Diagnosis of prostate cancer in Israel
The diagnosis usually begins with consultation of our doctor. If he suspects that you have a prostate cancer, he will do two preliminary tests – PSA protein levels in the blood.
Digital Rectal Exam (DRE)
As the prostate gland is located in front of the rectum, doctor can examine its state by inserting a gloved finger into the rectum. A benign enlargement of the prostate have a soft and smooth sensation, but prostate cancer area is hard and lumpy to the touch. However, there are cases when the gland is smooth, despite the presence of cancer cells in it. Digital Rectal Exam can be unpleasant, but it is not associated with pain.
As part of this test, it involves taking a blood sample, and then the lab will check PSA (prostate-specific antigen) concentrations by the next few days. PSA is a protein made by the prostate, and it is found in a small amount of blood naturally. Most men with prostate cancer have usually higher PSA blood concentration.
PSA levels also can increase due to various factors , such as:
- inflammation or benign prostatic hyperplasia (more common with age);
- prostate biopsy;
- prostate or bladder surgery;
- prostate massage;
- PSA levels are not exceeded about 30% of men with prostate cancer and its level is determined by the age.
Disagreement over PSA levels indicates a problem. The age is important, when levels below 4 nanograms per milliliter (ng / ml). An analysis of the situation shows that the higher the prostatic-specific antigen level, the higher it has an impact on the likelihood of a cancerous tumor. But there is currently no clear threshold for cancer, and increasing rate of PSA levels should also be considered conducting diagnostic tests.
After cancer treatment, PSA level decrease. So, the measurement of prostatic antigen is a good way to assess the disease stage, its progression and effectiveness. This test also serves as a measure for predicting the disease behavior after treatment (surgery or radiation therapy). Then the value of PSADT – PSA doubling time is used or a period when level of prostate-specific antigen doubles.
Transrectal Ultrasound – TRUS
Transrectal ultrasound test uses sound waves to build a three-dimensional image inside the body. This test helps to measure the size and density of the prostate gland. When it is viewed through the rectum, a small sensor is inserted and transmits a prostate image to a computer screen. During the test, the sample tumor also can be taken for biopsy (described in detail below). The test can be unpleasant, but it takes only a few minutes.
Prostate Tumor Biopsy
If preliminary tests indicate prostate cancer, you may be asked to do a biopsy. During the test a needle is inserted through the rectum wall into the prostate and a tiny tissue sample is taken from the gland. The prostate biopsy is usually guided by the supervision of ultrasound. A lab gets a tissue sample for microscopic examination, where pathologist determines a cancer presence and its grade.
A biopsy is performed without anesthesia and may include discomfort and sometimes pain. Some local anesthetics can be administered to reduce discomfort. If you have an artificial heart valve, or dental and surgical procedures have been performed, you will be asked to take antibiotics in order to avoid complications. A few days later, minor bleeding may occur in the urine, in feces, or after intercourse.
Sometimes the first prostate biopsy may not detect a tumor in the prostate gland. In about one fifth of cancer patients, a primary biopsy is not diagnosed. Therefore, after receiving a negative result at the first biopsy, you may be asked to perform another test and to monitor the PSA level of in the blood additionally. If prostatic antigen concentration is increasing, another biopsy will be performed.
In some cases, a biopsy will be performed using transperineal access. This biopsy is usually performed under general anesthesia when the needle is inserted through the area between the anus and the scrotum, into the untreated parts of the prostate gland.
Target biopsy using a combination of MRI and ultrasound
A prostate biopsy is based on two imaging methods – multiparametric MRI and ultrasound, which help to increase the efficiency of the biopsy. This test, also known as a «fusion biopsy» is performed when prostate cancer is suspected due to high PSA values, abnormal rectal examinations or their combination.
Сonducting a combination MRI ultrasound test or «fusion biopsy»
First, MRI scan of the prostate it is performed. Then a MRI specialist using a special three-dimensional model of the prostate points to the biopsy locations. Next step is a biopsy performed under ultrasound control with local or general anesthesia. A three-dimensional prostate model is superimposed in real time on the ultrasound image, and thus the urologist can accurately direct the biopsy needle to the neded sites and takes tissue samples for microscopic examination in the lab.
Blood test – 4KScore
4KScore is a blood test that checks the level of four biomarkers, which are indicators for detecting a disease and monitoring its development.
Biomarkers are known for detecting prostate cancer in the blood:
- total PSA
- free PSA
- bound PSA
The blood test helps to determine indication for a prostate biopsy in cases where PSA values are high. In addition, 4KScore is intended for patients who have undergone a normal biopsy, but there is still a prostate cancer problem.
The results of biomarkers blood test in combination with the patient’s clinical information which includes digital rectal exam, PSA level test and previous biopsies, are calculated using a risk assessment of aggressive prostate cancer (Gleason index above 7).
Additional tests after diagnosis
When prostate cancer is diagnosed, additional tests are needed to check the disease spread into the prostate and beyond. You may be asked to perform one of the following tests:
Bones are the most common place for prostate cancer beyond the prostate. A bone scan test helps to diagnose tumorous areas. During the bone scanning a very small amount of low radioactivity material with a harmless dose is injected into the vein. A bone affected with a cancerous tumor absorbs a larger amount of radioactive material than healthy bone, so the scanner recognizes and identifies abnormal areas. Remains for low-radioactive material will disappear from your body a few hours after the test. You will be asked to wait about three hours from the injection moment until bone mapping itself, so that the material is “absorbed by all the bones of the body”.
Doctor can routinely do chest and bone x-rays to check your general health status and the disease spreading to other parts of the body.
Magnetic resonance imaging (MRI scan)
This test is similar to CT scans, but uses a magnetic field instead of X-rays to construct body images in cross section. Imaging helps to determine if prostate cancer has spread to nearby tissues or lymph nodes near the prostate gland. And you can get an injection of contrast medium to improve the results of visualization. During the test, you will be asked to lie on the bed in a large roll for about 30 minutes. If you experience discomfort, you should tell your technician about this before the test.
People having a pacemaker or some type of surgical staple can’t get an MRI scan due to magnetic fields. Scanning is not related to pain, and you can return home after the examination.
Magnetic resonance imaging is used to evaluate disease in the prostate gland (endetal study) and to detect bone metastases (in vitro study) or any other specific organ. In cases where the first biopsy is negative and the PSA level continues to increase, MRI will be used as a diagnostic tool for repeated biopsy.
This test is a possible alternative to MRI scanning and projects a complex view of X-rays, creating a three-dimensional image of the body. Scanning is not painful, but it takes longer than conventional radiography (from 10 minutes to half an hour), and includes a long time without movement. You will be asked not to eat or drink at least four hours before the test.
CT uses a very small amount of radiation that cannot harm you or the people contacting with you. You may be offered a drink or a shot of colored material that will allow to better visualize certain areas of your body during CT scan. This substance can make you feel a heatwave all over your body for several minutes. You may also have a more serious reaction to the injection, if you are allergic to iodine, or asthma, so it is important to notify the diagnostician in advance. You can return home as soon as the scan is over.
It is new and complex test, including low-radioactive material that is absorbed directly into cancer cells or through various factors that relate to them. The PSMA PET-CT test is currently being conducted with the Ga68 isotope, which binds to a cancer cell to diagnose the distant distribution of cancer cells to the lymph nodes, bones or other organs. It also helps in diagnosing elevated PSA levels when the results other tests were correct.
Molecular tests for personalized treatment of prostate cancer:
- ♦ Decipher prostate
♦ ProMark Prostate Oncotest
♦ Oncotest Prolaris Prostate
♦ Oncotype DX Prostate
The goal of the tests of prostate cancer
The results of all tests will help to determine the stage of prostate cancer and enable doctors to decide which treatment is best for you. Results usually takes a few days to two weeks. You will have a follow-up meeting before your returning home.
♦ Molecular oncotests help to obtain more accurate and effective treatment for each patient. ⇒ See review of all the molecular oncotests done in Israel.