Prostate Cancer Treatment and Screening Options

Prostate cancer is the second most common cancer among men, with approximately 230,000 new cases diagnosed each year. However, because prostate cancer may progress slowly in some men, the side effects of some treatments may outweigh the benefits. 

Crucial in choosing the appropriate treatment option is to first determine an accurate staging of the prostate cancer.  Advanced prostate MR imaging with endorectal coil has been proven to be an important tool in the accurate staging of prostate cancer and detecting tumor spread outside the prostate gland.

Simply click on each question for more detail.

How Does Prostate Cancer Compare to Other Cancers?

Prostate cancer is the second most common cancer in men, after skin cancer.  One in 6 men will be diagnosed with prostate cancer.  The American Cancer Society estimates 239,590 new cases and 29,720 deaths from prostate cancer in 2013.  Compared to breast and lung cancer, prostate cancer is more common, but with a lower mortality rate.  The American Cancer Society 2013 estimates for breast cancer are 232,340 new cases and 39,620 deaths; lung cancer estimates are 228,190 new cases and 159,480 deaths.

Who is More Likely to Develop Prostate Cancer?

Prostate cancer can occur in any man, but certain factors may predispose men to develop prostate cancer.  The prostate is a small gland found only in males as part of their reproductive system.  The prostate is about the size of a walnut in younger men, but can be larger in older men.  There are several forms of the prostate cancer that can develop in the prostate, but most of them grow slowly and do not always require treatment.

African-American men are more likely to be diagnosed with prostate cancer, and are more than twice as likely to die of prostate cancer as Caucasian men.  It occurs less often in Asian-Americans and Hispanic/Latino men than it does in Non-Hispanic white men.  

Men with a first-degree relative (father or brother) who had prostate cancer are at higher risk. Prostate cancer is very rare in men under the age of 40, but the chance of developing prostate cancer increases significantly after age 50. Learn more.

Prostate Cancer Screening Controversy

Today most men over age 50 in the United States have a routine prostate-specific antigen (PSA) test for prostate cancer as part of their annual physical, despite the controversy surrounding the benefits for this screening test.  In 2012, the U.S. Preventative Services Task Force updated their guidelines to recommend that doctors stop doing routine PSA testing.  Many organizations, including the American Cancer Society and American Urological Association, do not agree with the Task Force and recommend men consult with their doctors. We believe that in the future, prostate MR imaging will play a very important role in prostate cancer screening.

What is PSA and Are There Other Screening Tests?

Prostate screening involves a physician giving a patient a digital rectal exam (DRE), inserting a gloved finger into the rectum to feel the prostate gland for abnormalities.  DRE is less effective than the PSA blood test in finding prostate cancer, but it can sometimes find cancers in men with normal PSA levels. For this reason, it may be included as a part of prostate cancer screening.

Researchers found that a certain chemical secreted by the prostate was often elevated in patients with prostate cancer.  The amount of this chemical, called prostate-specific antigen, or PSA, in a man's blood would provide some indication of prostate cancer if the blood level was elevated.  These days, a routine blood test in a physician's office will often include a PSA test.  The higher the PSA level, the greater the chance that a man may have prostate cancer. The chance of having prostate cancer goes up as the PSA level goes up.

PSA Results Table
PSA Level (ng/ml)
What it may suggest
4 or less Most healthy men have levels under 4 (ng/mL) of blood. When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn't have cancer – about 15% of men with a PSA below 4 will have prostate cancer on a biopsy.
4 to 10 Men with borderline PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer.
10 or more If the PSA is more than 10, the chance of having prostate cancer is over 50%. If your PSA level is high, your doctor may advise either waiting a while and repeating the test, or getting a prostate biopsy to find out if you have cancer.

Not all doctors use the same PSA cutoff point when advising whether to do a biopsy. Some may advise it if the PSA is 4 or higher, while others might recommend it at 2.5 or higher. Other factors, such as your age, race, and family history, may also come into play.

Why Is Screening for Prostate Cancer So Controversial?

There is no question that screening can help find many prostate cancers early, but the tests are not perfect.  PSA levels can sometimes be elevated even when a man does not have cancer or normal in a man who has cancer. 

When a man has an elevated PSA and the doctor performs a transurethral ultrasound (TRUS) biopsy to look for cancer, it may not be able to locate the cancer.   Initial TRUS biopsy procedure is negative in an estimated 66% of the time.  New procedures, like noninvasive Advanced Magnetic Resonance Imaging (MRI) increase the success in locating tumors and accurate staging of prostate cancer.

Here are some of the pros and cons of prostate cancer screening with PSA tests.

Pros and Cons of PSA Screening
Pros
Cons
Cancer can be detected early. Some prostate cancers grow slowly and never spread beyond the prostate gland.
Cancer is easier to treat and more likely to be cured if diagnosed in the early stages. Not all prostate cancers need treatment.  Treatment has risks and side effects, including urinary incontinence and erectile dysfunction.
PSA testing can be done with a simple, widely available blood test. PSA levels can sometimes be elevated even when a man does not have cancer or normal in a man who has cancer.
If a PSA test suggests cancer, the doctor can perform a TRUS biopsy.  These are usually done in the doctor’s office and take about 10 minutes. The initial TRUS biopsy procedure is negative in an estimated 66% of the time.  Repeat biopsies only increase the rate of tumor detection in 15 to 20%.  As with any biopsy, you may experience some pain and the risk of infection.
For some men, knowing is better than guessing.  If the PSA test suggests cancer and TRUS biopsies have been unsuccessful, Advanced Prostate Imaging techniques can successfully detect and locate clinically significant prostate cancer in 98% of patients. A diagnosis of prostate cancer can provoke anxiety and confusion.  Concern that the cancer may not be life threatening can make decision making complicated.
The number of deaths from prostate cancer has gone down since PSA testing became available. It is not yet clear whether the decrease in deaths from prostate cancer is due to early detection and treatment based on PSA testing or due to other factors.

What Do the Experts Recommend?

Some organizations, including the American Cancer Society and VCU Massey Cancer Center recommend men discuss the screening options with their doctors.  Other organizations, including the American Urological Association and the Mayo Clinic, give specific recommendations based on age and risk factors.

Recommendations
Organization
Recommendation
American Cancer Society (ACS) The ACS recommends men consult with their doctors to make a decision about PSA testing. According to the ACS, men should explore the risks and benefits of the PSA test starting at age 50, if they are at average risk of prostate cancer. They should start at age 45 if they are at high risk and at age 40 if they are at very high risk (those with several first-degree relatives who had prostate cancer at an early age).
VCU Massey Cancer Center

Asymptomatic men who have at least a ten-year life expectancy should have an opportunity to make an informed decision with their health care provider and to make a decision about PSA testing.  This informed decision-making should begin at various ages based on risk factors:

  • Age 50 for average risk
  • Age 45 for men at higher risk, including African-American men and men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65
  • Age 40 for men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65)
U.S. Preventive Services Task Force (USPSTF) The USPSTF recommends against PSA-based screening, regardless of age. The USPSTF states that there is moderate to high certainty that PSA testing has no net benefit or that the risks outweigh the benefits.
Centers for Disease Control and Prevention (CDC) The CDC recommends against PSA-based screening for men who do not have symptoms, but supports discussions between men and their doctors to make informed decisions about screening based on individual risks and preferences.
American Urological Association (AUA) The AUA recommends that beginning at age 55, men engage in shared decision-making with their doctors about whether to undergo PSA screening. The AUA doesn't recommend routine PSA screening for men over age 70, or for any man with less than a 10-to-15 year life expectancy.
Mayo Clinic Mayo Clinic recommends offering PSA screening and DRE annually to men ages 50 to 75 with a life expectancy greater than 10 years, to African-American men ages 45 to 75 with a life expectancy greater than 10 years, and to men ages 45 to 75 years with a positive family history of prostate cancer and a life expectancy greater than 10 years.
American College of Preventive Medicine (ACPM) The ACPM recommends that a man decide about whether to have PSA testing after discussing the risks and benefits with his doctor. The ACPM considers the need for screening questionable in older men with other chronic illnesses, and men with life expectancies of fewer than 10 years.
Institute for Clinical Systems Improvement (ICSI) The ICSI states that, while there is good evidence that PSA screening can detect early-stage prostate cancer, there is mixed or inconclusive evidence to clearly determine whether early detection improves health outcomes. It recommends that a man decide what's right for him based on talking with his doctor.

Options If Your Screening Tests Suggest Cancer:

Deaths from prostate cancer have declined over the past decade. Many believe that early detection may be one of the reasons. There is no question that screening tests like PSA and digital rectal exam (DRE) can help find prostate cancers early, but these tests are not perfect.  They can sometimes have abnormal results even when a man does not have cancer, or they can have normal results even when a man does have cancer.  Inconclusive or false test results can cause confusion and anxiety for the patient.

When prostate cancer is suspected, the urologist may perform a trans rectal ultrasound (TRUS) biopsy. However, locating a tumor in the prostate gland, no larger than a walnut isn’t always easy. TRUS biopsies are not always able to locate tumors.  Initial TRUS biopsies are negative in an estimated 66% of the time. Detection of tumors will only have an increase of 15 to 20% positive yield with repeat biopsies.

Advanced Magnetic Resonance Imaging may be an option for you when your PSA is up with multiple negative TRUS biopsies. After a target region is identified by MRI, a MRI guided biopsy to the target region can be performed at VCU with a very high success rate. The VCU Department of Radiology Prostate Imaging is one of the few places in the country that employs the most advanced, accurate and comprehensive prostate MRI diagnostic and biopsy techniques.

What Else Can Affect a PSA Test or Cause a Suspicious DRE Exam?

The PSA level can increase or decrease due to a number of factors other than prostate cancer, such as benign prostatic hyperplasia (BPH), prostatitis or medications.  A suspicious DRE exam can also be something other than cancer, such as benign prostatic hyperplasia.

Cause
Why it increases psa or affects DRe testing
Enlarged prostate Conditions such as benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate that affects many men as they grow older, may raise PSA levels and result in a suspicious DRE exam.
Older age PSA levels normally increase slowly as you get older, even if you have no prostate abnormality.
Prostatitis This term refers to infection or inflammation of the prostate gland, which may raise PSA levels.
Ejaculation This can cause the PSA to go up for a short time, and then go down again. This is why some doctors suggest that men abstain from ejaculation for 2 days before testing.
Riding a bicycle Some studies have suggested that cycling may raise PSA levels (possibly because the seat puts pressure on the prostate), although this was not found in all studies.
Certain urologic procedures Some procedures done in a doctor's office such as a prostate biopsy or cystoscopy, may result in higher PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the DRE, just in case.
Medication Taking male hormones like testosterone (or other medicines that raise testosterone levels) may cause a rise in PSA.

Certain medicines might cause PSA levels to go down (even if cancer is present):

cause
why it decreases psa
5-alpha reductase inhibitors Certain drugs used to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), may lower PSA levels. These drugs can also affect prostate cancer risk. You should tell your doctor if you are taking these medicines because they may lower PSA levels and require the doctor to adjust the reading.
Aspirin Recent research has suggested that men taking aspirin regularly may have lower PSA levels. The effect may be greater in non-smokers. More research is needed to confirm this finding. If you take aspirin regularly (such as to help prevent heart disease), talk to your doctor before you stop taking it for any reason.
Statins Cholesterol-lowering drugs known as statins, such as atorvastatin (Lipitor®), rosuvastatin (Crestor®), and simvastatin (Zocor®), are linked to lower PSA levels if taken over years.
Thiazide diuretics Thiazide diuretics, such as hydrochlorothiazide (HCTZ), are a type of water pill often used to treat high blood pressure. Taking a thiazide diuretic for years is linked to lower PSA levels. Taking both a thiazide diuretic and a statin is linked to even lower PSA levels than with either type of drug alone.
Herbal mixtures Some mixtures that are sold as dietary supplements may also mask a high PSA level. It is important to let your doctor know if you are taking any type of supplement, even ones that are not necessarily meant for prostate health. Saw palmetto (an herb used by some men to treat BPH) does not seem to affect PSA.
Obesity Obese (very overweight) men tend to have lower PSA levels.

What is a TRUS Biopsy?

Trans rectal ultrasound (TRUS) uses sound waves to make an image of the prostate on a video screen. TRUS is not used as a screening test for prostate cancer because it usually can't tell the difference between normal tissue and cancer.  Instead, it is most often used to look for prostate cancer, such as when a man has symptoms or to follow-up a high PSA level or an abnormal digital rectal exam (DRE). During a prostate biopsy, TRUS is used to guide the biopsy needles into the appropriate area of the prostate.

Using trans rectal ultrasound to "see" the prostate gland, the doctor quickly inserts a thin, hollow needle through the wall of the rectum into the prostate gland. When the needle is pulled out, it removes a small cylinder (core) of prostate tissue. This is repeated from 8 to 18 times, but most urologists will take about 12 samples.

What Can I Expect During and After a TRUS Biopsy?

Though the procedure sounds painful, it may only cause a brief uncomfortable sensation because it is done with a special spring-loaded biopsy instrument. The device inserts and removes the needle in a fraction of a second. Some doctors who perform the biopsy will numb the area first with local anesthetic, which also reduces the chance that the procedure will be painful.

The biopsy itself takes about 10 minutes and is usually done in the doctor's office. You will likely be given antibiotics to take before the biopsy and possibly for a day or two after to reduce the risk of infection.

What to expect after a TRUS biopsy:

For a few days after the procedure, you may feel some soreness in the area and will probably notice blood in your urine. You may also have some light bleeding from your rectum, especially if you have hemorrhoids. Many men also see some blood in their semen or have rust colored semen. This can last for several weeks after the biopsy, depending on how frequently you ejaculate.

How Is a Prostate Biopsy Sample Evaluated - How Is Prostate Cancer Graded?

If cancer is detected in your biopsy samples, the cancer will be assigned a grade. This is often expressed as a Gleason score.   Getting the biopsy results usually takes at least 1 to 3 days, but it can take longer.

Gleason score (grade)
What it suggests
Grades under 4 These cancer cells look similar to normal cells and the cancer is likely to be less aggressive.
Grades 5 to 7 These are in the intermediate range.  This suggests the cancer cells do not look like normal cells and are more likely to be aggressive and grow faster.
Grades 8 to 10 These cancer cells are more likely to be very aggressive in growth.

Why Would I Need to Have to Repeat a TRUS Biopsy and Is There an Alternative?

There are two primary reasons to have repeat TRUS biopsies:

  1. Even with many samples, biopsies can still miss a cancer if none of the biopsy needles pass through it. This is known as a false negative result. If your doctor still suspects prostate cancer, a repeat biopsy may be needed to help be sure.
  2. Prostate biopsy results are sometimes called suspicious. Suspicious results mean that the cells do not look quite normal, but they don't look like cancer, either. If your biopsy results come back suspicious, your doctor may want to repeat the biopsy.

Locating a tumor in the prostate, a gland no larger than a walnut, isn’t always easy.  TRUS biopsies are not always able to locate tumors. Initial TRUS biopsies are negative in an estimated 66% of the time and detection of tumors only increases 15 to 20% positive yield with repeat biopsies.  When repeat TRUS biopsies have been unsuccessful in locating the tumor; noninvasive Advanced Magnetic Resonance Imaging (MRI) is an alternative.  Advanced Prostate Imaging techniques can successfully detect and locate clinically significant prostate cancer in 98% of patients.

New Procedures: Knowing, Not Guessing in Prostate Cancer Diagnosis

When a PSA test indicates that cancer may be present, traditional procedures may be unsuccessful in locating the tumor.  Noninvasive Advanced Magnetic Resonance Imaging (MRI) may be an option for you. Treatment for prostate cancer is based on knowing the presence of the cancer and the accurate staging of the tumor. The VCU Department of Radiology Prostate Imaging is one of the few places in the country that employs the most advanced, accurate and comprehensive prostate MRI techniques.  These MRI techniques increase the success of locating tumors and the accurate staging of prostate cancer.  At the VCU Medical Center during a non-invasive 45-minute examination, we will perform multiple advanced imaging techniques, which when evaluated together, can successfully detect and locate clinically significant prostate cancer in greater than 98% of patients.  This reduces the need for multiple TRUS procedures, while improving the predictive diagnosis of prostate cancer.

What Are the Different MRI Techniques and How Can They Detect Clinically Significant Prostate Cancer in 98% of Patients?

Magnetic Resonance Imaging (MRI) uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures.  VCU Medical Center routinely uses multiple Advanced Prostate Imaging techniques including T2 weighted image, MRSI, MR diffusion and dynamic contrast enhanced imaging for each patient, during a non-invasive 45-minute examination.  MR diffusion and dynamic contrast enhanced imaging are relatively new MRI techniques routinely used at VCU Medical Center, which provide very powerful tool in the detection and staging of prostate cancer.

Different MRI Techniques
MRI Technique
what makes them different
Magnetic Resonance Imaging (MRI) Traditional MR T2 weighted images provide high sensitivity. This means in most cases traditional T2 weighted images can find prostate cancer if it exists.  However, the specificity is low, about 70%.  This means in about 30% of cases these images find abnormalities that turns out not to be cancer.  This is also known as a false positive.  Other conditions such as infection, inflammation or bleeding may look similar at T2 imaging and cause a false positive.
Magnetic Resonance Spectroscopic Imaging (MRSI) MRSI evaluates different biological chemicals in the prostate tissue that a T2 MRI identifies as possible cancer.  These chemicals help distinguish cancer from other conditions such as infection and inflammation.  MRSI has a specificity of about 82%. 
MR Diffusion Weighted Images (DWI) and ADC maps MR Diffusion, or DWI, is a new Advanced Prostate Imaging technique that improves the detection of cancer by evaluating how water diffuses or moves in the tissues.  Prostate tumors limit the movement of water and appear darker on ADC maps.  The specificity of DWI is about 86%. 
MR Perfusion or Contrast Enhanced Imaging (DCE) MR Perfusion, or DCE, is a new Advanced Prostate Imaging technique that maps out the blood flow in the prostate gland.  When prostate cancer is present, blood flow is increased.  The specificity of DCE is about 85%.
Multi-parametric MR scans Multi-parametric MR scan is routinely used at VCU Medical Center and only a very few places in the country where the MRI testing process includes MRSI.  By using all these scanning techniques at the same time, the accuracy is increased to about 98% for clinically significant prostate cancer.  This means that in about 98% of cases clinically significant prostate cancer can be detected by this prostate MRI technique. 

What Is MR Guided Biopsy?

Once the MRI study has detected a tumor in the prostate, in some cases your doctor can perform a repeat TRUS biopsy targeting on the suspicious area found by MRI.  However in most cases, a tumor may still be hard to find because it may be located in the anterior aspect of prostate or at the apex.  In these cases, a MR Guided Biopsy allows for precise placement of the biopsy needle under a direct guidance of  MRI.  MR guided biopsies have proven to be very accurate and have produced a positive tumor sample in up to 60% of those cases where traditional TRUS biopsies have failed multiple times.

What to Expect From MRI or MR Guided Biopsy?

VCU Medical Center has been using MRI technology for many years at both our Downtown Main Campus and our Stony Point Imaging Center.  Learn more about what to expect during an MRI procedure and other frequently asked questions.

What Are the Treatment Options for Prostate Cancer?

Once the cancer is accurately staged, treatment of prostate cancer is determined primarily by whether the cancer is localized, locally advanced or metastatic.  Generally speaking, localized cancer is treated by surgery, radiation or active surveillance.  Locally advanced cancer is treated mainly by radiation.  Hormone therapy is used in men with metastatic prostate cancer. 

VCU Massey Cancer Center suggests that active surveillance for low risk patients, which implies no aggressive treatment for prostate cancer at the time of diagnosis, is worth consideration. Given the potential side effects of surgical and radiation therapies, it is important to discuss the pros and cons of active surveillance and other strategies with your health care provider.

The benefit of active surveillance, which includes serial PSA testing, prostate MRI and possible repeat biopsies, is to avoid the potential risks of the side effects of incontinence and impotence that can happen with surgery or radiation.  It is very fortunate thing to happen, especially in low risk patients who are highly unlikely to die from their prostate cancer. If active surveillance produces warning signs, such as a rise in PSA levels or evidence of growing in size by MRI or higher grade or higher volume cancer found by repeat TRUS biopsy, physicians will re-evaluate the options of treatment.

At VCU Massey Cancer Center, you can find more information about treatment options. These options include the Calypso system, an imaged-guided radiation therapy and prostate cancer trials with the potential for reduced side effects.

Crucial in choosing the appropriate treatment option is to first determine an accurate staging of the prostate cancer. Clinical staging of prostate cancer has a limited accuracy.  MR imaging of the prostate has been proven to be an important tool in the accurate staging of prostate cancer and detecting tumor spread outside the prostate gland.

What Is the Role of MR Imaging in Treatment Options?

For newly diagnosed men with prostate cancer, multiparametric prostate MRI are being routinely used to better detect and stage prostate cancer and to assist surgeons in planning minimally invasive surgery and radiation oncologists in planning a more target therapy.

These advanced preoperative imaging techniques enable surgeons to more accurately decide when to remove or spare the delicate neurovascular bundles in different cases. These decisions hold significant impact in patients' quality of life after surgery since urinary continence and sexual potency may be negatively affected.

For patients who have been treated for prostate cancer, MR Imaging is an important tool in detecting recurrence.  When an increase in the level of PSA has been seen after radial prostatectomy or radiation therapy, it raised the possibility of recurrent tumor.  It is very important to know the location of any recurrence so the treatment can be targeted specifically to the recurrence without excessive impact to adjacent normal tissues such as rectum or bladder.

The specialized abdominal radiologist at VCU Medical Center use the most advanced techniques to assess patients with suspected prostate cancer, and those who may have recurrent disease. They work closely with radiation oncologists and urologists to provide the latest, most advanced diagnostic tools for prostate imaging.

Treatment for prostate cancer is based on knowing the accurate staging of the tumor.  At VCU Medical Center, during a non-invasive 45-minute examination, we will perform multiple advanced imaging techniques, which when evaluated together, can successfully detect and locate clinically significant prostate cancer in greater than 98% of patients. Advanced Prostate Imaging can determine the likelihood that significant disease exists, and guide biopsy or treatment options to ensure that no significant cancer is missed in diagnosis and is mistreated once it is detected.

To arrange an appointment for a MR of the prostate, call 804-628-9810.
For a MR-guided prostate biopsy, call 804-628-7651.

VCU Department of Radiology Virginia Commonwealth University VCU Medical Center