less doubtful.
Evaluation and Diagnostic Testing
The most common way to check for prostate cancer is to have a digital rectal exam and a PSA blood test. Prostate-specific antigen is a protein produced by cells of the prostate gland. A higher level of PSA could mean that you have prostate cancer. If your PSA is high, or if your doctor finds anything during the rectal exam, he or she may do a biopsy to figure out the cause. A biopsy means your doctor takes a sample of tissue from your prostate gland and sends it to a lab for testing.
Men who are concerned about their risk should see a urologist who may elect to evaluate for prostate cancer using these tools:
- Digital Rectal Examination and PSA
Prostate biopsy prompted by abnormal findings on a digital rectal exam (DRE), such as nodularity or induration of the prostate leads to a diagnosis of prostate cancer in only 15%-25% of cases. However, an abnormal DRE is associated with a five-fold increased risk of cancer present at time of screening.
PSA is a serine protease produced by the prostatic epithelium and secreted in the seminal fluid in large quantities. The level of PSA is increased in the blood by inflammation of the prostate, urinary retention, prostatic infection, benign prostatic hyperplasia, prostate cancer, and prostatic manipulation.
- Mi-Prostate Score
For men with an elevated PSA, the University of Michigan has begun offering a new urine test called Mi-Prostate Score to better assess the risk of cancer being present. The test developed from a discovery by U-M researchers of a genetic anomaly that occurs in about half of all prostate cancers, an instance of two genes changing places and fusing together.
This gene fusion, T2:ERG, is believed to cause prostate cancer. Studies in prostate tissues show that the gene fusion almost always indicates cancer.
The new urine test looks for the T2:ERG fusion as well as another marker, PCA3. This is combined with the PSA measure to produce a risk assessment for prostate cancer. The test also predicts risk for having an aggressive tumor, helping doctors and patients make decisions about whether to wait and monitor test levels or pursue immediate biopsy.
If your PSA or Mi-Prostate Score are high, or if your doctor finds something concerning during the rectal exam, he or she may do a biopsy to figure out the cause. A biopsy means your doctor takes a sample of tissue from your prostate gland and sends it to a lab for testing. Prostate biopsies are usually performed as an office procedure. The procedure is done without the need for anesthesia and carries a risk of significant infection of only 1 in 200. Some blood in the urine or in bowel movements can be common for two or three days following the biopsy. Blood in the semen may last for up to several weeks.
If the biopsy is negative, these men are typically followed by checking PSA and rectal exam annually. Repeat biopsy may be needed if PSA levels rise at abnormal rates (less than 0.8 ng/dL/year) or if rectal exam shows new nodularity or induration.
When the biopsy is positive and the cancer is staged, you and your interdisciplinary team will devise a personalized treatment plan that may include medical management and/or surgery.
Men in whom high-grade prostatic intraepithelial neoplasia (an abnormality thought to precede prostate cancer) is found on biopsy may undergo repeat biopsy, since about one-third will be found to have prostate cancer.
Medical management and treatment options
You and your doctor may decide to treat your cancer with surgery, radiation, hormone therapy, or a combination. As part of your treatment in the Multidisciplinary Urologic Oncology Clinic, patients have their cases reviewed weekly by nationally recognized experts in urologic oncology -- urologists, medical oncologists, radiation oncologists and pathologists -- who are supported by a specially trained nursing and physician-assistant staff with specific expertise in urologic oncology. Together, this team recommends personalized, patient specific treatment plans.
There are many variables that are taken into consideration when your treatment plan is devised and discussed in the weekly conference such as other health risks, the level of your disease and past health history. Main treatment options may include one or more of the following:
- Radical prostatectomy (surgery)
- Radiation therapy with the intent to cure
Treatment plans can include intensity modulated radiation therapy, proton therapy and brachytherapy (seeds) [see the Radiation Oncology website for more information].
- Hormone therapy
Chemical or surgical castration to remove the source of hormones fueling the cancer. Though not curative, hormone therapy can keep the cancer at bay for an extended time.
- Active surveillance with regular medical checkups
This procedure freezes the cancerous tissue and is used when other therapies have failed.
- Referral to the High Risk Prostate Cancer Clinic
- Clinical trials
Surgery for prostate cancer, called a radical prostatectomy, is used with intent to cure and involves removing the entire prostate gland and some of the nearby tissue. There are a number of ways to perform this surgery, including open, laparoscopic and robotic. Your surgeon will discuss the advantages and disadvantages for each of these options. Our team has considerable experience in performing this type of surgery. To learn more about our volumes and outcomes, visit the prostate cancer quality and safety page on the UofMHealth.org website.
Robotic prostatectomy with intent to cure is becoming a sought after surgical option. The minimally invasive procedure is performed with the assistance of da Vinci® surgical robot , and duplicates the standard surgery to remove the prostate gland but with smaller incisions. The goal of this procedure is to excise the cancer completely, provide good urinary continence post-operatively and maintain ability to have erections after the surgery.
Our robotic surgery team is made up of five urologic oncologists and one urologist, all specializing in robotic surgery and performs hundreds of prostatectomies each year.
Robotic surgery uses slender telescope-like instruments placed through small incisions as opposed to a large incision that is typical in an open surgery. The surgeon controls the robot from a console next to the patient where the operating field can be viewed in three dimensions. This type of technology, which acts as an extension of the surgeons hands, allowing for more accurate surgery with better outcomes, less pain, less risk of wound infection, less blood loss, less scarring and faster recovery time.
All prostate surgical techniques carry a risk of urinary incontinence and erectile dysfunction. Your surgeon will explain these risks and help you connect to our Prostate Cancer Survivorship Clinic where you and your spouse or partner can receive aftercare and support.
Still have questions?
The nurses at Cancer AnswerLine™ have answers. Call 1-800-865-1125 and you'll get a personal response from one of our registered nurses, who have years of experience in caring for people with cancer.