Understanding Diagnosis

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The basics:

• What is a prostate?
• What is prostate cancer?

-Bob Anderson, Founder of the Prostate Cancer Coalition of North Carolina

• The Diagnosis
• Gleason Score
• Clinical Stage
• Other Diagnostic Methods
• Finding the Right Doctor(s)
• The Treatment Decision
• Illustrative Cases
• A few things to remember

Talking to your family

Please note, other men in your family are at a greater risk if you have been diagnosed. Ask male relatives (your brother, father, son, uncle, nephew, cousin, etc.) to tell their doctor about your diagnosis, age of diagnosis, how it was diagnosed, and how they are related to you. This information may help their doctor determine their risk of developing prostate cancer. For more information please see Risk Factors and/or download the tip sheet for talking to your family about prostate cancer (20KB-PDF) from Wake Forest University's Prostate Cancer Genetics Study.

The Diagnosis

The biopsy provides the first definitive evidence of prostate cancer. Treatment recommendations are greatly influenced by specific factors related to the biopsy, such as the Gleason score, cancer location, and volume.

There are three critical factors to determine the significance of your cancer, your Prostate Specific Antigen (PSA) test results, clinical stage and Gleason's sum score, which determines the type of Prostate Cancer you have. Using the results of the Digital Rectal Exam (DRE) and Transrectal Ultrasound (TRUS) you will be assigned a clinical T stage. If additional tests are obtained such as a bone scan and CT scan of the pelvis then a complete TNM stage can be given. Every patient can be given a "tumor serial number" that helps them learn more about their disease and prognosis. It includes their TNM stage, Gleason's score and pre-biopsy PSA. With these factors you can try, with your doctors, to answer the following questions.

1. Is my cancer significant? Am I likely to die with the cancer rather than because of it or will it impact my life in some way? If I do nothing at all will the cancer kill me or affect me in some way?
2. Is my cancer confined to the prostate? What chance do I have that the cancer has not already spread outside of the prostate and to the lymph nodes or bone.
3. If my cancer is likely to be organ confined, then what local treatments are available to control the cancer? Amongst the choices are surgery, radiation, brachytherapy, and cryotherapy. What are the side effects associated with each?
4. Will I need more than one type of treatment? Will I need a combination of a systemic treatment such as hormonal blockade or chemotherapy with a definitive local treatment such as surgery, external beam radiation, or brachytherapy (seeds). Will I need some other form of therapy after my initial treatment sometime in the future and will it be effective?

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GLEASON SCORE

The Gleason score is a scoring system ranging from two to ten, a lower score indicates slower cancer growth and a higher score indicates more aggressive prostate cancer. The more the observed tissue resembles normal prostate tissue, the lower the Gleason score. The more bizarre the tissue appears, the higher the Gleason score. Most prostate cancer patients have Gleason scores of six or seven.

Your Gleason's Sum, combined with the Clinical Stage of your cancer, can help you to obtain a comprehensive understanding of your diagnosis. The Gleason's Sum is the most commonly used prostate cancer grading system. It involves assigning numbers (called a Gleason grade): to cancerous prostate tissue, ranging from 1 through 5, based on how much the arrangement of the cancer cells mimics the way normal prostate cells form glands. Two grades are assigned to the most common patterns of cells that appear; these two grades (they can be the same or different): are then added together to determine the Gleason score (a number from 1 to 10).

• If the cancerous cells appear to resemble the normal prostate tissue very closely, they are said to be very well differentiated and are considered to be Gleason grade 1. This means that the tumor is not expected to be fast growing.
• If the cells look fairly irregular and very different from the normal prostate cells, then they are very poorly differentiated and are assigned a Gleason grade 5.
• Grades 2-4 are used for tumors that fall between grades 1 and 5, with higher numbers corresponding to a faster growing tumor. Because prostate cancer tissue is often made up of areas that have different grades, the pathologist will closely examine the areas that make up the largest portion of the tissue. Gleason grades are then given to the two most commonly occurring patterns of cells.

The Gleason Grading System is used to evaluate or "grade" prostate cancer cells obtained by needle biopsy. The cells are assigned a number between 1 and 5—nearly normal cells are Grade 1 and the most abnormal are Grade 5. Then the grades of the two most common cell patterns are added together to determine the Gleason score. Gleason scores range from 2 to 10. The higher the score, the more aggressive the cancer.
	1 Simple round glands, closely packed in rounded masses with well-defined edges.
	2 Simple round glands, loosely packed in vague, rounded masses with loosely packed edges.
	3A Medium-sized single glands of irregular shape and irregular spacing with ill-defined infiltrating edges. 3B Very similar to 3A, but small to very small glands which must not form significant chains or cords. 3C Papillary and cribriform epithelium in smooth, rounded cylinders and masses; no necrosis.
	4A Small, medium, or large glands fused into cords, chains or ragged, infiltrating masses. 4B Very similar to 4A, but with many large clear cells, sometimes resembling "hypernephroma."
	5A No glandular differentiation, solid sheets, cords, single cells, or solid nests of tumor with central necrosis. 5B Anaplastic adenocarcinoma in ragged sheets.

According to Dr. John H. Lynch, MD from the Department of Urology at Georgetown University Hospital, several important studies during the 1990s demonstrate conclusively that "a lower Gleason score is associated with a much higher progression-free survival rate. This is not to say that patients with higher Gleason scores cannot be treated, but they are less likely to be treated successfully by local therapy alone. In addition to the Gleason score, the biopsy provides other items of prognostic value. These are the quantity of cancer within each biopsy specimen, the biopsy locations, and evidence of perineural/seminal vesicle invasion. Take the biopsy location, for example. A radiotherapist is unlikely to recommend brachytherapy alone if the patient has a lot of disease in the base of the prostate (the part of the prostate near the bladder) because he doubts that that area can be adequately implanted. So he will frequently recommend reliance on external beam radiation as adjuvant therapy to the seed implantation. The extent of disease is also a factor in recommending treatment. The Partin Tables developed at Johns Hopkins by Dr. Alan W. Partin provide some sense as to the extent of the disease based on Gleason score, PSA, and the digital rectal examination. A man with a Gleason score of six or less, and two biopsy cores with cancer located in one lobe of the prostate. 85% of such men likely would have organ-confined prostate cancer. But if the cancerous cores were bilateral (both lobes of the prostate), then only 50% of such men likely would have organ-confined cancer.

DISCLAIMER:
This article is for general informational use only and should not be construed as providing healthcare recommendations to individual readers. Consult your physician before adopting any information contained herein for your personal health plan.

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CLINICAL STAGE

Once cancer of the prostate has been found (diagnosed), more tests will be done to find out if cancer cells have spread from the prostate to tissues around it or to other parts of the body. This is called "staging." To plan treatment, a doctor needs to know the stage of the disease. The following stages are used for cancer of the prostate:

Stage I (A)
Prostate cancer at this stage cannot be felt and causes no symptoms. The cancer is only in the prostate and usually is found accidentally when surgery is done for other reasons, such as for benign prostatic hyperplasia. Cancer cells may be found in only one area of the prostate or they may be found in many areas of the prostate.

Stage II (B)
The tumor may be found by a needle biopsy that is done because a blood test (called a prostate-specific antigen (PSA) test) showed an elevated PSA level or it may be felt in the prostate during a rectal examination, even though the cancer cells are found only in the prostate gland.

Stage III (C)
Cancer cells have spread outside the covering (capsule) of the prostate to tissues around the prostate. The glands that produce semen (the seminal vesicles) may have cancer in them.

Stage IV (D)
Cancer cells have spread (metastasized) to lymph nodes (near or far from the prostate) or to organs and tissues far away from the prostate such as the bone, liver, or lungs.

Recurrent
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the prostate or in another part of the body.

Prostate staging can also be described by using T (tumor size), N (extent of spread to lymph nodes), and M (extent of spread to other parts of the body).

Risk Stratification for Clinically Localized Prostate Cancer
According to John H. Lynch, MD from the Department of Urology at Georgetown University Hospital, "studies have demonstrated that patients with clinically localized prostate cancer can be placed into one of three distinct risk categories or stratifications - low-risk, intermediate-risk, and high-risk. The stratification refers to the likelihood of a patient with clinically localized prostate cancer having PSA failure-free survival at ten years post-therapy. Patients with T1c and T2a, a PSA less than 10 ng/ml, and a Gleason score of 6 or less are considered low-risk. Their 10-year PSA failure-free survival rate is on the order of 80%. Men who have a detectable abnormality in the prostate, a PSA between 10 and 20 ng/ml, or a Gleason score of 7 are considered intermediate-risk. Their 10-year PSA failure-free survival rate about 50%. Finally, men with a detectable abnormality in the prostate, a PSA greater than 20 ng/ml, or a Gleason score of 8 or more are considered to be high-risk. Their 10-year PSA failure-free survival rate is 33%. When we consider "percent positive biopsies," we can stratify the risks in the same manner."

DISCLAIMER:
This article is for general informational use only and should not be construed as providing healthcare recommendations to individual readers. Consult your physician before adopting any information contained herein for your personal health plan.

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OTHER DIAGNOSTIC METHODS

The Partin Tables developed at Johns Hopkins by Dr. Alan W. Partin provide some sense as to the extent of the disease based on Gleason score, PSA, and the digital rectal examination.

"Once the positive biopsy is in hand and evaluated, are additional evaluations warranted? A bone scan is unnecessary for patients whose PSAs are less than 10 ng/ml and whose Gleason scores are 7 or less. The chance of having a positive bone scan in this case is less than one in a thousand. As you may know, a bone scan is not specific for prostate cancer. So a positive bone scan might detect sites of arthritis, old bone fractures and the like, leading us down the path of ordering x-rays, CT scans and MRIs that are very unlikely to provide useful information.

What I said regarding bone scans also goes for CT scans and MRIs in diagnosing the patient I just described. They are simply not accurate enough to help determine if the disease is outside the prostate capsule. Certainly, work needs to be done to improve these diagnostic tools to make them more useful, but at present, they are not indicated for the patient with a PSA below 10 ng/ml and a Gleason score of 7 or less.

You may have heard of the Prostascint? scan. Basically, it involves the injection of a radioactive medication that goes through the blood stream and binds to the prostate-specific membrane antigen (PSMA) wherever it finds it. Then a scanning machine detects the locations.

It is not particularly useful for newly-diagnosed patients because it is not accurate enough, so its clinical utility is questionable. Prostascint? is more useful in the diagnosis of patients who are experiencing PSA recurrence after their primary therapy for prostate cancer."

John H. Lynch, MD from the Department of Urology at Georgetown University Hospital

DISCLAIMER:
This article is for general informational use only and should not be construed as providing healthcare recommendations to individual readers. Consult your physician before adopting any information contained herein for your personal health plan.

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FINDING THE RIGHT DOCTOR

Prostate cancer is a complicated disease with many treatment options, each with its own set of pros and cons.

A good relationship with the right doctors is extremely important. Here are some tips for building and managing your doctor/patient relationship:

1. Ask friends or associates you are comfortable with for recommendations, and research each physician's reputation. Your insurance carrier or HMO may have to select your physician. You may also want to find a local support group where many patients seak out and share information on doctors and specialists.
2. Make sure that the expectations of both you and your doctor are clearly understood. There are as many variations of the patient-physician relationship as there are patients and doctors. Some patients want every bit of information they can get. Others want to hear nothing but instructions. Some want to know what the treatment alternatives are and want to make the final decision themselves. Others want the doctor to decide what's best. Some consider waiting in a waiting room an acceptable inconvenience, while others find it intolerable. Some want to ask questions, write down answers, and have other people in the examining room. Others don't. Physicians, just like everyone else, also are different, and those differences must be taken into account.
3. Often cancer patients are treated by a group of physicians that may include an oncologist, radiologist, surgeon, and/or some other specialist, along with the family doctor. Try to get one of the doctors to be the coordinator of the team and the repository of all information.
4. If your needs as a patient conflict seriously with the doctor's style, consider whether it's in your best interest to find another physician.

Find a Urologist
Find an Oncologist

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The Treatment Decision

Excerpt from the transcript of "Getting the Diagnosis, Making the Decision" by John H. Lynch, MD from the Department of Urology at Georgetown University Hospital

The patient's treatment decision is a momentous one. He must gather all the reliable information he can so he can participate in the diagnostic process, then ultimately select the therapy most reasonable under the circumstances.

The recommendation I as a physician would make to the patient newly-diagnosed with prostate cancer depends on a host of factors. The principal ones are:

• Age of patient
• Gleason score
• His medical condition
• PSA
• Extent of the disease
• Outcome sought (cure or palliation)

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The Treatment Recommendation, from the transcript of "Getting the Diagnosis, Making the Decision" by John H. Lynch, MD from the Department of Urology at Georgetown University Hospital
Here are some general guidelines I consider in making my treatment recommendations:

• If the patient is otherwise healthy, has clinically localized disease, and has a life expectancy greater than 10 years (and especially if life expectancy is greater than 15 years), then radical prostatectomy is probably the best option.
• Brachytherapy is a likely choice for patients with low-volume disease and a life expectancy of 10 years.
• External beam radiation therapy is a likely choice for patients with locally-advanced disease and a life expectancy of less than 10 years. Androgen deprivation therapy may be added if circumstances warrant.
• Combination radiation therapy (external beam and brachytherapy) for younger patients with higher volume disease/ higher Gleason score where the risk of extracapsular extension is greater.
• Watchful waiting is likely for older men with small volume disease/lower Gleason score. Watchful waiting does not imply "no treatment." Rather, it is "deferred treatment" until definitive treatment is indicated.

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1. A 55-year-old man in good health with no negative aspects to his medical history. He had a biopsy because his PSA went from 2.3 to 3.6 ng/ml. The biopsy revealed a Gleason score of 6 with cancer in two out of ten cores. I think most urologists certainly would recommend a radical prostatectomy (RP) in this case. Our radiation oncologists would probably also recommend a RP. The patient is too young for watchful waiting, although his pathology is relatively small-volume and low-grade.
2. A 68-year-old man who has coronary artery disease, hypertension, and diabetes, and he takes medications for these medical conditions. His PSA is 8.9 ng/ml, his Gleason score is 7 with cancer in seven out of ten cores. Given that volume, he is likely to have some disease in the immediate area outside the prostate. I would probably order a bone scan for him. If the bone scan is negative, I would recommend external beam radiation, given the patient's medical condition, and the potential for extracapsular extension.
3. A 74-year-old man who had a coronary bypass three years ago and who has a degree of hypertension. His PSA went from 5.7 to 6.9 ng/ml. His biopsy revealed a Gleason score of six with cancer in three of ten cores. It is not unusual to get a prostate cancer patient who has had a coronary artery bypass. A coronary bypass is not necessarily disqualifying for surgery because often the patient's cardiac condition is good. But this patient is probably beyond the limits for any advantage surgery might offer due to his age. Given the relatively small volume of the disease present, he was treated with brachytherapy.
4. A 76-year-old man in relatively good health had a PSA of 5.9 ng/ml and a Gleason score of six with cancer in one out of twelve cores. Given his age and low volume of disease, he was an ideal patient for watchful waiting. When I recommend watchful waiting and the patient makes that decision, I like to follow him every three months with a PSA test and a digital rectal examination. If the outcomes remain stable, I extend the interval to six months or so.
5. 61-year-old man with mild hypertension and hyperlipidemia (excess fat or lipids in the blood). He had a PSA of 4.5 ng/ml, an abnormal rectal examination (a one centimeter nodule on the left lobe), a Gleason score of 8, and cancer in five out of ten cores (all in the left lobe). This is an interesting case because it illustrates several points. First, there is a tendency for patients with high Gleason scores to have relatively low PSAs. We are not sure why. The point is that PSA does not necessarily correlate with either the grade or the extent of the disease. The patient is relatively young and physically active, so despite mild hypertension and cholesterol problems, he could have surgery. However, given the amount of disease and its location (left lobe), the nerve-sparing technique is not appropriate on the left side of the prostate. Also, surgery alone might not be enough under the circumstances. External beam radiation (ERBT) and hormonal therapy also may be required. Radiation could also be the primary therapy in this case. Our radiation oncologists at Georgetown would likely recommend a combination of EBRT and brachytherapy. As you can see, this patient's decision is a challenging one for him.
6. A 58-year-old man with a PSA of 38 ng/ml and an abnormal DRE, indicating that the disease extended beyond the prostate gland. He had a Gleason score of 8/9, and cancer was found in every core of the biopsy. Furthermore, he had trouble with urination. A bone scan was equivocal, but with this amount of disease and volume on the biopsy and his high PSA, he was likely to have cancer cells elsewhere, even though they were not detected by the bone scan. The question was then - would he benefit from local EBRT? After referral to a radiation oncologist, he chose a combination therapy of hormones and EBRT.
7. A 55-year-old man with an unremarkable personal medical history. His family history is significant because his brother had prostate cancer. His PSA rose from 2.4 to 2.9 ng/ml from one annual physical examination to another. He repeated the test with a free-to-total ratio (F/T). The repeat was 2.3 ng/ml, but the F/T was 4 percent. This led to a biopsy that showed a Gleason score of 6 with prostate cancer in two cores. THAT WAS MY SITUATION SIX MONTHS AGO!

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1. DON'T believe the old adage that "cancer equals death." There are eight million survivors of cancer in the United States today.
2. DON'T blame yourself for causing your cancer. There is no scientific proof linking specific personalities, emotional states or painful life events to the development of cancer. Even if you may have raised your cancer risk through smoking or some other habit, there is no benefit from blaming yourself or beating yourself up.
3. DO rely on ways of coping that helped you solve problems and handle crises in the past. If you've been a talker, find someone with whom you feel comfortable talking about your illness. If you're an inveterate non-talker, you may find relaxation, meditation or similar approaches helpful. The secret, however, is: use whatever has worked for you before, but if what you're doing isn't working, seek out some help to find another way to cope.
4. DO cope with cancer "one day at a time." The task of dealing with cancer seems less overwhelming when you break it up this way, and it also allows you to focus better on getting the most out of each day, despite illness.
5. DON'T feel guilty if you cannot keep a positive attitude all the time, especially when you don't feel good. Low periods will occur, no matter how good you are at coping. There is no evidence that those periods have a negative effect on your health or tumor growth. If they become frequent or severe, though, seek help.
6. DON'T suffer in silence. Do use support and self-help groups if they make you feel better. Leave a group that make you feel worse, but don't try to go it all alone. Get support from your best resources -- your family, friends, doctor, clergy, or those you meet in support groups who understand what you are going through.
7. DON'T be embarrassed to seek counseling with a mental health professional for anxiety or depression that interfere with your sleep, eating, ability to concentrate, or ability to function normally if you feel your distress is getting out of hand.
8. DO use any methods that aid you in getting control over your fear or upset feelings, such as relaxation, meditation, as well as spiritual approaches.
9. DO find a doctor who lets you ask all your questions and for whom you feel mutual respect and trust. Insist on being a partner with him or her in your treatment. Ask what side effects you may expect and be prepared for them. Anticipating problems often makes it easier to handle them if they occur.
10. DON'T keep your worries or symptoms (physical or psychological) secret from the person closest to you. Ask this person to accompany you to visits to the doctor when treatments are to be discussed. Research shows that you often don't hear or absorb information when you are very anxious. A second person will help you interpret what was said.
11. DO reexplore spiritual and religious beliefs and practices such as prayer that may have helped you in the past. (If you don't consider yourself a religious or spiritual person, garner support from any belief system or philosophy that you value, such as humanism.) These beliefs may comfort you and may even help you find meaning in the experience of your illness.
12. DON'T abandon your regular treatment in favor of an alternative or complementary treatment (see Chapter 10). Use alternative treatments that do no harm and that can safely be used along with your regular treatment. Be sure to tell your doctor which complementary therapies you are using or want to use, since some should not be used during chemotherapy or radiation treatments. Discuss the benefits and risks of any alternative or complementary treatments with someone you trust who can assess them more objectively than you when you are under stress. Psychological, social and spiritual approaches are helpful and safe, and doctors encourage their use today.
13. DO keep a personal notebook with all your dates for treatments, laboratory values, x-ray reports, symptoms and general status. Information is critical in cancer treatment, and no one can keep it better than you.

"At some point in a person's life one will learn to enjoy and treasure each day. The younger we are when we reach that point the more we will enjoy our lives."

-Bob Anderson

"Life is all about stalling the disease and living and having a good time."

-Israel Barken M.D

The information and opinions expressed on this web site are not an endorsement or recommendation for any medical treatment, product, service or course of action by the Prostate Cancer Coalition of North Carolina or its officers and directors. For medical, legal or other advice, please consult appropriate professionals of your choice.