How is prostate cancer diagnosed?

Dr Shauli Minkowitz navigates the diagnostic landscape of prostate cancer in 10 easy steps.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

Prostate cancer, a prevalent health concern among all aging men especially black South Africans, demands early detection for effective management. The diagnostic journey often involves a multi-faceted approach, tailored to individual risk factors and symptoms.

Prostate-specific antigen (PSA) test

Blood levels of PSA, a protein produced by the prostate, can be measured at any lab to assess for potential abnormalities. Elevated PSA levels indicate a prostate problem but it’s not specific for prostate cancer as many other factors can contribute to PSA fluctuations. An increased PSA level prompts further investigations rather than definitively diagnosing cancer.

Digital rectal exam (DRE)

A cornerstone in prostate cancer diagnosis, the DRE involves a physician manually examining the prostate through the rectum. While discomfort may be a concern, this hands-on approach provides valuable information about the gland’s size, shape, and texture.

Imaging studies

Advanced imaging technologies, specifically prostate MRI scans, play a pivotal role in diagnosing and staging prostate cancer. A dedicated prostate MRI allows doctors to better assess your cancer risk and the need for a biopsy, based on a prostate imaging reporting and data system (PIRADS) score.

In the event that a suspicious area (generally PIRADS 3 or more) is located on the MRI scan, this acts as a region of interest which will be specifically targeted on your needle biopsy, thereby reducing the risk of falsely negative biopsies. 

Prostate biopsy

A core needle biopsy remains the gold standard and the only definitive way to diagnose prostate cancer. Guided by real-time imaging techniques like MRI and ultrasound, a needle is inserted into the prostate through the perineal skin to extract tissue samples. A pathologist then examines these samples for signs of cancer cells. Biopsies offer a precise diagnosis, determining the cancer’s grade and stage, which further inform which treatment option may be best for you.

Gleason score

The Gleason score, derived from biopsy results, assigns a grade based on its microscopic appearance. Ranging from a total Gleason score of 6 to 10, a higher score indicates a more aggressive cancer. This crucial information guides treatment decisions, helping physicians tailor interventions to the cancer’s aggressiveness.

Nowadays, Gleason scores are also described as International Society of Urological Pathology (ISUP) scores of 1-5 for ease of standardising results. You may see one or both terms on the pathology report.

Clinical staging

Determining the stage involves assessing the tumour’s size, whether it has spread to nearby tissues or lymph nodes, and if it has metastasised to distant organs. Staging aids in prognosis and treatment planning, ensuring a comprehensive understanding of the disease’s progression. Staging is often done with a combination of MRI and nuclear studies, such as a prostate-specific membrane antigen (PSMA) scan or a bone scan.

Genetic testing

African ancestry is a significant risk factor for prostate cancer and advanced disease. While the majority of prostate cancers are sporadic, meaning they occur by chance, inherited genetic factors contribute to a higher risk in certain individuals. Yet, genetic studies have largely been conducted outside the context of Sub-Saharan Africa.

It’s recognised that mutations in specific genes, such as BRCA1 and BRCA2, have been linked to an increased likelihood of developing prostate cancer. Additionally, family history serves as a notable risk factor, with individuals having a first-degree relative diagnosed with prostate cancer facing a higher predisposition. Understanding the genetic basis not only aids in identifying at-risk populations but also informs personalised approaches to screening, prevention, and treatment strategies.

Discussing treatment options

Once a diagnosis is confirmed, you’ll consult with healthcare professionals to explore treatment options. These may include surgery, radiation therapy, hormone therapy, chemotherapy, or a combination of these modalities. The decision is often influenced by the cancer’s stage, grade, and your overall health.

Delaying active treatment

Not all prostate cancers require immediate treatment. In cases of low-risk cancer, healthcare providers might recommend watchful waiting or active surveillance which is a strategy in which we regularly monitor slow-growing cancers for changes through PSA tests, DREs, and occasional biopsies. This allows for timely intervention if the cancer shows signs of progression.

Embracing a holistic approach

Beyond medical interventions, a holistic approach includes lifestyle modifications, nutritional guidance, and emotional support. Encouraging a healthy diet, regular exercise, and addressing mental well-being can enhance the overall quality of life during and after treatment.

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