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Prostate Cancer (cont.)

Exams and Tests

A proper medical interview and physical examination are essential in the diagnostic workup of any man in whom prostate cancer is suspected. You may be referred to a physician who specializes in urinary tract diseases (a urologist) or in urinary tract cancers (a urologic oncologist). You will be asked questions about your medical and surgical history, your lifestyle and habits, and any medications you take.

Because the symptoms may indicate a variety of conditions, you will undergo testing to pinpoint their cause. Initial screening tests include the digital rectal examination as well as blood testing for PSA and urine testing for blood or signs of infection.

Blood tests: These are used to detect complications of prostate cancer.

Complete blood cell count: Your hemoglobin level and relative amounts of different blood cells are checked. Anemia is a common sequel to cancers, as are certain other blood irregularities.
Hepatic transaminases: These are enzymes produced in the liver. They are called alanine aminotransferase(ALT) and aspartate aminotransferase (AST). In known prostate cancer, these levels are usually elevated when the cancer has spread to the liver. However, levels of these enzymes can be abnormally high in a number of different conditions that have nothing to do with cancer.
Alkaline phosphatase: This enzyme is found in the liver and in bone. It is a sensitive indicator of both liver and bone cancer.
BUN and creatinine: These measures are used to assess how well the kidneys are working. Levels can be elevated in a number of conditions and may suggest an obstruction.
Prostatic acid phosphatases (PAP): PAP levels are elevated in 80% of men with metastatic prostate cancer. It is increased in 30% of men with locally advanced disease and in 4-10% of men whose cancer is confined to the prostate. However, the use of PAP as a routine examination is declining because there are many other conditions in which its level is elevated. Some of these conditions include osteogenic sarcoma, osteoporosis, Gaucher disease, hyperthyroidism, and liver diseases.

Prostatic specific antigen (PSA): This is an enzyme produced by both normal and abnormal prostate tissues.

It may be elevated in benign conditions, such as prostatitis (inflammation of the prostate) and benign prostatic hypertrophy, as well as in cancer of the prostate.
PSA values may be more helpful over time in following recurrence of cancer and the response to therapy than in diagnosing a previously unknown cancer.
The following standards have been set for PSA levels:
- Less than 4 ng/mL - Normal value
- 4-10 ng/mL - Either benign disorder or cancer
- Greater than 10 ng/mL - Most likely cancer
- Less than 0.2 ng/mL - After prostate is surgically removed

Imaging studies: These reveal the size and location of the tumor in the prostate as well as the extent of spread of the disease.

CT scan of abdomen and pelvis: This is the best way to detect the extent of the primary cancer as well as distant metastases.
Chest x-ray film: This is a simple test that shows whether cancer has spread to the lungs.
Intravenous pyelogram (IVP): This test is used to visualize the upper urinary tract from the kidneys to the bladder. Contrast dye is injected through a vein in the arm, and many x-ray films are taken of the abdomen. If there is an obstruction as a result of prostate cancer, evidence will be seen in the kidneys, ureters, and bladder.
Renal ultrasonography: Ultrasonography can be used to look for the effects of a urinary blockage on the kidneys.
Cystoscopy: This is an endoscopic test. A thin, flexible, lighted tube with a tiny camera on the end is inserted through the urethra to the bladder. The camera transmits images to a video monitor. This shows whether the cancer has spread to the urethra or bladder.
Technetium Tc 99m bone scan: This test is like an x-ray film of the entire body taken after a mildly radioactive substance is administered into a vein. The radioactive substance highlights areas where the cancer has affected the bones. This test is usually reserved for men with prostate cancer who have deep bone pain or a fracture.

Biopsy: When the findings of the physical exam, lab tests, and imaging studies suggest that a cancer is present in the prostate, the diagnosis must be confirmed by taking a sample of the tumor (biopsy). The tumor tissue is examined by a doctor who specializes in diagnosing diseases by looking at cells and tissues (a pathologist).

There are several different ways of obtaining a prostate biopsy.
The standard method uses transrectal ultrasonography to guide collection of the tissue sample. The sample is collected by inserting a needle into the tumor and withdrawing cells. This technique also helps in detecting involvement by the cancer of the capsule and the seminal vesicle.

Staging: If the biopsy finding is positive for cancer, further staging procedures will be done.

Staging is a system of classifying tumors by size, location, and extent of spread, local and remote.
Staging is an important part of treatment planning because tumors respond best to different treatments at different stages.
Stage is also a good indicator of prognosis.
Staging is usually accomplished through imaging studies and lab tests.
Prostate cancers are also assigned a grade, which indicates how different the cancer cells are from normal prostate tissue. Grade gives an indication of how fast a cancer is likely to grow.

The stages of prostate cancer are as follows:

Stage I (or A): The cancer cannot be felt on digital rectal exam, and there is no evidence that it has spread outside the prostate. These are often found incidentally during surgery for an enlarged prostate.
Stage II (or B): The tumor is larger than a stage I and can be felt on digital rectal exam. There is no evidence that the cancer has spread outside the prostate. These are usually found on biopsy when a man has an elevated PSA level.
Stage III (or C): The cancer has invaded other tissues neighboring the prostate.
Stage IV (or D): The cancer has spread to lymph nodes or to other organs.