Evaluating Your Cancer
Not all cancers are alike and your situation is unique. The first step in understanding your treatment options is to understand your cancer.
Learn about PSA, the first step in finding cancer, the different stages of cancer, Gleason scores and the importance of pathology reports. All of these tools will help you, your family and your physicians make solid decisions about how to treat your prostate cancer for long-term success.
If you have been newly diagnosed with prostate cancer and would like to learn more about how ProstRcision® can help you, call 800-952-7687.
Prostate Specific Antigen, PSA
Question 3:
Help me understand my own cancer. My PSA is 6.3 ng/ml, but what is PSA?
Answer:
PSA is an enzyme that is produced only by prostate cells, both normal and cancerous, and secreted into the semen to keep it liquefied. Additionally, a small amount of PSA is continually leaked into the blood stream by prostate cells. The PSA in the blood is measured by the PSA test.
Question 4:
How much PSA is produced by a normal prostate?
Answer:
The amount of PSA is generally related to prostate size, and the prostate typically enlarges as men age. Overall, a PSA level of up to 4.0 ng/ml is considered normal for men older than 60, and 2.5 ng/ml is the upper normal range for men age 60 or younger. These are rough guidelines because some younger men will have enlarged prostates and some older men will have normal-sized glands. Furthermore, prostate cancer can occur with PSA less than 2.5 ng/ml.
Question 5:
How much PSA is produced by prostate cancer?
Answer:
Prostate cancer cells leak a lot more PSA into the blood stream. On average, one prostate cancer cell will produce 10 times more PSA than one normal prostate cell. Consequently, a man with prostate cancer will usually, but not always, have a PSA level above 4.0 ng/ml or 2.5 ng/ml for men age 60 or younger.
Question 6:
What is the average PSA level of men with prostate cancer?
Answer:
The average PSA level is 7.2 ng/ml, but there is a wide variation. We have treated men for prostate cancer with a PSA as high as 430 ng/ml and as low as 0.3 ng/ml.
Question 7:
If a man has prostate cancer, does the amount of PSA measure how much cancer he has?
Answer:
The amount of PSA is our best measurement for the amount of prostate cancer in a man. For example, a man with 100 prostate cancer cells would typically have a higher PSA than a man with 10 cancer cells. Based on a man’s PSA level, we classify men with prostate cancer into four PSA groups, shown in Table 2.
Question 8:
Does the PSA level always measure the amount of prostate cancer?
Answer:
Unfortunately, no. Some prostate cancers make very little PSA and are called low-PSA producing cancers. Often, these are men with high Gleason scores indicating more aggressive cancers. Low-PSA producing cancers can be advanced and fool doctors. We discover low-PSA producing cancer based on digital rectal examination through palpation of a cancer. Additionally, these cancers can be discovered by measuring PSA velocity. Even though a man’s PSA may be within normal limits, if the PSA is progressively rising, for example 0.5 ng/ml to 1.0 ng/ml to 1.8 ng/ml in less than a year, this rise should alert doctors to the possibility of prostate cancer.
Question 9:
Is PSA produced only by prostate cancer cells located in the prostate?
Answer:
No. This is a common misconception. Prostate cancer cells found in any place in a man’s body produce PSA whether they are located in bone, lung, prostate, lymph nodes or any other area. A prostate cancer cell in a man’s left shoulder makes the same amount of PSA as one in his prostate. For this reason, a PSA test checks for prostate cancer throughout a man’s body, but PSA gives no information about where the cancer cells are located.
Question 10:
Do all men with a PSA above normal levels have prostate cancer?
Answer:
No. Another cause for PSA elevation is a prostate disease called benign prostate hyperplasia (BPH) or enlarged prostate. BPH is the most common prostate disease in men and is present in half of men age 60 or older. BPH, not cancer, is the reason men have difficulty with urination, such as a weak, slow urine stream because the urethra tube is squeezed by the enlarged prostate. Inflammation of the prostate, called prostatitis, can also cause elevated PSA levels.
--Stage--
Question 11:
My cancer stage is T1c. What is cancer stage?
Answer:
Clinical stage of cancer is determined by physical examination of the prostate called a digital rectal examination (DRE). The eight different stages are in Table 3:
Question: 12:
How accurate is staging of prostate cancer?
Answer:
The purpose of staging is to locate the cancer, but this is often inaccurate. In fact, compared to the PSA and Gleason score, staging of prostate cancer is the most inaccurate measure of the extent of your cancer. The biggest area of inaccuracy concerns stages T1 and T2 disease, the stages that most men have. In reality, one-third or more of men with stage T1 or T2 prostate cancer actually have stage T3 prostate cancer, cancer outside the prostate due to microscopic capsule penetration of cancer cells, which cannot be detected before treatment. For more information on microscopic capsule penetration, refer to Questions 32 – 41.
--Prostate Biopsy Pathology Report--
Question 13:
Why is a prostate biopsy pathology report important?
Answer:
Your prostate biopsy pathology report is the key to understanding your particular case of prostate cancer. It is far more important than PSA, stage, bone scans or anything else. The information in the pathology report tells doctors how fast your cancer is growing, how extensive it is within the prostate, and the likelihood of capsule penetration (leakage of cancer cells outside the prostate). The pathology report is the cornerstone to tailoring treatment to the extent and aggressiveness of your prostate cancer, as well as to the calculation of your 10-year Individual Cure Rate (ICR).
Question 14:
What’s a prostate biopsy pathology report? (See Figure 1 and Table 4.)
Answer:
As noted in Question 1, when your physician found your PSA of 6.3 ng/ml, you were referred to a urologist. Your urologist performed a prostate biopsy, which is an outpatient office procedure in which 12 small needles were inserted into your prostate and tiny cores of tissue were removed from all areas of the gland.16,17 The prostate is divided into halves and needles were inserted into the top (base), middle and bottom (apex) of each half of the prostate. Two biopsies were obtained from each of these six areas, the medial and the lateral (inside and outside). Each of the needle cores should be placed in a separate container and labeled by its location within the prostate. All of the prostate cores were sent to a pathologist who processed the material and examined the biopsy needle cores under a microscope. The pathologist’s findings were described in a written report called the prostate biopsy pathology report. You should get a copy of your biopsy report from your urologist and carefully study it.
Question 15:
What does a prostate biopsy pathology report look like? (See Table 4.)
Answer:
A copy of an RCOG Second Opinion Prostate Biopsy Pathology Report is shown in Table 4. Do not be alarmed if this report seems too complicated; it was written for doctors who specialize in prostate cancer. However, you can easily learn the basic points of this report. Learning the basic points is critical, because the pathology report is the key to a man’s particular case of prostate cancer. This report was written by our consulting pathologists, Dr. Aileen O’Neill, Dr. Joanne Piratzky and Dr. Charles Andrews. They have been reviewing outside biopsies and writing Second Opinion Prostate Biopsy Pathology Reports for RCOG for 15 years.
Question 16:
Please explain the pathology report. (See Table 4.)
The urologist inserted 12 needles into this man’s prostate, and each was labeled according to needle location within the prostate. See Figure The needles were evaluated by our consulting pathologist.17,18 A written report was made, which is Table 4. Needle core #1 was taken from the medial side of the base of the right half of the prostate (the inner right half of the prostate at the top) and showed no cancer. Needle core #2 also had no cancer; however, needle cores 3-7 and 9-12 had cancer. Altogether, of the 12 biopsy needle cores from this man’s prostate, 10 had cancer of different Gleason scores. This is important information because the overall percent of positive needle cores (in this case 83%) is directly related to the best treatment for this man and his chance of cure.17 More needle cores with cancer means more extensive cancer.
Question 17:
What is Gleason score? (See Table 5.)
Answer:
Gleason score predicts how fast your cancer is growing.19 It is the most important measurement in a pathology report. Gleason score consists of two numbers called grades, which range from 1–5. Grade 1 indicates slow growth, and grade 5 is a rapidly growing cancer. The predominant grade seen in a needle core is the first number of the Gleason score. The second number is the next most common grade. In needle core #3 of Table 4, the most common grade is grade 3 and the next most common is grade 4 (40%), which indicates a total Gleason score of 7. In contrast, needle core #5 primarily has grade 4 (70%) and, thus, 30% in grade 3. The cancer in needle core #5 is more aggressive than the cancer in core #3 because it has more grade 4. Men are classified by their highest Gleason score, which in this case is Gleason score 8 (needle cores #7 and #9).18
Question 18:
What does needle core length mean? (See Figure 1 and Table 4.)
Answer:
This measurement is the total length of the needle core. For example, needle core #3 was 16mm long, which means that a core of prostate 16mm long was removed from this man’s prostate.
Question 19:
What does cancer length mean? (See Table 4.)
Answer:
This is a measurement of the length of the cancer in the needle core. Of the 16mm of core #3, 4mm was cancer.
Question 20:
What does TLTL/CSLCSLCSL ratio mean? (See Table 4.)
Answer:
This is the percent of cancer in the needle core. Four mm, or 25%, was cancer in the 16mm core #3. A higher percentage cancer in a core lowers the chance of cure.20
Question 21:
What does percent grade 4 or 5 mean? (See Table 4.)
Answer:
This shows the percentage of grade 4 or 5, which are the most aggressive grades of prostate cancer. The percent grade 4 in core #3 was 40% (thus, 60% was grade 3). This is an important measurement because an increasing percent of grade 4 or 5 indicates a more aggressive cancer with an increased chance of additional cancer cell leakage outside the prostate and reduces the chance of cure.21 The amount of grade 4 or 5 you have greatly impacts how you should be treated, as well as your chance of cure.
Question 22:
What does perineural invasion mean? (See Figure 2 and Table 4.)
Answer:
The finding of perineural (meaning “around the nerve”) invasion, as in core #5, helps identify a greater chance of cancer cell leakage through the capsule to outside the prostate (called microscopic capsule penetration) and a lower cure rate.22,23,24,25 A man has two sex nerves. One runs along the right side of the prostate, and the other along the left. Branching off these two large nerves are many smaller nerves that go through the prostate capsule (which surrounds the prostate like a shell around an egg) and enter the prostate. The smaller nerves have a space around them called the perineural space. Cancer cells in the prostate can get in the perineural space and use it as a “tunnel” to travel and escape through the capsule and grow and spread outside the prostate.26,27 Perineural invasion was found in two needle cores in this man – core #5 and #11.
