You or your loved one has just been diagnosed with prostate cancer. You may be experiencing a number of feelings: disbelief,
fear, anger, anxiety, and depression. The good news is that there are many treatment options and support resources that
can help you or your loved one lead a normal, healthy life. This section provides information on diagnosis of prostate cancer, staging of prostate cancer, what to expect after
an initial diagnosis of prostate cancer, questions to ask the doctor as you or your loved one
enter treatment and during recovery, and where to find support.
Two tests are used to help diagnose prostate cancer—the digital rectal exam and a blood test that measures a protein
called prostate specific antigen or PSA. There is no normal PSA level but the higher it is the greater the odds
that cancer is present. Prostate cancer may also be present when the PSA is increasing. If any abnormalities
are detected in the prostate during the DRE, or if PSA levels are above a certain level, the doctor may recommend
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.
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 to collect small tissue
samples from the prostate for analysis by a pathologist. Biopsy results are usually obtainable within 48 hours.
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. Injecting a local anesthetic can greatly reduce pain
and discomfort and should be used on all patients. The biopsy begins by inserting an ultrasound probe into the
rectum. The ultrasound images show the contour of the prostate and allow the doctor to direct the biopsy needle
to specific locations in 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, 10-12 random 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 the biopsy shows cancer, 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.
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 or tissues near the prostate.
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
The size of the cancer area (percent of biopsy with cancer)
The type of cancer cells
The pathologist will assign a Gleason score based on how the cancer looks under a microscope. Cancer cells are assigned a
Gleason grade from 1 to 5. The score of the two most common types of cells are added together to give the Gleason
score. In general, the lower the score, the better the prognosis. The most common score is 6. Gleason scores
of 8-10 are the most dangerous.
Most of the information listed above will appear on the biopsy report. The report often will describe the length of cancer
in each biopsy sample and the percentage of cancer on each core.
After all of the necessary tests are run and the results are available, your doctor will determine the stage of prostate
Stage I cancer (also called T1) is found only in the prostate
cannot be detected by the doctor during the DRE. Stage I tumors are usually diagnosed after an abnormal
PSA or after prostate surgery has been performed for men with urinary difficulties.
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 including the bladder or pelvic wall.
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, the doctor will work with you to select the best
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 with non-metastatic disease are placed
into risk categories based on clinical and pathologic features. The three 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), and high risk (PSA >20 ng/mL, Gleason score 8-10, clinical stage T3a).
Partin Tables: predict the
likelihood of the patient's cancer being organ-confined after surgery (i.e. pathologic stage) or having
spread to the lymph nodes or seminal vesicles
Nomograms: paper-based or online calculator methods that incorporate clinical and pathological information to provide risk
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. However, their
clinical utility is still evolving.
Risk assessment incorporating molecular analysis as well as clinical and pathologic information:
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.
Tissue extracted during the biopsy is examined under microscope by pathologist to assign subjective score that’s the
sum of two Gleason grades from 3 to 6.
Cell formations are graded on a scale of 1 to 5 (Subjective evaluation)
Grade 1 and 2: cell formation is normal and therefore not factored into the Gleason score
Cell formations are graded on a scale of 3 to 5
Grade 5: cancer cells appear as sheets; high-grade cancer/aggressive
Grade 4: cancer cells appear poorly differentiated (irregular shapes and combinations)
Grade 3: cancer cells appear moderately differentiated
Gleason score is one number from 6 to 10 that’s the sum of the primary grade and secondary grade
First number (primary grade) is most common Gleason score cell pattern found in all tissue samples
Second number (secondary grade) is second most common Gleason score cell pattern
Therefore a Gleason score of 7 can reflect a different state of prostate cancer depending upon the order of the numbers adding
up to 7: 3 + 4 = 7 or 4 + 3 = 7
Consider getting a second opinion on biopsy tissue analysis and Gleason score
New Prostate Cancer Grading System
Gleason scores of 2 to 5 are no longer assigned
Therefore the lowest Gleason score is a 6
Rather than 6 being in the middle of scale of 2 to 10, it’s actually the lowest score on scale of 6 to 10
Logical assumption of Gleason score of 6 being in the middle can lead to patients expecting that treatment is necessary
New 5 Grade Group System
Grade Group 1 (Gleason score ≤ 6) Only individual discrete well-formed glands
Grade Group 2 (Gleason score 3+4=7) Predominantly well-formed with lesser component of poorly-formed
Grade Group 3 (Gleason score 4+3=7) Predominantly poorly-formed glands with lesser component of well-formed
Grade Group 4 (Gleason score 8) Only poorly-formed/fused glands
Grade Group 5 (Gleason score 9 to 10) Lacks gland
What to Expect
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, which may include a physician with a different specialty.
Research prostate cancer and treatment options
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
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.
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 are the odds my cancer will return with this therapy and how does it compare to the other treatments available?
What side effects are associated with the type of therapy that you are recommending and how often do they occur in your patients?
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?
How many of these operations have you performed?
What level of success have you had following surgery in preserving erectile function and/or continence in patients similar
to me in age and health?
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?
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?
Will I also receive androgen deprivation therapy and, if so, for how long?
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).
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.
Find a listing of them here.