Screening & Diagnosis of Prostate Cancer

It is recommended that the process of prostate cancer screening be governed by a 'shared decision making' model.

 

This means that your input is required. You will need to invest some time to become informed in order to make consulatation with your urologist efficient and productive. The urologist will assist you in making a decision (and may make a recommendation) but ultimately the decision is yours.

 

Be Aware of The Steps In The Screening Process

 

  1. Decide if prostate cancer screening is right for you. Discussion can be initiated by the patient or physician.
  2. If a patient consents to screening then a PSA and prostate exam are done. Both are necessary. PSA alone is not accurate enough to establish risk.
  3. Risk assessment is completed and discussed. 
  4. You make a decision with assistance from the urologist. Be prepared to select one of the following options based on the risk assessment and your preferences: 
    1. Repeat the PSA and prostate exam at an appropriate time interval.
    2. Secondary risk assessment (e.g. prostate MRI).
    3. Prostate biopsy.
    4. Discontinue screening altogether.
    5. Go home and think about it.

 

Read the information on this page prior to your consulation. You may be re-directed here to reinforce the discussion you have with the urologist or if you require clarification for routine questions.

 

STEP 1: Decide If Prostate Cancer Screening Is Right For You.

 

Most people assume that cancer invariably leads to death and that early diagnosis results in better outcomes. Prostate cancer screening can lead to early detection in some men. Early treatment can lead to longer life in some men. Treatment may not cause problems for some men. However, these outcomes do not occur in all men - sometimes an undesirable result occurs. There are several reasons for this but they all come down to the fundamental problem of predicting the future. The 3 primary characteristics of prostate cancer that make prediction challenging are:

 

  1.  Prostate cancer behavior can be unpredictable.
    1. The cancer may never progress and cause any problems BUT can cause suffering and/or death.
    2. The cancer may progress so slowly that a man dies of another condition before the prostate cancer has an opportunity BUT some men will live long enough that the cancer has an opportunity to cause suffering and/or death.
    3. The cancer may have spread prior to diagnosis rendering it incurable and thereby removing the benefit of screening BUT evidence of incurability may only be apparant in hindsight - sometimes years after one must make a decision on whether to receive (or forego) radiation or surgery.
  2. Treatments to cure prostate cancer may not be harmful BUT sometimes are harmful. Occasionally the complications from the treatment can be devastating. Radiation and surgery can cause irreversible problems with:
    1. Urinary function.
    2. Sexual function.
    3. Bowel function.
  3. Life-expectancy can be challenging to assess. Men need to live long enough to beneft from treatment. Many men with prostate cancer will 'die with it instead of from it' without any treatment. Accurate assessment of life expectnacy is challenging over the 10+ year time horizon that prostate cancer screening requires to be of benefit.
    1. Younger men are more likely to benefit from screening.
    2. Older men are less likely to benefit from screening.

 

It bears emphasizing that screening and treatment of prostate cancer relies on prediction of the future. An inherent property of prediction is uncertainty. In the absence of certainty, the best that we can do is make educated guesses with the information at hand. Information also changes with time. This is not just a problem with prostate cancer screening but with virtually everything in life - the future is alwasy uncertain to some degree. In prostate cancer screening this results in an unavoidable tension between overdiagnosis and underdiagnosis which can, in hindsight,  be a source of overtreatment and undertreatment. The aim is to strike the right balance for the each patient at a specific time in their life.

 

The following websites provide information on the pros and cons of screening. READ AT LEAST ONE OF THESE BEFORE YOUR VISIT.

 

Prostate Cancer Canada: Prostate Cancer Basics: Screening and Diagnosis

Americal Cancer Society: Testing for Prostate Cancer

American Society for Clinical Oncology (ASCO) Prostate Cancer Screening Decision Aid Tool

National Institutes for Health/NCI PSA

 

If you are confident that screening isn't for you and do not require more discussion, please cancel your appointment.

For all others, we look forward to your consultation.

 

Interesting in learning more about the nuts and bolts of screening and diagnosis?

 

 

STEP 2: Have a PSA and Prostate Exam

 

This part of the process is the most straightforward.

 

PSA is a blood test. Click here for information on Prostate Specific Antigen.

From a screening perspective, one should be aware that a confirmatory test is often necessary to confirm the accuracy of the test.

 

Prostate exam is an integral part of the process. It is sometimes called a DRE or digital rectal exam. DRE evaluates for prostate size, symmetry, nodularity, consistency (hardness or induration), margins and the status of the adjacent structures (seminal vesicles, rectum and pelvic muscles). Abnormal findings generally are not enough to confirm a diagnosis of prostate cancer but affect the risk that cancer is present.

 

 

STEP 3: You Will Be Provided an Estimate of Risk and Further Discussion

 

There is NO currently available test that can exclude the presence of prostate cancer with anywhere close to 100% certainty. The conequence is that every man has some risk of having prostate cancer. Cancer may be present even if the PSA is low, the prostate feels normal, if a prostate biopsy does not show cancer or if an MRI is normal - though all of these are asociated with a lower risk of having cancer.

 

The only answer to the question "Do I have cancer?" can only be "Maybe". For some men, the 'maybe' is closer to 'very unlikely' but for others it maybe 'very likely'. It should of some reassurance that by undergoing screening men are taking at least some control of that risk.

 

A equally vexing issue is that the only way to prove that prostate cancer is present is with a biopsy. The vast majority of men have nothing more than discomfort and recover quickly from biopsy but some may experience serious infection, bleeding or urinary retention.

 

Ultimately, we need a measure of risk so that you may make a decision. You will be provided an assessment of risk which will help you make a decision. Information that constribute to asessing risk of harboring prostate cancer includes:

 

  1. PSA
  2. Prostate exam
  3. Hereditary risk/family history
  4. Biopsy history
  5. Additional test results (e.g. MRI)
  6. Other tests

 

Tools to evaluate risk and provide a quantitative assessment are available in the CaP Calculators section and are strongly recommended for clinical use. These calculators greatly outperform using any of the aforementioned pieces of information individually.

 

 

STEP 4: You Make a Decision

 

If you decided to undergo prostate cancer screening, you will ultimately need to select one of the following options (with the assistance of your urologist):

 

  1. Repeat the PSA and prostate exam at an appropriate time interval (i.e. 'serial risk assessment/screening').
  2. Secondary risk assessment (e.g. prostate MRI).
  3. Prostate biopsy.
  4. Discontinue screening altogether (may be appropriate in men with life-expectancies less than 10 years or very low risk of harboring cancer).
  5. Go home and think about it. Take time for more thought/discussion about your options. Ensure you let your physician know your decision or if you require more discussion - it's your responsibility.

 

It's your health and this is why it is so important that you participate in the process. Your urologist has the expertise and experience to guide you but they can't make the decision for you.

 

 

Prostate Cancer Screening Guidelines

 

Many organizations have prostate cancer screening guidelines. These continue to change as evidence accumulates regarding the benefits and harms of screening and as the diagnostic testing continues to evolved.

 

 

 

 

On The Web

Genetic testing for BRCA1, BRCA2: saliva test. Myriad Genetic Laboratories, Ambry Genetics and Gene Dx (2-4 weeks)

Deciding on When a Prostate Biopsy Should be Done

About Prostate Biopsy: Interpretation & Limitations

 

Prostate Cancer on the Web

 


General Prostate Cancer Web-Resources

Prostate Cancer Canada Resources

Prostate Cancer Basics: Screening and Diagnosis

Prostate Cancer Treatment Options

Prostate Cancer Post-Treatment Recovery and Side Effects

Memorial Sloan-Kettering Cancer Center in New York is an excellent resource for information on prostate cancer. Balanced, unbiased discussions of the disease, including discussion regarding some of the controversies in prostate cancer.

General Information on Cancer

UNDERSTANDING CANCER - Metrovan Urology info on the principles of diagnosis, staging, prognosis and more.

American Cancer Society

BC Cancer Agency: Good general website from the British Columbia Cancer Agency. Has contact information on locations.

National Cancer Institute: Excellent source of understandable and mainly unbiased information. Several very good brochures on every stage of prostate cancer.

National Comprehensive Cancer Network: peer-reviewed expert content/prostate cancer guidance on evidence-based cancer diagnosis and management. Best for Prostate and Kidney Cancer. The most in-depth information is located in the physician section and requires registration.