Prostate Cancer Diagnosis & Treatment

Diagnosis

Physicians at MD Anderson specialize in diagnosing prostate cancer. They have the expertise and technology to evaluate the growth pattern and extent of each particular cancer, which will affect treatment.

If you have prostate cancer, it’s important to get an accurate diagnosis as soon as possible. This helps increase the odds for successful treatment and recovery.

If you have symptoms that may signal prostate cancer, your doctor will ask you questions about your health, your lifestyle, and your family medical history.

One or more of the following tests may be used to find out if you have cancer and if it has spread. These tests also may be used to find out if treatment is working.

Digital rectal exam (DRE)

The simplest screening test for prostate cancer is the digital rectal exam (DRE). The health care provider gently inserts a gloved forefinger into the rectum to feel the prostate gland for enlargement or other abnormalities, such as a lump.

The DRE is not a definitive cancer test, but regular exams help detect changes in the prostate over time. These changes might signal cancer or pre-cancerous conditions.

Although this test usually is not as reliable as the PSA blood test (see below), a DRE may be able to find cancer in a man with a normal PSA level. A DRE also may be used to tell if prostate cancer has spread or returned after treatment.

Prostate-specific antigen (PSA) test

Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. It is found mostly in semen, but a small amount is in the blood as well.

A blood test measures the amount of PSA circulating in the blood. This level is used to assess prostate cancer risk. A PSA of 4 nanograms per milliliter or lower is considered normal. A higher PSA level usually means a higher chance of having prostate cancer.

PSA tests have limitations. Prostate tissue and prostate cancer both produce PSA. Sometimes prostate cancer does not produce much PSA. In other cases, high PSA levels can be caused by factors other than cancer. These include:

• Enlarged prostate, also called benign prostatic hyperplasia (BPH), which is found often in older men
• Age: PSA levels normally go up slowly as men age
• Prostate infection or inflammation, which also is called prostatitis
• PSA may rise briefly after ejaculation, then return to normal levels

Certain conditions may make PSA levels low, even when a man has prostate cancer. These include:

• Some drugs used to treat BPH or other conditions
• Certain herbal medicines or supplements
• Obesity

Despite its limitations, PSA testing has helped detect prostate cancer in countless men. In 1984, before PSA testing was available, the chance of finding early prostate cancer was about 50%. In 1993, after PSA testing became widely used, that figure jumped to more than 90%.

Men with very low PSA levels may need to be tested every two years. If PSA is higher, the doctor may recommend more frequent testing.

Because prostate cancer develops slowly, physicians usually do not recommend the PSA test for men who are older than 75 or have other significant health issues.

PSA tests can also be used in men who have been diagnosed with prostate cancer. For instance, they may:

• Help doctors plan treatment or further testing
• Determine if cancer has metastasized (spread beyond the prostate)
• Find out if treatment is working or cancer has returned
• Aid in active surveillance (also called watchful waiting) by showing if cancer is growing

Imaging exams

If prostate cancer is suspected, your doctor may order imaging tests to get a better view. Imaging exams can help identify the area of the prostate that should be sampled and studied under a microscope. They can also determine how far cancer has spread beyond the prostate. Imaging tests may include:

• Transrectal ultrasound: During a transrectal ultrasound, a small probe is inserted through the rectum. This probe generates high-energy sound waves that bounce off your tissue and create a picture of your prostate gland on a screen. This picture can be examined for abnormalities or tumors.
• Magnetic resonance imaging (MRI): An MRI uses magnetic fields and radio waves to generate pictures of the soft tissue and organs of the body. Your doctor may order this to see if and how far prostate cancer has spread to other organs.

Learn more about our diagnostic imaging procedures

Biopsy

In a biopsy, a small amount of suspected cancer tissue is removed and examined under a microscope. This is the only way to tell for sure if you have prostate cancer.

Biopsies for prostate cancer are usually outpatient procedures done in a doctor’s office or another facility. A local anesthetic like dentists use, often lidocaine is injected into the area close to the prostate to make the procedure more comfortable.

In most cases, a small transrectal ultrasound (TRUS) probe with an imaging device is inserted into the rectum. The doctor can then view the prostate on a video screen. Using this image as a guide, the physician injects a thin needle through the wall of the rectum into the prostate. Several tiny samples of tissue are removed.

Based on the patient’s situation, MD Anderson also conducts biopsies where the needle is inserted through the perineum (the skin between the scrotum and the anus) instead of the rectum. Fusion biopsies, which use special software to target abnormalities found in an MRI, are also an option.

Sometimes a biopsy will not find prostate cancer, even if it is there. If your doctor is concerned that you may have prostate cancer based on a follow-up PSA test, a second biopsy may be performed.

In other cases, the biopsy will not show cancer but will reveal changes in the size and shape of the cells in the prostate. This is called prostatic intraepithelial neoplasia (PIN). Patients whose cells look significantly abnormal have a higher risk of developing prostate cancer. Men with this condition, called high-grade PIN, should undergo regular prostate cancer screenings, including digital rectal exams and PSA tests.

What are the grades and risk groups for prostate cancer?

If a biopsy finds prostate cancer, it will be classified using the Gleason grading system. This helps doctors choose the best treatment options and predict how quickly the cancer is growing.

To grade the cancer, a specialist will examine the arrangement patterns of the two most common cell types and compare them with normal prostate cells. If the prostate cancer cells in the sample look almost normal, they receive a grade of 1. If the cells are highly irregular compared to normal cells, they will receive a higher grade, up to 5. The Gleason score is the sum of the grades assigned to each cell type. The higher the Gleason score, the more aggressive the cancer.

Gleason grades 1 and 2 are rarely seen since the changes are so small and unlikely to be discovered. That means the usual lowest grade is 3. Gleason scores are categorized as follows:

• 3+3 are low grade and have the lowest risk of harm. This is also called Gleason Grade Group 1.
• 3+4 and 4+3 are intermediate risk, the latter being the more aggressive type. These are also called Gleason Grade Groups 2 and 3, respectively.
• 4+4 through 5+5 are the highest risk. These are Gleason Grade Groups 4 and 5.

Prostate cancer risk assessment

If you are diagnosed with prostate cancer, your doctor will also make a series of estimates about the risk that the disease may be harmful in the future. Factors include:

• Gleason score
• PSA level
• Clinical stage, which is based on findings of the digital rectal exam (DRE) and/or an imaging exam.

There are three main risk groups, each of which has its own set of treatment options.

Low risk:

• Less than 10% chance of having spread to other parts of the body
• Low risk of progressing if not treated
• PSA less than 10 ng/mL
• Gleason score of 6 or lower
• No tumor felt on DRE or feels contained within the prostate gland with only a small abnormal area

Intermediate risk:

• 10% to 15% chance of having spread
• Higher chance (up to 70% over 15 years) of progressing if not treated
• PSA of 10 to 20 ng/mL
• Gleason score of 7
• The tumor can be felt on one or both sides of the prostate on DRE, but it seems to be contained within the gland

High risk:

• Aggressive features that increase the chance of spreading now or in the future
• PSA over 20 ng/mL
• Gleason score of 8 to 10
• The tumor can be felt on DRE and seems to have spread outside the gland

If the prostate cancer is determined to be intermediate or high risk, imaging tests such as bone scans and CAT (computed axial tomography) or MRI (magnetic resonance imaging) scans may be used to determine if the cancer has spread.

Taken together, the disease risk status and imaging results will help your doctor plan the best treatment.

Some cases of prostate cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Learn more about the risk to you and your family on our genetic testing page.

At MD Anderson, you receive customized care that is planned by some of the nation’s leading prostate cancer experts. Your personal team of specialists works together at every step to be sure you receive the most advanced therapies with the fewest possible side effects.

Through our Multidisciplinary Prostate Clinic, your care team can help you weigh the benefits of each treatment and help you decide which is best for you.

Treatment

Your treatment plan will depend on a variety of factors, including:

• Overall health and well-being
• Age
• Grade and associated risk of your cancer
• Goals for treatment outcomes

Talk with your doctor about which treatments are available and how those treatments may affect you. One or more of the following therapies may be used to treat your cancer.

Active surveillance or watchful waiting

Because prostate cancer usually grows slowly, doctors may recommend some patients not be treated. These patients are typically older and/or have a very low-risk form of prostate cancer.

Instead, these patients can be put on active surveillance, or “watchful waiting.”

This approach involves closely monitoring the cancer without treatment. Prostate biopsy procedures and PSA tests are repeated at set intervals. Treatment may be recommended if the tests show the disease is progressing.

Surgery

Surgery for prostate cancer is known as a radical prostatectomy. During this procedure, the surgeon removes the entire prostate. Lymph nodes near the prostate may also be removed to look for evidence that the disease has spread.

Nearly all prostate cancer surgeries at MD Anderson are minimally invasive procedures performed with surgical robots. These surgeries result in smaller incisions, less blood loss, less pain and shorter hospital stays.

Surgery for prostate cancer usually requires an overnight hospital stay. Patients must wear a catheter for about one week after the procedure. They typically can return to work after two weeks. There are no restrictions on activity after four weeks.

Studies have shown that working with an experienced surgeon increases the odds for a successful procedure with fewer side effects. The surgeons at MD Anderson are among the most experienced and skilled in the world in prostate cancer surgeries.

Radiation therapy

Radiation therapy uses high-energy beams to kill disease cells. Along with surgery, it is one of the two most common primary treatments for prostate cancer. Compared to surgery, it offers better urinary control but is more likely to cause bowel and bladder irritability. Both can cause erectile dysfunction.

There are several different types of radiation therapy doctors recommend to prostate cancer patients. Most treatment plans require daily treatment for a number of weeks.

• Intensity-modulated radiation therapy (IMRT): IMRT focuses multiple radiation beams of different intensities directly on the tumor for the highest possible dose of radiation. Radiation oncologists use special planning software to make sure the patient is properly positioned for the most accurate treatment.
• Stereotactic body radiation therapy (SBRT): Also known as stereotactic ablative radiotherapy (SABR), SBRT administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor. This treatment usually takes around 10 days, making it significantly shorter than other forms of radiation therapy.
• Brachytherapy:  Brachytherapy delivers radiation therapy with small pieces of radioactive material (usually about the size of a grain of rice) that are placed inside the patient’s body as close to the tumor as possible. This allows doctors to deliver very high doses of radiation directly to the patient’s tumor while limiting radiation exposure to healthy tissue.
• Proton therapy: This type of therapy is similar to traditional radiation therapy, but it uses a different type of radiation and is much more accurate at targeting tumors.
• Radionuclide therapy: This type of radiation therapy is actually administered through an IV. It is used to treat prostate cancer bone metastases (prostate cancer that has spread to the bones).

MD Anderson has the most advanced radiation therapies and has radiation oncologists who specialize in prostate cancer. This allows us to offer the most effective radiation treatments while minimizing side effects.

Hormone therapy

The majority of prostate cancers are hormone-sensitive, which means male hormones (androgens) such as testosterone fuel the growth of prostate cancer. About one-third of prostate cancer patients require hormone therapy (also known as androgen deprivation therapy). While hormone therapy can reduce tumor size and make cancer grow more slowly, it does not cure the disease.

There are two main types of hormone therapy for prostate cancer patients:

• Antiandrogens: Antiandrogens are medications that block testosterone and other androgens from interacting with the cancer cell. They are taken by mouth every day. Antiandrogens are used most often in combination with androgen synthesis inhibitors.
• Androgen synthesis inhibitors: These drugs reduce levels of testosterone and other androgens produced by the body. A common type of androgen synthesis inhibitor is luteinizing hormone-releasing hormone (LHRH) agonists. Because LHRH agonists are often associated with a temporary increase in testosterone levels, they may be combined with anti-androgen medications. Androgen synthesis inhibitors are delivered by injections, which last from one to six months, or by small pellets implanted under the skin.

Hormone therapy is most often used for late-stage, high-grade tumors with a Gleason score of 8 or higher or in patients with cancer that has spread outside the prostate.

Hormone therapy may be used to treat prostate cancer if:

• Surgery or radiation is not possible
• Cancer has metastasized (spread) or recurred (come back after treatment)
• Cancer is at high risk of returning after radiation
• Shrinking the cancer before surgery or radiation increases the chance for successful treatment

Side effects of hormone therapies for prostate cancer may include:

• Impotence, inability to get or maintain an erection
• Loss of libido (sex drive)
• Hot flashes
• Growth of breast tissue and tenderness of breasts
• Loss of muscle mass, weakness
• Decreased bone mass (osteoporosis)
• Shrunken testicles
• Depression
• Loss of alertness and higher cognitive functions
• Anemia (low red blood cell count)
• Weight gain
• Fatigue
• Higher cholesterol levels
• Increased risk of heart attacks, diabetes and high blood pressure (hypertension)

If you are treated with hormone therapy and have side effects, be sure to mention them to your doctors. Many of these side effects can be treated successfully.

Chemotherapy

Chemotherapy drugs are designed to kill fast-growing cells, including cancer cells. For prostate cancer, chemotherapy is most often used to treat patients with a high-risk disease or whose cancer has recurred or metastasized.

Cryotherapy

Though rarely used, cryotherapy is the best choice for localized prostate cancer where tumors are small and surgery is not an option. During these procedures, a long, thin probe is inserted into the tumor, freezing and killing cancer cells. Intensive follow-up with X-rays or other imaging procedures is used to ensure that the tumor has been destroyed.

Immunotherapy

Immunotherapy recruits a patient's own immune system in the fight against cancer. Patients may be given a type of immunotherapy that involves engineering the immune cells of the body in a lab to recognize prostate cancer. This approach may be especially useful for patients with advanced prostate cancer that does not respond to hormone therapy.

High-intensity focused ultrasound (HIFU)

High-intensity focused ultrasound (HIFU) kills cancer tissue in the prostate with heat generated by focused ultrasound waves. The treatment may offer improved urinary and sexual function to some prostate cancer patients. HIFU is typically offered to patients with early-stage prostate cancer that is low- to intermediate-risk. The tumor must be visible on MRI. It must be confined to the prostate and be confirmed to contain prostate gland cells.

Clinical trials

As one of the world’s leading cancer centers, MD Anderson is home to many clinical trials for prostate cancer patients. Your care team may discuss clinical trials with you if they believe they offer you a better outcome than standard treatments.

Trials are designed to improve prostate cancer survival rates, minimize treatment side effects and support a higher quality of life for patients. They may include new drugs or drug combinations, new approaches to prostate cancer surgery, different forms of radiation therapy, or some combination of all three. Learn more about clinical trials.

Treatment plans for prostate cancer

When prostate cancer is diagnosed, doctors use several different tests to determine the risk of disease progression. Patients in each risk group often get the same general recommendations for treatment.

Low-risk prostate cancer treatment

Many low-risk prostate cancers can go years or even decades without causing any serious health problems. Because of this, doctors often recommend active surveillance for these patients. During active surveillance, a patient is closely monitored for changes to his cancer.

In some cases, low-risk prostate cancer patients do choose to have treatment. A younger patient, for example, may select treatment instead of potentially decades of surveillance. Patients with low-risk disease may also choose treatment if they have certain genetic conditions or a large amount of cancer tissue.

Intermediate-risk prostate cancer treatment

Men with intermediate-risk prostate cancer should be treated in most cases. Treatment options typically are surgery to remove the prostate or radiation therapy. The patient may also get hormone therapy along with radiation therapy.

High-risk prostate cancer treatment

Low- and intermediate-risk prostate cancers are usually considered curable. Some high-risk prostate cancers can be cured. In other cases it is not curable and is treated like a chronic disease that must be managed.

Whether curable or not, high-risk prostate cancer is usually treated with a combination of therapies. Standard options include surgery, radiation therapy, hormone therapy and chemotherapy. Doctors will recommend the combination based on each patient’s specific cancer subtype, its stage, the patient’s age and other factors. They may also recommend a clinical trial if they believe that trial offers the best treatment. Clinical trials can be used to test new therapies or new combinations of existing therapies.

Recurrent prostate cancer treatment

For most patients, initial prostate cancer treatment includes either radiation therapy or surgery. If a patient’s prostate cancer returns, the other treatment option may be used. In addition, doctors may recommend the use of systemic therapies (therapies that travel throughout the body), like hormone therapy and possibly chemotherapy.

In some cases, patients can have what is known as biochemical recurrence. These patients have elevated PSA levels that indicate the disease has returned, but imaging exams do not show any cancer. Patients with biochemical recurrence are given intermittent hormone therapy and are monitored closely for further changes.

Metastatic prostate cancer treatment

If a patient’s prostate cancer has spread beyond the prostate and the surrounding area, he is given systemic therapies like hormone therapy and possibly chemotherapy. While cancer responds to hormone therapy, it is called castrate-sensitive disease. Over time, the disease may become less responsive to hormone therapy and start growing again. This is called castrate-resistant disease. Patients with castrate-resistant disease can be treated with a number of additional therapies. Many are eligible for clinical trials with newer drugs or drug combinations, including immunotherapy.

Some cases of prostate cancer can be passed down from one generation to the next. Learn more about genetic testing.