• Urine test. Urine is analyzed for abnormalities that may indicate a problem other than prostate cancer, such as bacterial infection, or to rule out conditions that may cause the same signs and symptoms of prostate cancer, such as prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (enlarged prostate).
• Transrectal ultrasound. This procedure uses sound waves to visualize the prostate gland and detect any abnormalities. 
• Transrectal power Doppler ultrasound (also known as Doppler scan). This procedure is similar to the transrectal ultrasound, but a Doppler shift measures blood flow and resistance levels in veins and arteries. The rapid flow of blood through tiny blood vessels that are characteristic of tumors can be observed. Currently, there are very few Doppler scans in clinical use. 
• Prostate MR scan. Prostate MR is the imaging of prostate gland using magnetic resonance (MR) or magnetic resonance imaging (MRI) technology. See video of patient experience.

Ultrasounds help in diagnosing, staging, and treatment plans by measuring prostate gland volume, recognizing varied patterns of cancer, and identifying appropriate sites for biopsy. Ultrasonography alone, however, cannot detect all cancers. 

If these test results indicate the presence of prostate cancer, the next step is a prostate biopsy. A biopsy is a procedure in which small tissue samples from the prostate are collected and sent to a pathologist for analysis. Biopsy results are usually obtainable within 10 days. 

Two kinds of biopsies are generally performed – transrectal or transperineal. Transrectal is the most common. An enema and an oral antibiotic are often given prior to the biopsy. Local anesthesia is rarely used. The doctor will insert an ultrasound probe into the rectum. The probe will visualize images to guide the doctor to abnormal areas of the prostate. From outside the rectum wall, a handheld device with a spring-loaded, slender needle is positioned and inserted into the abnormal areas to collect tissue samples. If no abnormal areas are detected, various tissue samples are collected from different areas of the prostate.

The transperineal procedure is the same as the transrectal procedure, only the needle is inserted through the skin between the rectum and scrotum (perineum). This method is used when access through the rectum wall is not possible.

If cancer is present, the doctor (urologist) will assess the stage of the cancer and how fast it is likely to grow. The doctor may decide to run further tests to determine if the cancer has spread to other tissues in the body.

• Bone scan. Detects whether the cancer has spread to the bones. 
• Ultrasound. Detects whether the disease has spread to nearby tissues. 
• Chest X-ray. Shows whether the cancer has spread to the lungs, ribs, or backbone. 
• Computerized tomography (CT) scan. Identifies general signs of disease, such as enlarged lymph nodes* or organ abnormalities that may be related to prostate cancer. 
• Magnetic resonance imaging (MRI). Detects spread of cancer to lymph nodes and bones. 
• Lymph node biopsy. Determines whether the cancer has spread to the lymph nodes. 

*Lymph nodes are small glands located in many parts of the body that help defend against harmful foreign particles. Lymph nodes in the pelvic region are usually the first place to which cancer spreads outside the prostate.

Staging of prostate cancer is a necessary step to determine the extent of the disease and select the best treatment strategy. A pathologist will look at the tissue that was taken during the prostate biopsy and will determine

1. The size of the cancer area (percent of biopsy with cancer)
2. The type of cancer cells

The pathologist will assign a Gleason score based on how the cancer looks under a microscope. This score is an estimate of how fast the cancer is likely to grow and the life expectancy of the patient. In general, the lower the score, the better the prognosis.

2 to 4. Indicates tumors with cells that are expected to grow slowly and not spread rapidly.
5 to 7. Indicates tumors with cells that are moderately dispersed and are anticipated to grow with moderate aggressiveness.
8 to 10. Indicates tumors with cells that are likely to grow rapidly and metastasize (spread to other parts of the body).

Most of the information listed above will appear on the biopsy report. The biopsy report (also known as the pathology report) typically has a diagram illustrating the cross section of the prostate. On the diagram, locations where tissue samples were collected will be indicated. These locations will be labeled either “no prostate cancer” or “prostate cancer”. 

Below the diagram is a table listing more detailed information of each sample collected. The samples are listed in the first column according to their location/site within the prostate. Other columns in the table list the length of the tissue sample collected, whether prostate cancer was found (Yes or No), the percentage of the sample in which prostate cancer exists, and the Gleason score. 

The Gleason score on the report may consist of two numbers (eg, 3,4). The first number is the grade assigned to the cancer type that is most numerous in the tissue sample. The second number is the grade assigned to the cancer type that is the second-most numerous. To determine the total Gleason score, these two numbers are added together. (See above for the interpretation of your score.) 

After all of the necessary tests are run and the results are available, your doctor will determine the stage of prostate cancer.

Stage I cancer (also called T1) is found only in the prostate and may be small enough that no tumor can be felt by the doctor during the DRE. Stage I tumors are usually diagnosed after an abnormal PSA or transrectal ultrasound.		Stage II cancer (also called T2) is still found only in the prostate gland, but is big enough to be felt by the doctor during the DRE.
Stage III cancer is no longer confined to the prostate gland but has not yet spread (metastasized) to tissues outside the pelvic area. T3 tumors may have spread to the nearby seminal vesicles. T4 tumors are slightly more spread out and may have invaded other nearby tissues within the pelvic area.		Stage IV cancer is detected in tissues far from the prostate, including the lymph nodes (N+) or more distant tissues, such as bone (M+).

Once the doctor has determined the stage of the prostate cancer, he will work with you to select the best treatment option.

Risk Assessment

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After a prostate cancer diagnosis and staging, you should familiarize yourself with the available risk assessment tools to help understand your risk of disease recurrence and progression.

What is risk assessment?

Prostate cancer can either present as a slow growing tumor causing minimal harm or a more aggressive type which spreads quickly. Risk assessment is the critical step of determining the nature of each patient’s disease. Physicians look at clinical and pathology features (PSA, Gleason score, clinical stage, etc) to determine which patients may have aggressive forms of prostate cancer, and which patients do not.

Risk assessment using clinical and pathologic information:

• American Urology Association (AUA) groups (D’Amico classification): Patients are placed into risk categories based on clinical and pathologic features. The four groups are low (PSA <10 ng/mL, Gleason score 4-6, clinical stage T1-T2a), intermediate (PSA 10-20 ng/mL, Gleason score 7, clinical stage T2b-T2c), high risk (PSA >20 ng/mL, Gleason score 8-10, clinical stage T3a), and locally advanced very high risk (clinical stage T3b-T4)
• Partin Tables: predict the likelihood of the patient's cancer being organ confined after surgery (i.e. pathologic stage)
• Nomograms: paper-based or online calculator methods that incorporate clinical and pathological information to provide risk assessment

Newly diagnosed men become very familiar with their individual PSA and biopsy Gleason scores. Over the last several decades, annual PSA screening has helped identify more men earlier in the disease process. As a result, many patients present with a narrow Gleason score range (Gleason 6 or 7) and low PSA values which compress the results of existing risk assessment and prognostic tools, making them less useful for individual patients. New personalized methods of risk assessment using molecular biomarker analysis are available to assess progression risk.

Risk assessment incorporating molecular analysis as well as clinical and pathologic information:

• Systems Pathology Approach (Prostate Px+): analyzes the histology and molecular biomarkers from existing patient biopsy tissue with clinical information to provide personalized risk assessment

Patients should learn as much as possible about their disease prior to treatment selection. Risk assessment and disease prognosis tools assist in making informed treatment decisions.

What to Expect

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So what happens next?

Learning more about prostate cancer and the available treatments is the first step towards improving your or your loved one’s outlook and relieving some of the anxiety and stress caused by diagnosis.

• Always get a second opinion
• Research prostate cancer and treatment options
  • Read Us TOO’s Pathways for New Prostate Cancer Patients – brochure listing options for the newly diagnosed
  • Request Us TOO’s free kit: Resource Kit for Making Prostate Cancer Decisions – kit of brochures & materials for the newly diagnosed
  • Visit our Online Communities: Prostate Pointers section for information on prostate cancer and its treatment
• Jot down questions for your doctor
• Ask about your doctor’s experience in treating prostate cancer
• Bring along your companion, a family member, or a friend for support and an objective observer who can help translate what occurred in the doctor’s office

Once you or your loved one are diagnosed, your doctor will want to run tests and may need to ask you to have one or two imaging tests such as a bone scan or a computed tomogram (CT) or magnetic resonance image (MRI) to determine the extent of the disease. Depending on the stage of the cancer, the doctor will discuss treatment options.

Certain treatments for prostate cancer are associated with side effects that can have a profound effect on one’s lifestyle. The important thing to remember as a patient is to keep a diagnosis of prostate cancer and the side effects of treatment from interfering with your life or your emotional health. 

• Try to stick to your normal routine
• Eat a heart healthy diet and enough calories to support your ideal weight
• Get plenty of rest
• Pursue activities that are purposeful and meaningful – go back to work, play with your children or grandchildren
• Do things you enjoy – take a trip, go golfing
• Exercise regularly – it improves your physical and emotional sense of well-being
• Anticipate changes in your lifestyle and find ways to accommodate them
  • Incontinence (loss of urinary control) – sit at the back of the movie theater, sit on the aisle in an airplane
  • Erectile dysfunction – seek out sexual contact and reestablish intimacy
• Seek out support from your family and friends

Join a support group for prostate cancer patients

Questions For Your Doctor

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The following is a list of questions to ask your doctor if you have been diagnosed with prostate cancer. It may be worthwhile to audio record your conversation with your doctor so that you can review his answers to each question and be able to make informed decisions about your treatment options.

After Diagnosis

• What additional tests will I need?
• What is the stage of my cancer?
• Has my cancer spread and if so, how far?
• What are the treatment options for this stage of cancer?
• What are the benefits and risks of the type of therapy you are recommending?
• What side effects are associated with the type of therapy that you are recommending?
• What can I do to improve the success of my therapy?
• Are there other treatment options?
• Should I consider participating in a clinical trial?
• Can you refer me/us to a colleague who is not associated with this institution for a second opinion?
• Where can I find out more about my or my loved one’s treatment options?
• Where can I find advice about coping with the emotional impact of prostate cancer diagnosis and therapy?
• Are there any cancer support centers nearby?

Surgery

• How many of these operations have you performed?
• What level of success have you had in preserving erectile function and/or continence in your patients following surgery?
• What can I expect following the surgery in terms of recovery time and short- and long-term side effects?
• What kind of follow-up can I expect after surgery?

Radiation Therapy

• What type of radiation therapy will you be using and why?
• What level of success have you had in preserving erectile function in your patients following this type of radiation therapy?
• What can I expect following radiation therapy in terms of recovery time and short- and long-term side effects?
• What kind of follow-up is needed after radiation therapy?

Hormone Therapy

• What type of hormone therapy do you recommend and why?
• What side-effects can I expect from this type of therapy?
• How long will I need to receive hormone therapy?
• What are my options in terms of continuous versus intermittent hormone therapy?

Read a list of questions for urologists, radiation oncologists and medical oncologists, as compiled by an experienced prostate cancer patient

View list of questions created by Prostate Problems mailing list participants 

You can also post questions for physicians and join discussions on specific topics about prostate cancer on the Physician-to-Patient (P2P) bulletin board located in the Online Communities: Prostate Pointers section of this Web site.

This section lists only some of the many support resources available that can help you learn more about prostate cancer and its treatment, and that can connect you to medical experts, other patients, caregivers, and families. For a more comprehensive list, please visit the Helpful Resources section.

While the Internet has become a valuable source of information and support for those dealing with prostate cancer, Us TOO recommends that you verify all information you obtain from the Internet with your doctor.
 

• Your doctor is a good resource who can give you information about prostate health and cancer, and who can direct to you other resources of support.
   

• Find a urologist. Also visit AUA’s Urology Health website for additional excellent information on adult conditions of the prostate.
   

• Find a medical oncologist in your area by consulting the American Society of Clinical Oncology (ASCO). Also visit ASCO’s website entitled People Living With Cancer for additional excellent information about prostate cancer.
   

• Find a local Us TOO support group chapter. The Us TOO mission is based on the Chinese proverb, “To know the road ahead, ask those coming back.” Talk to other men who have been diagnosed and treated, and/or speak to the wives and companions who are supporting their partners through their diagnosis, treatment and life after cancer.
  

• There are several national and international groups in addition to Us TOO that promote education about prostate cancer and its treatment, provide support, and act as advocates for prostate cancer awareness. 
  
  National Prostate Cancer Coalition
  1154 15th St., NW
  Washington, DC 20005
  Tel: 202-463-9455
  Toll-free: 888-245-9455
  Fax: 202-463-9456
  E-mail: info@pcacoalition.org 
  www.4npcc.org
  
  Prostate Cancer Foundation
  1250 Fourth Street
  Santa Monica, CA 90401
  1.800.757.CURE
  Main 310.570.4700
  Fax 310.570.4701
  E-mail: info@prostatecancerfoundation.org
  www.prostatecancerfoundation.org
  
  American Prostate Society
  188 Ridge Road
  Hanover, MD 21076
  Phone: 410-859-3735
  Fax: 410-850-0818
  E-mail: info@ameripros.org
  www.ameripros.org
  
  American Foundation for Urologic Disease (AFUD)
  300 W. Pratt Street, Suite 401
  Baltimore, MD 21201
  Phone: 401-727-2908 / 1-800-828-7866
  www.afud.org
  
  Education Center for Prostate Cancer (ECPCP)
  380 North Broadway - Suite 304
  Jericho, NY 11753
  Phone: 516-942-5000
  Fax: 516-942-5025
  E-mail: JL3730@aol.com
  www.ecpcp.org
  
  You Are Not Alone (YANA)
  E-mail: ghanesh@49er.co.za
  www.yananow.net
  
  

• Several academic and private hospitals and research institutes are dedicated to understanding prostate cancer and discovering new ways to treat the disease. 
  
  The Robert Benjamin Ablin Foundation for Cancer Research
  115 Franklin Turnpike, Suite 200
  Mahwah, NJ 07430
  Phone: 973-248-9395
  E-mail: mark@prostatefoundation.org
  www.prostatefoundation.org
  
  Center for Prostate Disease Research (CPDR)
  Department of Surgery Uniformed Services University of the Health Sciences
  1530 E. Jefferson Street
  Rockville, Maryland 20852
  Phone: 240-453-8900 / 202-782-8105
  Fax: 240-453-8912
  www.cpdr.org
  
  Cancer Research Institute
  681 Fifth Avenue
  New York, New York 10022
  Phone: 1-800-99CANCER or 1-800-992-2623
  E-mail: info@cancerresearch.org
  www.cancerresearch.org
  
  University of Texas MD Anderson Cancer Center
  www.mdanderson.org
  
  Memorial Sloan-Kettering Cancer Center 
  1275 York Avenue
  New York, NY 10021
  www.mskcc.org
  
  Dana-Farber Cancer Institute
  Massachusetts General Hospital
  cancercare.harvard.edu
  
  University of California San Francisco
  Comprehensive Cancer Center
  cc.ucsf.edu
  
  University of Michigan Comprehensive Cancer Center
  www.cancer.med.umich.edu
  
  

• There are also several government agencies and professional societies that provide a wide range of information, including information on health services and government-sponsored research programs.
  
  National Cancer Institute
  1-800-4-CANCER
  E-mail: cancergovstaff@mail.nih.gov
  www.cancer.gov
  
  American Cancer Society
  1-800-ACS-2345
  www.cancer.org
  
  American Urological Association
  www.urologyhealth.org
  
  Division of Cancer Prevention and Control 
  National Center for Chronic Disease Prevention and Health Promotion 
  Centers for Disease Control and Prevention 
  4770 Buford Highway, NE, MS K-64 
  Atlanta, GA 30341-3717
  1-888-842-6355
  E-mail: cancerinfo@cdc.gov 
  www.cdc.gov/cancer
  
  

• Clinical trials that are testing new treatments of prostate cancer are listed by several different organizations and hospitals. Ask your doctor about whether you or your loved one is eligible to participate in any current clinical trials. 
  
  CenterWatch Clinical Trials in Nephrology/Urology
  www.centerwatch.com/patient/studies/area9.html 
  
  National Cancer Institute Clinical Trials
  www.cancer.gov/clinicaltrials
  
  

• Us TOO is a network of hundreds of support group chapters for men with prostate cancer. You can locate the nearest chapter by visiting the Chapters and Support Groups section of this Web site. 

• If you or your loved one don’t feel comfortable discussing your or your loved one’s prostate health or cancer openly in a support group setting, there are several available on-line resources, bulletin boards, and mailing lists where you can learn about and discuss the disease and its treatment privately.

  • Physician-to-Patient (P2P)

  • The Circle

  • Prostate Cancer and Intimacy (PCAI)

  • Spirit

  • Humor and Healing (HaH)
    
    

• In addition, there are several independent Web sites maintained by survivors of prostate cancer who have shared their stories and information about prostate cancer and its treatment.