If you have concerns, the first step is to visit your GP. It is natural to feel embarrassed and anxious, but it is important not to let your feelings deter you from making the appointment.
GP checks – urine and blood
Your GP is likely to call for a urine test to check for any infection that could be causing you problems passing urine. This may also help rule out diabetes. You will also need a blood test to make sure your kidneys are working properly.
Digital rectal exam
Either your GP or your urologist will give you a digital rectal examination (DRE) to check if your prostate is enlarged or whether there are any hard and irregular areas. The doctor will be as gentle as possible and use a gloved, lubricated finger to carry out this test. It may be uncomfortable, rather than painful but only takes a short time.
Your urologist – what to expect
The digital rectal examination is less effective than the PSA blood test at finding prostate cancer but it can sometimes find cancer in men with normal PSA levels.
Some GPs also offer a prostate specific antigen (PSA) test before referring a patient to a specialist (a urologist) while others prefer the urologist to do this. PSA is a protein produced by the prostate gland and is made by normal and cancer cells. PSA levels tends to rise if you have any problems with your prostate.
Urine flow test
You may also have a urine flow test which involves passing urine into a machine to measure the speed of its flow. You need a full bladder for this test. As the prostate lies close to the tube (urethra) carrying urine, the flow can sometimes easily be reduced if the prostate becomes enlarged.
Understanding the PSA test
PSA is useful in detecting a potential problem but, on its own, it is not accurate (the medical term is ‘specific’) enough to determine if the problem is cancer. Before you decide to have the test you need to think it through carefully and understand the potential benefits and the downside of going ahead. (more)
If prostate cancer is found during screening with the PSA test or DRE, indications are that your cancer will likely be at an early, more treatable stage.
An abnormal PSA level – one requiring further investigation - is usually defined as a value of 3 – 4ng/ml, or higher. However, some cancers are detected when PSA levels are still under
4ng/ml and in men who have few or no symptoms.
Clinicians have to decide if early cancers detected by PSA screening are likely to be life-threatening or if they can safely monitor them without asking their patients to go through more invasive diagnostic testing. This is when your urologist would refer to medical risk calculator 5 to help determine the risk.
Transrectal Ultrasound (TRUS)
An ultrasound scan using sound waves to make an image of your prostate on a video screen, will check the size (the medical term is ‘volume’) of your prostate. If your prostate is larger than it should be for your age, it could be a non-cancerous condition called benign prostatic hyperplasia (BPH). An ultrasound scan may also be carried out after the flow test to check that your bladder is emptying fully. The information would be used by your doctor in medical risk calculator 3.
Once these tests are done, your urologist has to decide if you need a biopsy, a sample of tissue taken from your prostate for examination under a microscope.
Prostate biopsy and assessing your risk
The five risk calculators for use by your clinician will help to determine this more accurately. If the risk is high, then it would be wise to agree to a biopsy. However, if the risk calculators help to indicate that your risk of an aggressive cancer is low, it may be safe to delay or even avoid a biopsy. Instead, your PSA can be monitored regularly.
Results from the European Randomized Study of Screening for Prostate Cancer (ERSPC) already show that using PSA to screen for prostate cancer can reduce the chance of men aged 55-70 of dying from the disease by up to 30%. Further indications from the ERSPC study also show that most cancers occurring in men with lower PSA values do have non-aggressive characteristics.
The biopsy
The biopsy is carried out using an ultrasound probe inserted into your rectum. The transrectal ultrasound is used to guide the doctor to the right area of the prostate. You may find this uncomfortable and it can be painful. You can ask for a local anaesthetic to be used to reduce the discomfort.
Usually, eight or more biopsies are taken, depending on how enlarged your prostate is. Afterwards, you are likely to see a small amount of blood in your urine and possibly even in your semen. Some people develop a slight fever. On very rare occasions, patients may need to be admitted to hospital because of fever or bleeding. This happens to between five and six men out of 1,000.
Prostate MRI as diagnostic tool
Next to the gold standard of transrectal ultrasonography (TRUS) and systematic prostate biopsies (SBx), multi-parametric MRI appears to be one of the most promising techniques for prostate cancer detection. The MRI could make a more accurate image of your prostate and could guide the doctor better to a suspicious area in the prostate than ultrasound images only. In case of persistent suspicion on prostate cancer after previous negative systematic prostate biopsy your doctor may be decide to perform a prostate MRI. The test will take around 30 minutes. The radiologist will interpret the images and together with your urologist you will decide if targeted biopsies are necessary.
Recent study results imply a strong role for MRI before biopsy in detecting prostate cancer. MRI-targeted biopsy compared to TRUS biopsy improved the detection of significant prostate cancer in men with a previous negative biopsy by a factor of 1.56. Thus, using MRI and MRI targeted biopsy instead of TRUS biopsy would theoretically lead to a) fewer men biopsied overall, b) a greater proportion of men with clinically significant prostate cancer biopsied, and c) fewer men attributed a diagnosis of clinically insignificant prostate cancer. However, still 13% significant cancers were missed by this approach. Therefore, MRI and MRI targeted biopsy is still advocated in addition to TRUS biopsy. In the near future the TRUS-pathway vs. MRI-pathway, both following upfront risk stratification, will be evaluated in the Netherlands (MR PROPER study / www.mrproper.org).