Prostate Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is prostate cancer diagnosed?

Most prostate cancers are first found during screening with a prostate-specific antigen (PSA) blood test and or a digital rectal exam (DRE). (See Prostate Cancer Prevention and Early Detection.) Early prostate cancers usually don’t cause symptoms, but more advanced cancers are sometimes first found because of symptoms they cause. Whether cancer is suspected based on screening tests or symptoms, the actual diagnosis can only be made with a prostate biopsy.

Medical history and physical exam

If your doctor suspects you might have prostate cancer, he or she will ask you about any symptoms you are having, such as any urinary or sexual problems, and how long you have had them. Your doctor may also ask about bone pain, which could be a sign that the cancer might have spread to your bones.

Your doctor will also examine you, including doing a digital rectal exam (DRE), during which a gloved, lubricated finger is inserted into the rectum to feel for any bumps or hard areas on the prostate that might be cancer. If you do have cancer, the DRE can sometimes help tell if it is only on one side of the prostate, if it is on both sides, or if it is likely to have spread beyond the prostate to nearby tissues.

Your doctor may also examine other areas of your body. He or she might then order some tests.

PSA blood test

The prostate-specific antigen (PSA) blood test is used mainly to try to find prostate cancer early in men without symptoms (see Prostate Cancer Prevention and Early Detection). But it is also one of the first tests done in men who have symptoms that might be caused by prostate cancer.

    Most healthy men have PSA levels under 4 nanograms per milliliter (ng/mL) of blood. The chance of having prostate cancer goes up as the PSA level goes up.

When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn’t have cancer – about 15% of men with a PSA below 4 will have prostate cancer on a biopsy.

    Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50%.

Not all doctors use the same PSA cutoff point when considering whether to do a prostate biopsy. Some may advise it if the PSA is 4 or higher, while others might recommend it at 2.5 or higher. Other factors, such as your age, race, and family history, may also come into play.

The PSA test can also be useful if prostate cancer has already been diagnosed.

  • In men just diagnosed with prostate cancer, the PSA test can be used together with physical exam results and tumor grade (from the biopsy, described further on) to help decide if other tests (such as CT scans or bone scans) are needed.
  • The PSA test is a part of staging and can help tell if your cancer is likely to still be confined to the prostate gland. If your PSA level is very high, your cancer has probably spread beyond the prostate. This may affect your treatment options, since some forms of therapy (such as surgery and radiation) are not likely to be helpful if the cancer has spread to the lymph nodes, bones, or other organs.

PSA tests are also an important part of monitoring prostate cancer during and after treatment (see “Following PSA levels during and after treatment”).

Transrectal ultrasound (TRUS)

For this test, a small probe about the width of a finger is lubricated and placed in your rectum. The probe gives off sound waves that enter the prostate and create echoes. The probe picks up the echoes, which a computer then turns into a black and white image of the prostate.

The procedure often takes less than 10 minutes and is done in a doctor’s office or outpatient clinic. You will feel some pressure when the probe is inserted, but it is usually not painful. The area may be numbed before the procedure.

TRUS is often used to look at the prostate when a man has a high PSA level or has an abnormal DRE result. It is also used during a prostate biopsy to guide the needles into the right area of the prostate.

TRUS is useful in other situations as well. It can be used to measure the size of the prostate gland, which can help determine the PSA density (described in Prostate Cancer Prevention and Early Detection) and may also affect which treatment options a man has. TRUS is also used as a guide during some forms of treatment such as brachytherapy (internal radiation therapy) or cryosurgery.

Prostate biopsy

If certain symptoms or the results of early detection tests – a PSA blood test and/or DRE – suggest that you might have prostate cancer, your doctor will do a prostate biopsy to find out.

A biopsy is a procedure in which a sample of body tissue is removed and then looked at under a microscope. A core needle biopsy is the main method used to diagnose prostate cancer. It is usually done by a urologist, a surgeon who treats cancers of the genital and urinary tract, which includes the prostate gland.

Using transrectal ultrasound to “see” the prostate gland, the doctor quickly inserts a thin, hollow needle through the wall of the rectum into the prostate. When the needle is pulled out it removes a small cylinder (core) of prostate tissue. This is repeated from 8 to18 times, but most urologists will take about 12 samples.

Though the procedure sounds painful, each biopsy usually causes only a brief uncomfortable sensation because it is done with a special spring-loaded biopsy instrument. The device inserts and removes the needle in a fraction of a second. Most doctors who do the biopsy will numb the area first by injecting a local anesthetic alongside the prostate. You might want to ask your doctor if he or she plans to do this.

The biopsy itself takes about 10 minutes and is usually done in the doctor’s office. You will likely be given antibiotics to take before the biopsy and possibly for a day or 2 after to reduce the risk of infection.

For a few days after the procedure, you may feel some soreness in the area and will probably notice blood in your urine. You may also have some light bleeding from your rectum, especially if you have hemorrhoids. Many men also see some blood in their semen or have rust colored semen, which can last for several weeks after the biopsy, depending on how frequently you ejaculate.

Your biopsy samples will be sent to a lab, where a pathologist (a doctor who specializes in diagnosing disease in tissue samples) will look at them under a microscope to see if they contain cancer cells. If cancer is present, the pathologist will also assign it a grade (see the next section). Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer.

Even when taking many samples, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer (because your PSA level is very high, for example) a repeat biopsy might be needed to help be sure.

Grading prostate cancer

Pathologists grade prostate cancers according to the Gleason system. This system assigns a Gleason grade, using numbers from 1 to 5 based on how much the cells in the cancerous tissue look like normal prostate tissue.

  • If the cancerous tissue looks much like normal prostate tissue, a grade of 1 is assigned.
  • If the cancer cells and their growth patterns look very abnormal, it is called a grade 5 tumor.
  • Grades 2 through 4 have features in between these extremes.

If cancer is present, most biopsies are grade 3 or higher, and grades 1 and 2 are not often used.

Since prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added to yield the Gleason score (also called the Gleason sum). The higher the Gleason score, the more likely it is that the cancer will grow and spread quickly.

The Gleason score can be between 2 and 10, but most biopsies are at least a 6.

There are some exceptions to this rule. If the highest grade takes up most (95% or more) of the biopsy, the grade for that area is counted twice as the Gleason score. Also, if 3 grades are present in a biopsy core, the highest grade is always included in the Gleason score, even if most of the core is taken up by areas of cancer with lower grades.

  • Cancers with a Gleason score of 6 or less are often called well-differentiated or low-grade.
  • Cancers with a Gleason score of 7 may be called moderately-differentiated or intermediate-grade.
  • Cancers with Gleason scores of 8 to 10 may be called poorly-differentiated or high-grade.

Other information in a biopsy report

Along with the grade of the cancer (if it is present), the pathologist’s report also often contains other pieces of information that can give a better idea of the scope of the cancer. These can include:

  • The number of biopsy core samples that contain cancer (for example, “7 out of 12”)
  • The percentage of cancer in each of the cores
  • Whether the cancer is on one side (left or right) of the prostate or both sides (bilateral)

Suspicious results

Sometimes when the pathologist looks at the prostate cells under the microscope, they don’t look cancerous, but they’re not quite normal, either. These results are often reported as suspicious.

Prostatic intraepithelial neoplasia (PIN): In PIN, there are changes in how the prostate cells look under the microscope, but the abnormal cells don’t look like they’ve grown into other parts of the prostate (like cancer cells would). PIN is often divided into low-grade and-high grade.

Many men begin to develop low-grade PIN at an early age but don’t necessarily develop prostate cancer. The importance of low-grade PIN in relation to prostate cancer is still unclear. If a finding of low-grade PIN is reported on a prostate biopsy, the follow-up for patients is usually the same as if nothing abnormal was seen.

If high-grade PIN is found on a biopsy, there is about a 20% chance that cancer may already be present somewhere else in the prostate gland. This is why doctors often watch men with high-grade PIN carefully and may advise a repeat prostate biopsy, especially if the original biopsy did not take samples from all parts of the prostate.

Atypical small acinar proliferation (ASAP): This is sometimes just called atypia. In ASAP, the cells look like they might be cancerous when viewed under the microscope, but there are too few of them to be sure. If ASAP is found, there’s a high chance that cancer is also present in the prostate, which is why many doctors recommend getting a repeat biopsy within a few months.

Proliferative inflammatory atrophy (PIA): In PIA, the prostate cells look smaller than normal, and there are signs of inflammation in the area. PIA is not cancer, but researchers believe that PIA may sometimes lead to high-grade PIN or to prostate cancer directly.

For more information about how biopsy results are reported, see the Prostate Pathology section of our website.

Imaging tests to look for prostate cancer spread

If you are found to have prostate cancer, your doctor will use your digital rectal exam (DRE) results, prostate-specific antigen (PSA) level, and Gleason score from the biopsy to figure out how likely it is that the cancer has spread outside your prostate. This information is used to decide if any imaging tests need to be done to look for possible cancer spread. Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body.

Men with a normal DRE result, a low PSA, and a low Gleason score may not need any other tests because the chance that the cancer has spread is so low.

The imaging tests used most often to look for prostate cancer spread include:

Bone scan

If prostate cancer spreads to distant sites, it often goes to the bones first. A bone scan can help show whether cancer has reached the bones.

For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in damaged areas of bone throughout the body over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.

Areas of bone damage appear as “hot spots” on your skeleton – that is, they attract the radioactivity. Hot spots may suggest cancer in the bone, but arthritis or other bone diseases can also cause hot spots. To make an accurate diagnosis, other tests such as plain x-rays, CT or MRI scans, or even a bone biopsy might be needed.

Putting in the IV line can cause some brief pain, but the scan itself is not painful. The radioactive material passes out of the body in the urine over the next few days. The amount of radioactivity used is very low, so it carries very little risk to you or others. But you still might want to ask your doctor if you should take any special precautions after having this test.

Computed tomography (CT) scan

This test isn’t often needed for newly diagnosed prostate cancer if the cancer is likely to be confined to the prostate based on other findings (DRE result, PSA level, and Gleason score). Still, it can sometimes help tell if prostate cancer has spread into nearby lymph nodes. If your prostate cancer has come back after treatment, the CT scan can often tell if it is growing into other organs or structures in your pelvis.

The CT scan uses x-rays to make detailed, cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.

For some scans, you might be asked to drink 1 or 2 pints of oral contrast before the first set of pictures is taken. This helps outline the intestine so that it looks different from any tumors. You might also need an IV (intravenous) line through which a different kind of contrast is injected. This helps better outline structures in your body.

The IV contrast can cause you to feel flushed (a feeling of warmth with some redness of the skin). Some people are allergic and get hives. Rarely, more serious reactions, like trouble breathing or low blood pressure, can occur. Medicines can be given to prevent and treat allergic reactions, so be sure to tell your doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.

You will also need to drink enough liquid to have a full bladder. This will keep the bowel away from the area of the prostate gland.

CT scans are not as useful as magnetic resonance imaging (MRI) for looking at the prostate gland itself.

Magnetic resonance imaging (MRI)

MRI scans can be helpful in looking at prostate cancer. They can produce a very clear picture of the prostate and show whether the cancer has spread outside the prostate into the seminal vesicles or other nearby structures. This information can be very important for your doctors in planning your treatment. But like CT scans, MRI scans aren’t usually needed for newly diagnosed prostate cancers that are likely to be confined to the prostate based on other factors.

MRI scans use radio waves and strong magnets instead of x-rays to create pictures. Like a CT scan, a contrast material might be injected, but this is done less often. Because the scanners use magnets, people with pacemakers, certain heart valves, or other medical implants may not be able to get an MRI.

MRI scans take longer than CT scans – often up to an hour. During the scan, you need to lie still inside a narrow tube, which is confining and can upset people who don’t like enclosed spaces. The machine also makes clicking and buzzing noises. Some places provide headphones with music to block this noise out.

To improve the accuracy of the MRI, you might have a probe, called an endorectal coil, placed inside your rectum for the scan. This must stay in place for 30 to 45 minutes and can be uncomfortable. If needed, medicine to make you feel sleepy (sedation) can be given before the scan.

ProstaScintTM scan

Like the bone scan, the ProstaScint scan uses an injection of low-level radioactive material to find cancer that has spread beyond the prostate. Both tests look for areas of the body where the radioactive material collects, but they work in different ways.

While the radioactive material used for the bone scan is attracted to bone, the material for the ProstaScint scan is attracted to prostate cells in the body. It contains a monoclonal antibody, a type of man-made protein that recognizes and sticks to a particular substance. In this case, the antibody sticks to prostate-specific membrane antigen (PSMA), a substance found at high levels in normal and cancerous prostate cells.

After the material is injected, you will be asked to lie on a table while a special camera creates an image of the body. This is usually done about half an hour after the injection and again 3 to 5 days later.

This test can find prostate cancer cells in lymph nodes and other soft (non-bone) organs, although it’s not as helpful for looking at the area around the prostate itself. The antibody only sticks to prostate cells, so other cancers or benign problems should not cause abnormal results. But the test is not always accurate, and the results can sometimes be confusing.

Most doctors don’t recommend this test for men who have just been diagnosed with prostate cancer. But it may be useful after treatment if your blood PSA level begins to rise and other tests can’t find the exact location of your cancer. Doctors may not order this test if they believe it will not be helpful for a given patient.

Lymph node biopsy

In a lymph node biopsy, also known as lymph node dissection or lymphadenectomy, one or more lymph nodes are removed to see if they contain cancer cells. This isn’t done very often for prostate cancer, but can be done to find out whether the cancer has spread from the prostate to nearby lymph nodes. A lymph node biopsy might be done at different times.

Biopsy during surgery to treat prostate cancer

The surgeon may remove lymph nodes in the pelvis during the same operation as the radical prostatectomy. (See the section “Surgery for prostate cancer” to learn more about radical prostatectomy.)

If there is more than a very small chance that the cancer might have spread (based on factors such as a high PSA level or a high Gleason score), the surgeon may remove some lymph nodes before removing the prostate gland.

In some cases a pathologist will look at the nodes right away, while you are still under anesthesia, to help the surgeon decide whether to continue with the radical prostatectomy. This is called a frozen section exam because the tissue sample is frozen before thin slices are taken to check under a microscope. If the nodes contain cancer, the operation might be stopped (leaving the prostate in place). This would happen if the surgeon feels that removing the prostate would be unlikely to cure the cancer, but would still probably result in serious complications or side effects.

But more often (especially if the chance of cancer spread is low), a frozen section exam is not done. Instead the lymph nodes and the prostate are removed and are then sent to the lab to be looked at. The lab results are usually available several days after surgery.

Biopsy as a separate procedure

A lymph node biopsy is not often done as a separate procedure. It is sometimes used when a radical prostatectomy isn’t planned (such as for certain men who choose treatment with radiation therapy), but when it’s still important to know if the lymph nodes contain cancer.

Laparoscopic biopsy: A laparoscope is a long, slender tube with a small video camera on the end that is inserted into the abdomen through a small cut. It lets the surgeon see inside the abdomen and pelvis without needing to make a large incision. Other small incisions are made to insert long instruments to remove the lymph nodes around the prostate gland, which are then sent to the lab.

Because there are no large incisions, most people recover fully in only 1 or 2 days, and the operation leaves very small scars.

Fine needle aspiration (FNA): If your lymph nodes appear enlarged on an imaging test (such as a CT or MRI scan) a doctor may take a sample of cells from an enlarged node by using a technique called fine needle aspiration (FNA).

To do this, the doctor uses a CT scan image to guide a long, hollow needle through the skin in the lower abdomen and into the enlarged node. The skin is numbed with local anesthesia before inserting the needle. A syringe attached to the needle lets the doctor take a small tissue sample from the node, which is then sent to the lab to look for cancer cells.

You will be able to return home a few hours after the procedure.

Last Medical Review: 12/22/2014
Last Revised: 03/12/2015