Second Opinion on Prostate cancer

The diagnosis of prostate cancer is initially a shock for many men. However, the outcome can in many cases be favorable, and not each condition would require comprehensive therapy. If you know more about your issue, you will be able to cope with it better and choose the treatment that is right for you.

Most important facts

Prostate cancer is a common malignancy. Worldwide, one in six men over the age of 50 is diagnosed with it. However, 4 out of 5 of the affected patients do not die from the disease, because it often takes a favorable course. However, there are different types of prostate carcinoma cells. Some multiply very quickly and aggressively; others grow slowly. Accordingly, the cancer is classified it into various risk groups. Depending on what group each particular case refers to, one may tell whether the condition is likely to be harmless or dangerous.

The treatment options are correspondingly different. To find the right therapy, several examinations are necessary. They are aimed at defining the relevant features of your disease and assessing the risks.

Prostate cancer diagnostics

• Digital rectal examination (DRE)

Using a lubricated glove, the doctor feels the prostate with his finger for hard, lumpy, or abnormal areas. However, this test can only detect superficial and larger carcinomas. This means that tumors that are unfavorably located or still very small remain undetected. Therefore, the benefit of this examination is limited.

• PSA blood test

The prostate specific antigen (PSA for short) is a protein produced only by prostate cells. With its help, the risk of malignant transformation can be assessed even at very early stages. Small quantities of PSA can be found in blood. The higher the value, the more likely it is that a tumor is present. Very high levels indicate advanced disease and the presence of metastases.

The PSA test might not be part of insurance-covered screening programs. Before the patient decides for or against taking it, he should get detailed information about its advantages and disadvantages from his treating physician. For example, one should know that such test results only predict the probability of prostate carcinoma. Furthermore, a normal PSA value is no guarantee that malignancy is not present. And vice versa, its elevated level does not necessarily mean cancer: urinary tract or prostate inflammation, benign changes, and pressure on the prostate (from a digital-rectal exam or from exercise) can also affect the result. However, if the value is too high (above 4 ng/ml), or there is a sharp increase in the course of several tests, further exams are necessary to confirm or rule out the suspicion.

• Transrectal ultrasound

This exam (abbreviated as TRUS) allows the prostate and surrounding tissue structures to be visualized on a screen using an ultrasound probe inserted into the rectum. The examination is painless, but may be considered uncomfortable.

TRUS is sometimes performed in addition to DRE to more accurately determine the size, location and extent of a tumor. However, in terms of cancer diagnosis itself, the procedure is no more reliable than DRE alone.

• Multiparametric magnetic resonance imaging (mpMRI)

Oncology guidelines recommend that magnetic resonance imaging of the prostate gland should be multiparametric. In this way it determines not only the prostate volume and the localization of suspicious areas, but also its other features. These include, for example, cell density, certain metabolic processes, or the blood supply to the prostate.  Thus, radiologists can thus better assess suspicious areas, which helps doctors decide which therapy should be selected and whether surgery can be performed in a nerve-sparing manner. In addition, enlarged lymph nodes can be detected, which may indicate lymph node metastases.

The mpMRI is also used in combination with a biopsy. Under its guidance, tissue samples can be taken from the gland with more precision.

• Biopsy

Using a thin hollow needle, the doctor takes samples from the prostate at 10 to 12 specified locations. Pathologists examine the tissue samples under a microscope to determine the presence of malignant cells and find out how aggressive the cancer is.

Staging

If the PSA value and the results of the histological examination indicate advanced disease or the patient has bone pain, various imaging methods are used to find out how much the cancer has spread. Bone scans are used to search for skeletal metastases.  PSMA-PET (prostate specific membrane antigen positron emission tomography) with or without CT  may be helpful to find cancer growth in other parts of the body. MRI or CT of the pelvic region is performed to look for lymph node involvement.

Blood tests can also provide information about the stage of the disease. Increased levels of the enzyme alkaline phosphatase (AP) and calcium levels can indicate bone metastases.

Prostate cancer treatment

Early, low-risk prostate cancer does not necessarily require immediate therapy. Should it need treatment, the key objective is to remove or destroy the malignant cells as completely as possible. This can be achieved by:

• an operation: a surgical removal of the prostate (radical prostatectomy);
• radiation (external or internal).

Other methods of prostate carcinoma management include hormone, chemo-, immune therapy, as well as treatment with radionuclides.

Which management plan should be applied depends on whether the tumor is still confined to the prostate at the time of diagnosis or has already affected surrounding tissue involving lymph nodes and other parts of the body.