Table of ContentsView AllTable of ContentsScreening TestsTests and ProceduresStaging TestsStagesTests for RecurrenceDifferential DiagnosesFrequently Asked QuestionsNext in Prostate Cancer GuideUntreated Prostate Cancer
Table of ContentsView All
View All
Table of Contents
Screening Tests
Tests and Procedures
Staging Tests
Stages
Tests for Recurrence
Differential Diagnoses
Frequently Asked Questions
Next in Prostate Cancer Guide
A diagnosis ofprostate cancercan involve screening tests such as a serum PSA or digital rectal exam, as well as procedures that can include MRI-TRUS fusion with targeted biopsy, or an ultrasound-guided random 12-core biopsy.
Based on biopsy findings, aGleason scoreis used to describe the aggressiveness of the tumor.
Further tests, such as a CT scan,magnetic resonance imaging (MRI), bone scan, or PET scan may be done to stage the tumor. Since prostate cancers can differ in their tendency to grow or spread, staging is important in choosing the best treatments, determining the risk of recurrence, and estimating the prognosis of the disease.
The vast majority of prostate cancers are discovered on screening tests before anysigns and symptomsoccur. The two main screening tests are theprostate-specific antigen(PSA) test and digital rectal exam, which are best when used together; neither of these tests should be used alone.
In general, screening is recommended for males beginning at age 50, though this is an area of active debate.
Males who haverisk factors for prostate cancer, such as a family history of the disease, are usually advised to begin testing earlier than this.
Screening tests cannot diagnose prostate cancer, but they can help direct further testing.
Prostate-Specific Antigen (PSA) Testing
It is not a perfect test in that:
There are ranges of PSA that are considered normal and high, but the most important factor in interpreting the test (unless it is very high) is a change in the value over time.
A PSA level that is increasing is often more meaningful than the absolute value of the test.
In the past, an arbitrary cutoff of 4 nanograms per milliliter (ng/ml) was used to separate normal and possibly abnormal PSA levels. That said, more than half of the time when a level is greater than 4, the cause is not cancer. Similarly, prostate cancer may be present even with a level less than 4 ng/ml.
PSA measures can include:
Digital Rectal Exam (DRE)
During adigital rectal exam(DRE), a healthcare provider inserts a gloved, lubricated finger into the rectum to palpate the prostate gland and check for lumps, hardness, or tenderness.Since the prostate gland lies just in front of the rectum, the prostate is fairly easy to palpate with this approach.
A DRE can be somewhat uncomfortable and may cause a sense that you need to urinate. This test is safe and it only takes a few minutes.
What Is a Prostate Exam?
Tumor Markers
The 4K score and the prostate health index (PHI) can be used to determine prostate cancer risk and may help guide the need for tumor marker screening.
Controversy and Risks
In recent years there has been considerable controversy surrounding screening since it’s thought that PSA testing results in significant overdiagnosis.
That said, prostate cancer remains the second leading cause ofcancer-related deaths in males, and the disease may be easier to treat in the earlier stages.
Have a conversation with your healthcare provider about your recommended testing schedule in relation to your overall risk profile.
Prostate Cancer Healthcare Provider Discussion GuideGet our printable guide for your next healthcare provider’s appointment to help you ask the right questions.Download PDFEmail AddressSign UpThank you, {{form.email}}, for signing up.There was an error. Please try again.
Get our printable guide for your next healthcare provider’s appointment to help you ask the right questions.
Download PDF
Email AddressSign UpThank you, {{form.email}}, for signing up.There was an error. Please try again.
Sign Up
Thank you, {{form.email}}, for signing up.
There was an error. Please try again.
If a screening test (PSA and/or DRE) is abnormal, further testing with diagnostic tests may be needed to determine if prostate cancer is actually present and, if so, the aggressiveness of the cancer.
Transrectal Ultrasound (TRUS)
Atransrectal ultrasound (TRUS)may be used to help identify abnormalities.This approach may be used alone to calculate PSA density or combined with MRI to determine areas that should be biopsied.
Before a transrectal ultrasound, an enema is given. During the test, a thin, lubricated ultrasound probe is inserted into the rectum. Sound waves are delivered to the prostate (which lies directly in front of the rectum) and a picture of the prostate gland is generated.
Discomfort is usually mild and consists of a feeling of fullness in the rectum. If a TRUS is abnormal, a biopsy is needed to determine if abnormal appearing regions are cancerous.
Feeling Prepared Before a Prostate Biopsy
Random 12-Core Biopsy
A random 12-core biopsy may be done if a PSA is persistently abnormal, or if abnormalities are felt on a DRE or seen on TRUS. During this procedure, samples are taken from 12 random areas in the prostate gland and examined with a microscope to determine if prostate cancer cells are present.
This is usually an outpatient procedure. Practices vary, but a clear liquid diet is usually recommended for 24 hours before the test and an enema is given an hour or two before the procedure.
During the test, you would have a full bladder and you will be asked to lie on your left side. The area of the rectum where the biopsies will be done is numbed locally with lidocaine. A thin ultrasound is inserted into the rectum to visualize the prostate throughout the procedure, and 12 to 14 samples are taken with thin, hollow needles that are placed into the prostate gland. The procedure takes roughly 20 to 30 minutes.
You may experience some rectal soreness for a few days after the procedure or have spots of blood in your stool, urine, or semen for a few days. Warm soaks and compresses may alleviate discomfort.
Multiparametric MRI (mp-MRI)
Random biopsies may miss some areas of cancer and inadvertently remove normal tissue.
Multiparametric MRI (mp-MRI) is a special type of MRI used to detect abnormalities in prostate tissue. The procedure is similar to the random 12-core biopsy, but an MRI is done in advance. Targeted biopsies are limited to abnormal appearing regions.
It’s thought that this approach may help reduce the risk of overdiagnosis and overtreatment of prostate cancer. This procedure is not available at all cancer centers.
MRI Fusion Biopsy
An MRI fusion biopsy is similar to a multiparametric MRI, but it uses a combination of MRI and transrectal ultrasound (TRUS) to look for abnormal areas in the prostate. It’s thought that selective biopsies will improve the accuracy of diagnosis. As with multiparametric MRI, the procedure is not available everywhere.
Prostate Cancer Gene 3 (PCA3) RNA Test
For males over age 50, if a PSA is persistently elevated but a biopsy does not reveal cancer, the genetic test gene 3 (PCA3) RNA may be recommended. This test measures the ratio of PCA3 RNA to PSA RNA in the urine. Depending on the results, a repeatbiopsymay be recommended.
Cancer grading is done to describe the aggressiveness of a tumor, and lab and imaging tests may be done to look for evidence of spread. Some prostate cancers are non-aggressive and would not cause a problem if left alone.
Gleason Score Grading
To determine the Gleason score, the prostate cancer cells in two different areas of the tumor are each given a grade between 3 and 5 based on their microscopic appearance.
A score of 3 means that the cells look well-differentiated (very much like normal prostate cancer cells); a score of 5 means that the cells appear poorly differentiated (highly abnormal).
The two scores in the two biopsies are combined to determine the final Gleason score:
Based on these scores, prostate cancers are often placed in groups called grades, and these grades are included in staging (below).
Additional tests may be done to further stage the tumor.
Prostate cancer typically first metastasizes (spreads) to the tissues immediately adjacent to the prostate, including the seminal vesicles, rectum,bladder, andlymph nodes.
Prostate cancer has a strong tendency to spread to bones. This is most common in the lower spine, the pelvis, and the upper legs, though prostate cancer can spread to bones anywhere in the body.
Lab Tests
In addition to PSA levels that are included with staging, an alkaline phosphatase blood level may be done, as this blood test may be elevated if bone metastases are present.
Imaging Tests
Imaging tests may be done to look for the spread of prostate cancer.These tests are not usually needed for early prostate cancers or those with low Gleason scores.
Imaging tests may include:
Gene Testing
Recently, gene tests have begun to play a role in determining the aggressiveness of some prostate cancers.
Examples of mutations associated with both an increased risk of developing prostate cancer, as well as a greater likelihood that a diagnosed prostate cancer will be aggressive includeBRCA2 gene mutations, mutations in BRCA1, ATM, CHEK2, NBN, and more. There are a number of panels available that test for several of these mutations, including Oncotype Dx, ProstaVysion, Prolaris, Test, and Decipher.
At the current time, gene testing is often done for those who have a family history of prostate cancer.
Prostate cancer is assigned a stage based on several factors—the cancer grade, PSA levels, and the size and metastases (spread).
TNM Staging
As with many other cancers, TNM staging of prostate cancer can help to determine the most appropriate treatments and predict prognosis. In this system, T represents the tumor, N represents lymph nodes, and M represents metastases, with numbers that follow these letters describing the extent of spread.
Clinical TNM Staging
In clinical staging, T is broken down into:
T0: With T0 tumors, there is no evidence of a tumor in the prostate gland.
T1: These tumors might be discovered accidentally, such as when surgery is done on the prostate gland for another reason, such as BPH, and no abnormalities are noted on a digital rectal exam or imaging studies.
These are broken down into:
T2: The tumor is large enough to be felt on a rectal exam but has not spread beyond the prostate.
This is broken down into:
T4: The tumor is either fixed (immobile), or has grown into tissues beyond the prostate and seminal vesicles such as into the bladder, rectum, pelvic wall, pelvic (levator) muscles, or the muscle that controls urination (external sphincter).
Pathological Staging
With pathological staging, T is broken down into:
T2: The tumor is only in the prostate.
T3: The tumor extends beyond the prostate
T4: The tumor is fixed (immobile), or is growing into regions other than the seminal vesicles such as the rectum, bladder, pelvic wall, or levator muscles.
N is broken down into:
M is broken down into:
M0: Cancer has not spread.M1: Cancer has metastasized.
There are three substages of M1:
Stage I:These tumors cannot be felt on a rectal exam and involve half of one side of the prostate gland or less. In a case when a radical prostatetomy is performed, the cancer is confined to prostate. The cells look very normal (grade group 1). PSA is less than 10.
Stage II:These tumors have not spread beyond the prostate gland and PSA is less than 20.
Stage III:These tumors are considered locally advanced and differ from stage II tumors in that PSA levels are high, the tumor has been growing, or the tumor is high grade (aggressive).
Stage IV:Stage IV prostate cancers have spread beyond the prostate.
Risk Groups
Prostate cancers are also broken down into risk groups. The National Comprehensive Cancer Network has combined information including the level of PSA, the size of the prostate, biopsy results, and stage, to predict the chance that a prostate cancer will grow and spread.
After prostate cancer is treated, some cancers can recur. When prostate cancer comes back it may do so locally (near the site of the original tumor) or distantly (such as in bones).
Prostate cancers are more likely to recur if they have spread beyond the prostate, if they have a higher Gleason score, if they are a higher stage, and if cancer had spread to lymph nodes.
After treatment, PSA is monitored, though the frequency of testing may depend on the initial stage of the tumor and the treatments used. There are three ways in which PSA levels after treatment may predict the prognosis of the disease:
If PSA is increasing or if symptoms occur, tests to look for recurrence may include:
All of this information will be useful to you if you have a positive screening test or are formally diagnosed with prostate cancer and need to better understand your disease. However, it’s important to know that a number of other conditions can cause similar symptoms.
While some of these conditions are easily distinguished from prostate cancer, others pose more of a challenge.
Advances in magnetic resonance imaging (MRI) have greatly improved the ability to discriminate between prostate cancer and some conditions that were previously hard to tell apart.
Conditions and causes that need to be considered in the differential diagnosis of prostate cancer include:
Gleason Score 6 Prostate Cancer: What It Means
Frequently Asked QuestionsIt doesn’t mean you definitely have cancer. The test for prostate-specific antigen to identify a possible cancer has a false-positive rate of 70%.Based on the screening results, though, your healthcare provider will redo the test or order additional tests, which may include a biopsy, to confirm the diagnosis.A Gleason score is the scale used to determine whether prostate cells are cancerous and, if so, the grade or seriousness of the cancer.Two sections of cells from a biopsy are examined. Each section is graded on a scale of 1 to 5 based on how abnormal and aggressive the cells are. The scores are added together: the higher the score, the more serious the cancer.
It doesn’t mean you definitely have cancer. The test for prostate-specific antigen to identify a possible cancer has a false-positive rate of 70%.Based on the screening results, though, your healthcare provider will redo the test or order additional tests, which may include a biopsy, to confirm the diagnosis.
A Gleason score is the scale used to determine whether prostate cells are cancerous and, if so, the grade or seriousness of the cancer.Two sections of cells from a biopsy are examined. Each section is graded on a scale of 1 to 5 based on how abnormal and aggressive the cells are. The scores are added together: the higher the score, the more serious the cancer.
12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
National Cancer Institute.Prostate Cancer Screening (PDQ®)–Patient Version.
Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J.Prostate-Specific Antigen-Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force.JAMA. 2018;319(18):1914-1931. doi:10.1001/jama.2018.3712
American Cancer Society.If Prostate Cancer Screening Test Results Aren’t Normal.
American Cancer Society.Understanding Your Pathology Report: Prostate Cancer.
Axumin.Prescribing information.
National Cancer Institute.Genetics of Prostate Cancer (PDQ®)–Health Professional Version.
American Cancer Society.Prostate Cancer Stages and Other Ways to Assess Risk.
National Comprehensive Cancer Network.NCCN Guidelines for Patients: Prostate Cancer.
Penn State Health. Milton S. Hershey Medical Center.Conditions with Similar Symptoms as: Prostate Cancer.
Mulhem E, Fulbright N, Duncan N.Prostrate Cancer Screening.Am Fam Physician. 2015 Oct 15;92(8):683-688.
Prostate Cancer Foundation.Gleason Score and Grade Group.
American Society of Clinical Oncology.Prostate Cancer: Diagnosis. www.cancer.net/cancer-types/prostate-cancer/diagnosisFenton, J., Weyrich, M., Durbin, S., Liu, Y., Bang, H., and J. Melnikow.Prostate-Specific Antigen-Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;319(18):1914-1931.Filella, X., Fernandez-Galan, E., Fernandez-Bonifacio, R., and L. Foi.Emerging Biomarkers in the Diagnosis of Prostate Cancer. Pharmgenomics and Personalized Medicine. 2018;11:83-94.National Cancer Institute.Prostate Cancer Screening (PDQ)—Health Professional Version. www.cancer.gov/types/prostate/hp/prostate-screening-pdq#section/_1Buyyoumouski, M., Choyke, P., McKenney, J. et al.Prostate Cancer: Major Changes in the American Joint Committee on Cancer Eight Edition Cancer Staging Manual.CA: A Cancer Journal for Clinicians. 2017;67(3):245-253.Li, Q., Xiang, F., Lin, X. et al.The Role of Imaging in Prostate Cancer Care Pathway: Novel Approaches to Urologic Management Challenges Along 10 Imaging Touch Points. Urology. 2018;119:23-31.
American Society of Clinical Oncology.Prostate Cancer: Diagnosis. www.cancer.net/cancer-types/prostate-cancer/diagnosis
Fenton, J., Weyrich, M., Durbin, S., Liu, Y., Bang, H., and J. Melnikow.Prostate-Specific Antigen-Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;319(18):1914-1931.
Filella, X., Fernandez-Galan, E., Fernandez-Bonifacio, R., and L. Foi.Emerging Biomarkers in the Diagnosis of Prostate Cancer. Pharmgenomics and Personalized Medicine. 2018;11:83-94.
National Cancer Institute.Prostate Cancer Screening (PDQ)—Health Professional Version. www.cancer.gov/types/prostate/hp/prostate-screening-pdq#section/_1
Buyyoumouski, M., Choyke, P., McKenney, J. et al.Prostate Cancer: Major Changes in the American Joint Committee on Cancer Eight Edition Cancer Staging Manual.CA: A Cancer Journal for Clinicians. 2017;67(3):245-253.
Li, Q., Xiang, F., Lin, X. et al.The Role of Imaging in Prostate Cancer Care Pathway: Novel Approaches to Urologic Management Challenges Along 10 Imaging Touch Points. Urology. 2018;119:23-31.
Meet Our Medical Expert Board
Share Feedback
Was this page helpful?Thanks for your feedback!What is your feedback?OtherHelpfulReport an ErrorSubmit
Was this page helpful?
Thanks for your feedback!
What is your feedback?OtherHelpfulReport an ErrorSubmit
What is your feedback?
