Prostate cancer is a disease with a favorable prognosis, if this term can be ascribed to a malignant tumor. Like any cancer, it is characterized by infiltrative growth and metastases. However, the tumor grows slowly and metastasizes later on.
Early diagnosis of prostate cancer is difficult to determine due to the lack of symptoms and late turnover of the patients. However, up to stage 3, the disease is well treatable when there are no distant metastases present.
Because of the high prevalence among men, prostate cancer is considered the second most common oncological cause of death among males (after lung cancer). In developed countries prostate cancer is diagnosed on average in 1 out of 9 men during their lifetime. However, for every 1 male out of 40, prostate cancer causes death. Thus, more than 75% patients who have received qualitative treatment will not die from this disease. However, it is very important to identify prostate cancer in time, before the spreading of metastases, to conduct treatment successfully.
How is prostate cancer diagnosed?
The most important part in the diagnosis of prostate cancer is a blood test that identifies prostate specific antigen. It gives reason to suspect prostate cancer and conduct further diagnostic procedures that either to confirm or dismiss the suspicion.
The general algorithm for determining prostate cancer is as follows:
- The patient had a blood test for PSA (prostate-specific antigen)
- If the PSA level is raised, the doctors conduct in-depth laboratory diagnosis, clinical examination of the patient and ultrasound of the prostate
- When the tests show a high probability of detecting a malignant tumor, biopsy of the prostate gland is indicated
Since it is impossible to diagnose prostate cancer in the early stages by symptoms, since they appear late and are not specific (this is common in many other diseases), it is very important to undergo regular screening after 50 years. It includes blood test for the prostate-specific antigen. This study allows patient to go to the doctor on time, confirm or dismiss the diagnosis, and, if necessary, receive treatment.
How is prostate cancer test called?
Testing of PSA(prostate-specific antigen) level in the blood is the main way of early prostate cancer diagnosis. However, the results of the study are not 100% reliable and require confirmation. PSA levels are always elevated in case of prostate cancer. Nevertheless, not every increase in the PSA level indicates a malignant tumor.
This indicator often increases with other pathologies, such as:
- Benign prostatic hyperplasia
- A recent surgery on the prostate gland
- Prostate massage or digital rectal examination
- Catheterization of the bladder, cystoscopy, colonoscopy
- The use of drugs
What tests are taken for diagnosing prostate cancer? In total, there are 2 PSA fractions in the blood: total and free. Total PSA is the sum of PSA free and protease-related protease inhibitors.
If the blood test showed that the PSA level does not exceed 4 ng / ml, the patient most likely does not have prostate cancer. The probability of tumor detection during biopsy with this PSA concentration does not exceed 0.5%.
If the PSA is higher than 20 ng / ml, the probability of detecting cancer reaches 75%. Therefore, at such an oncomarker level, a biopsy is immediately prescribed. Histological tissue examination will confirm or refute the diagnosis.
The so-called "gray zone" represents the greatest difficulty for diagnosis. This includes a group of patients with a PSA level above 4 ng / ml, but below 15 ng / ml. Since it is very difficult to detect prostate cancer in the early stages without conducting a biopsy, and the biopsy can not be performed for everybody (this procedure is painful and it may cause complications), additional methods of diagnosis are required to increase the specificity of diagnosis.
Since it is impossible to distinguish prostate cancer from an adenoma or an inflammatory process based on the PSA level alone, all patients in the "gray zone" need additional examination, as well as several laboratory and calculative figures, which show how high the risk of developing prostate cancer or adenoma is.
The doctors take into account:
The age. The older the person, the higher the PSA level. Whereas up to 50 years the concentration of this substance in men does not exceed 2.5 ng / ml, after 70 years the norm is 6 ng / ml.
Ratio of PSA fractions. As it was already mentioned, there is free and total prostate-specific antigen. Their ratio is determined by measuring them in percentile. This indicator conducts differential diagnosis between a benign hyperplasia and a prostate cancer.
The lower the percentage of free PSA from the total one, the higher the risk of a malignant neoplasm. Interpretation of the analysis results may reveal prostate cancer:
- Below 15% - the probability of a tumor is high
- 15-23% - average
- More than 23% - low (most likely, the cause of PSA increase was BPH)
Studies show that when the ratio of free and total PSA is less than 10%, the risk of detecting prostate cancer is 44%. If this ratio is within 10-15%, the probability of cancer is 33%. In 26% or more, the probability of detecting a tumor during a biopsy does not exceed 11%.
PSA density index. This index is used for calculation. It uses two indicators: the volume of the prostate (determined by ultrasound) and the level of PSA. In prostate cancer, the density of the prostate exceeds 0.15 ng / ml per cubic centimeter. If the indicator is lower, the probability of detecting a tumor during a biopsy is not high.
Dynamic of the PSA increase. It is normal for the total PSA to increase by no more than 0.75 ng / ml per year. If there is higher annual increase, the probability of cancer is estimated as high.
Biochemical recurrence of prostate cancer
We discussed the blood test which is the most informative in the primary diagnosis of prostate cancer. However, this study is used not only to detect a tumor.
PSA level also determines:
- Stage of the prostate cancer - this, in turn, determines the treatment course
- How likely the presence of distant metastases is
- How likely prostate cancer recurrence is
- How successful the treatment was
After conducting radical prostatectomy, the PSA level should decrease to 0.2 ng / ml or lower. Success of radiation therapy is determined by a decrease of the PSA to 1 ng / ml or lower.
After treatment, the patients regularly takes this test to detect the recurrence of process in time. If the patient had surgery which removed the prostate, the doubling of PSA in less than 4.3 months shows a systemic relapse, and the doubling of the indicator in less than 11.7 months - local relapse.
The main clinical sign that helps to diagnose prostate cancer is a digital rectal examination. It is conducted only after the PSA testing, as any mechanical effect on the prostate gland increases the level of prostate-specific antigen. This can cause a false positive result.
It is impossible to distinguish prostate cancer from prostatitis or adenoma with digital rectal examination. All that a doctor can reliably determine is the presence or absence of a tumor-like formation. However, not every tumor is cancer. The prostate can be enlarged due to the inflammatory process, and in this case it is often painful or an increase in its volume may be caused by benign tissue proliferation (BPH).
After undergoing digital rectal examination all patients are divided into two groups:
- With a palpable tumor
- Without palpable tumor
We have already determined what PSA found out that its level can be in the "gray zone". In this case, if the palpable tumor has not been detected, the patient goes home - no further examination is required.
If the palpable formation is present, additional studies are needed:
- Free PSA with determining ratio of the free and total fraction
- Ultrasound of the prostate
- PSA density index
- Dynamic of the PSA increase
All these measures do not detect prostate cancer, but they determine the need for a biopsy, which can determine the diagnosis.
Can prostate cancer be seen on the ultrasound?
The ultrasound is used in the diagnosis of prostate cancer, but this study is not conclusive, since the ultrasound is not enough to detect prostate cancer.
The doctor can only estimate:
- Size of the prostate gland
- The presence of hyperechoic or hypoechoic areas (fragments of tissue into which ultrasonic waves penetrate better or worse)
Echogenicity determines the density of the tissue. Prostate cancer cannot be detected with ultrasound. However, it can be suspected.
The main objectives of this study are:
- Determining additional signs of cancer and evaluating the feasibility of biopsy
- Determining hypo-and hyperechoic areas in order to improve the accuracy of the biopsy`s location (identifying suspicious areas where the doctor will take tissue fragments for histological examination)
A few words about how prostate cancer looks on ultrasound. The classical ultrasound image of prostate cancer shows the presence of hypoechoic focal zones on the periphery of the prostate gland. The prostate itself is enlarged. As the tumor increases, it becomes heterogeneous in structure. Both hypo- and hyperechoic areas appear.
However, the classical ultrasound image is not always the same. More than a third of prostate cancer cases are manifested by the presence of isoechoic areas. That is, the tumor can have a density similar to that of a healthy prostate tissue.
Thus, the ultrasound can not accurately differentiate a benign proliferation of prostate tissue (adenoma) from a malignant tumor, because prostate cancer and other pathologies look the same. However, if the likelihood of malignancy is assessed as high, in combination with other symptoms (the ratio of PSA fractions, PSA density, etc.), ultrasound results indicate the need for biopsy.
Confirmation of diagnosis
All diagnostic measures, including PSA levels testing, ultrasound, clinical diagnosis, have one goal: to assess the need for biopsy for each particular patient, since prostate cancer can only be detected with histological examination. Other tests cause suspicion of a tumor, but they can not be used to establish a proper diagnosis.
Often patients are afraid of a biopsy, because this is an unpleasant procedure. They ask their doctor if prostate cancer can be diagnosed without a biopsy. Theoretically, this is possible in the later stages of the oncology process. When the PSA level goes off scale, prostate cancer becomes evident. However, a biopsy is necessary in any case. It is used not only to discover prostate cancer, but also to determine the histological type of tumor, evaluate the prognosis of the disease and form a therapeutic strategy.
Undoubtedly, a biopsy is an unpleasant procedure. However, modern clinics do not make it that painful. The doctor inserts the needle into the prostate through the rectum. With a special mechanism, the needle is immediately removed from the prostate, so the injection takes a fraction of a second. The procedure is usually repeated 12 times - samples are taken from different parts of the prostate. Infiltration anesthesia is used to reduce pain.
As it was already mentioned, a biopsy not only confirms the diagnosis. It also provides an opportunity to assess the prognosis of the disease. The degree of tumor aggressiveness (growth rate, probability of metastases) is estimated with the Gleason scale. Prostate cancer is determined by two digits, which are summed up.
They can appear in different ways, for example:
- 3 + 4 = 7
- Gleason 3/4
- Gleason 7 (3 + 4)
Let's briefly discuss what the Gleason scale is. Prostate cancer can have degrees of malignancy from 1 to 5, where 1 is a common prostate tissue, and 5 is the most malignant tumor. Prostate cancer has a different structure. The tumor has tissues of greater and lesser degree of malignancy. Therefore, two digits are used, which are summarized. The ones that are found in the samples most often are chosen. Thus, the score in the Gleason score can be from 2 to 10.
Cancer begins at 6 points. As 1 and 2 are normal indicators, 6 points indicate the most favorable prognosis. 10 points is the most aggressive cancer. Differences in indicators are very significant. For example, prostate cancer, which has 9 or 10 points, grows twice as fast as a tumor that has 8 points.
The system has certain drawbacks. For example, prostate cancer 5 + 3 Gleason should be treated differently than 4 + 4, although both have 8 points in total. The first case has the most common type of malignant tissue - 5 points (the most malignant tumor). However, the tumors with 7 points have the greatest differences. Tumors 3 + 4 and 4 + 3 have completely different prognosis (in the first case it is more favorable).
Therefore, for diagnosis doctors use classes based on the Grade Group system, where:
- 1st grade - 6 points according to Gleason or less (favorable forecast)
- 2nd class - 7 points (3 + 4)
- 3rd grade - 7 points (4 + 3)
- 4th grade - 8 points
- Grade 5 - 9 or 10 points (worst-case scenario)
How accurately does the Gleason Scale predict the disease? It is believed to give the correct diagnosis with a probability of 80%. The mistake of 20% is caused by the fact that during the biopsy the doctor takes tissue samples from random sites. It can falsely show predominance of certain malignant sites.
Now you know how prostate cancer is diagnosed. The treatment largely depends on the results of the biopsy, so the biopsy is mandatory for all men with suspected malignant tumor of the prostate. PSA level testing, ultrasound, digital rectal examination - all these diagnostic methods are indicative. They may well indicate a prostatitis or BPH. It is impossible to reliably identify prostate cancer without conducting a biopsy.
Diagnosis will not be complete without establishing the stage of prostate cancer. It is determined by the following criteria:
- Characteristics of the tumor
- Presence of regional and distant metastases
- Class of tumor (based on the Gleason scale)
- PSA level
Stage 1. Thanks to laboratory tests, it is possible to detect prostate cancer of the 1st stage even without the presence of a palpable tumor. It corresponds to grade 1 (6 or less Gleason score), and PSA level below 10 ng / ml.
Stage 2. The tumor can already be palpated. The ultrasound can detect prostate cancer of this stage as well. The tumor is located on one or both sides of the prostate gland. Class 1, 2 or 3 (corresponds to substages A, B and C), PSA within 10-20 ng / ml.
Stage 3. The tumor reaches a large size and spreads into the surrounding organs and tissues. It is possible to detect prostate cancer of the 3rd stage based on symptoms - patients often go to the urologist with complaints of pain or urination problems. There are no metastases yet. PSA can be any. The class can be from 1 to 4 (subcategory A) or 5 (subcategory B).
4th stage. It is determined regardless of the class and level of PSA. If metastases are found in the nearest lymph nodes, stage 4A is established. Prostate cancer of the 4B stage can be detected by the presence of distant metastases.
Various methods of visualization can be used to assess the prevalence of oncology. This includes transrectal ultrasound, CT, MRI, chest X-ray and scintigraphy of the skeleton. Metastasized prostate cancer is revealed by the biopsy of seminal vesicles or pelvic lymph nodes. It is performed if 8 or more points are determined by Gleason, since if there are 7 or less points the probability of detecting metastases is only 3%.
Clinical signs of prostate cancer
We have already talked about what type of analysis detects prostate cancer even in the early stages. The level of PSA establishes a diagnosis long before the first symptoms of prostate cancer appear. Symptoms, as a rule, indicate that the tumor has reached considerable dimensions. It may even be the third stage, when the tumor spreads into the surrounding organs and tissues.
Although some symptoms of prostate cancer in men can appear during the 2nd stage - the likelihood of their appearance depends on the location of the tumor.
The first signs of prostate cancer
Most patients want to know which symptoms appear in prostate cancer first. Their occurrence allows them to consult a doctor and establish a diagnosis in time. However, in most cases there are no clinical signs. Adenocarcinoma most often develops in the peripheral parts of the prostate gland. Therefore, even when reaching a palpable size, the tumor does not push the surrounding organs.
However, the specific location of the tumor leads to the fact that it can affect:
At the initial stage, the symptoms of prostate cancer and adenoma are the same. They arise due to the compression of the urethra.
As a result:
- The patient experiences difficulty during urination
- A weak jet of urine is noted
- There is a feeling of an incomplete emptying of the bladder
Additional symptoms of cancer and prostate adenoma appear when prostate tissue affects the rectum. In this case, the patient suffers from constipation. When the tumor spreads to the seminal vesicles, blood appears in the ejaculate.
How does prostate cancer develop in the 3rd stage?
After it reaches a large size, a tumor is usually manifested by pronounced symptoms. Here are some symptoms of prostate cancer that appear depending on the location of the tumor:
- When affecting the ureter - inflammatory diseases of the kidneys, pain in the lower back due to regurgitation (back current) of urine. With complete obstruction of the ureter, an acute pain syndrome appears- similar urolithiasis during renal colic. The pain appears because kidney capsule widens, as it contains many sensitive nerve endings.
- When affecting the bladder - the size of the bladder decreases. A man goes to the toilet more often. When the tumor spread into the bladder, such symptom of prostate cancer as hematuria appears. Possible incontinence of urine or an imperative (uncontrolled) urge to urinate.
- When affecting the nerves - pain syndrome appears and an erection is dysfunctional. The pain is localized in the perineum, scrotum or rectum. Often patients notice irradiation into the penis. There can be pain of uncertain localization, when the patient feels the pain, but can not clearly determine where exactly it hurts.
Symptoms of prostate cancer of the 4th stage
The fourth stage differs from the third one by the presence of metastases. They first appear in the lymph nodes. That's why the legs swell with the prostate cancer.
Sometimes the first signs of prostate cancer are pathological fractures of the spine and tubular bones. The first location where the tumor metastasizes are the bones. Remote metastases manifest themselves only during the last stage. Up until that point, other symptoms of prostate cancer may be absent.
Every patient should know which symptoms of prostate cancer appear first. However, it is also important to understand that their appearance often indicates a late stage of oncological co-process and an unfavorable prognosis. Therefore, for timely diagnosis of the disease it is advisable to be screened regularly. It includes an examination by urologist and a blood test for PSA.
Organization of Treatment in Germany
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Author: Dr. Nadezhda Ivanisova