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Prostate Cancer (cont.)

Urologist and Oncologist Perform Prostate Cancer Evaluation and Diagnosis

Medical interview and physical examination:

A proper medical interview eliciting a thorough medical history and a physical examination are essential in the diagnostic workup of any man in whom prostate cancer is suspected. He may be referred to a physician who specializes in urinary tract diseases (a urologist) or in urinary tract cancers (a urologic oncologist). A man will be asked questions about his medical and surgical history, lifestyle and habits, and any medications he takes. Risk factors including family history of prostate cancer will be assessed (see prostate cancer risk factors).

Digital rectal examination (DRE) is part of the physical examination: All men with firm swelling, asymmetry, or palpable, discrete, firm areas or nodules in the prostate gland require further diagnostic studies to rule out prostate cancer, particularly if they are over the age of 45 or have other risk factors for the disease (see risk factors of prostate cancer).

Because urological symptoms (see prostate cancer symptoms) can indicate a variety of conditions, a man may undergo further testing to pinpoint their cause. Initial screening tests include blood testing for PSA and urine testing for blood or signs of infection.

Prostate specific antigen (PSA):

PSA is an enzyme produced by both normal and abnormal prostate tissues. It may be elevated in noncancerous conditions, such as prostatitis (inflammation of the prostate) and benign prostatic hypertrophy (noncancerous enlargement of the prostate), as well as in cancer of the prostate. Therefore, confirmation of an elevated serum PSA is advisable prior to proceeding to prostate biopsy.

PSA values over time may also be more helpful for monitoring recurrence of cancer and the response to treatment than in diagnosing a previously unknown cancer.

The following standards have been set for PSA levels:

  • Less than 4 ng/mL: Normal value. The management of men with lower PSA elevations (<4 ng/mL) is less clear since most will have negative biopsies. However, a substantial number of men with prostate cancer do have a serum PSA concentration less than 4 ng/mL.
  • 4 to 10 ng/mL: Prostate biopsy is usually recommended for men with a total serum PSA between 4 to 10 ng/mL, regardless of the digital rectal examination findings, in order to increase the chances of diagnosing disease while it is organ-confined. In men with PSA in this range, approximately one in five biopsies will reveal cancer.
  • Greater than 10 ng/mL: Prostate biopsy is strongly recommended. Although the chance of finding prostate cancer is over 50 percent, benign prostatic disease does produce a marked increase in serum PSA in some men.
  • Less than 0.2 ng/mL: After the prostate is surgically removed.

Traditionally, a PSA of 4 ng/mL has been used as a cutoff value for deciding for or against doing a prostate biopsy. However, some experts now recommend lowering that to 2.5 ng/mL and performing the biopsy in men who have levels in excess of this threshold. The American Urological Association guidelines (2009) do not define a definite cutoff point but advise that all the other risk factors for prostate cancer be taken into account while making a decision on whether to proceed for a biopsy. One of the important factors that needs to be considered is the rate at which the PSA value has increased over time on repeated measurements (referred to as the PSA velocity).

Based upon the symptoms, physical examination, DRE and PSA level, further blood tests may include:

  • Complete blood cell count (CBC): The relative amounts of different blood cells are checked. Anemia is a common sequel to cancers, as are certain other blood irregularities.
  • Alkaline phosphatase: This enzyme is found in the liver and in bone. It is a sensitive indicator of both liver and bone abnormalities including cancer spread to these areas.
  • BUN and creatinine: These measures are used to assess how well the kidneys are working. Levels can be elevated in a number of conditions (such as kidney failure) and may suggest an obstruction or blockage in the urinary system.
Medically Reviewed by a Doctor on 3/31/2015

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