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Developments in Prostate Cancer Screening
The U.S. Preventive Services Task Force recently finalized their recommendation that men ages 55 to 69 should speak with their health care providers about prostate cancer screening using the prostate-specific antigen, or PSA.
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Prostate cancer screening consists of:
UCLA Urologists follow the American Urological Association’s guidelines for prostate cancer screening. Screening is not without controversy – the PSA test, for instance, is often elevated when there is no cancer, and may not be elevated when there is (though this is rare). In addition, PSA alone cannot distinguish life-threatening tumors from those that are so slow-growing that they would be unlikely to pose any problem before the patient dies of something else. Patients should discuss the pros and cons of screening with their physician.
Early detection is key to achieving cure in men with prostate cancer. At UCLA, our ability to identify men at an early stage is enhanced by our cutting-edge prostate imaging program, which utilizes the most advanced MRI technology to find tumors that conventional approaches such as ultrasound can miss. We also use specialized testing to evaluate men at high risk for prostate cancer who have had prior negative prostate biopsies.
Men will typically be referred to a urologist if an abnormal PSA value is found. It is important to have the PSA lab repeated to ensure that PSA is truly elevated. For men with an abnormal PSA, there are now numerous additional tests to consider ordering before proceeding with a prostate needle biopsy. These include prostate Magnetic Resonance Imaging (MRI), blood test such as the 4K test or urinary test such as Select Mdx.
By utilizing these additional tools, men who require a prostate needle biopsy can be further identified. The sequence of using these tests is often a personalized decision made between the patient and provider. However, at UCLA we most frequently use MRI as the next step in evaluating an elevated PSA. This allows us to identify discrete suspicious lesions in the prostate and potentially biopsy those areas directly if needed.
Magnetic resonance imaging (MRI) uses magnetic fields to create detailed pictures of the prostate. An MRI of the prostate is most frequently obtained to evaluate for prostate cancer. MRI is the best test to non-invasively identify suspicious lesions within the prostate which can help guide the location of a biopsy. Also due to the high resolution of MRI, in men diagnosed with prostate cancer, the cancer stage and relationship of the cancer to the nerve bundles can be determined. This is very important to help decide the appropriate treatment for patients and also to help guide surgical planning.
Due to improvements in the MRI magnet, we no longer need to use an endorectal coil which was previously a source of discomfort for patients.
Prostate-specific membrane antigen (PSMA) PET imaging is an innovative diagnostic tool used at UCLA to diagnose prostate cancer. This scan is approved by the U.S. Food and Drug Administration and it enables more precise detection of prostate cancer allowing for individualized and targeted care. This imaging technique locates cancer lesions found not only in the prostate but also in other parts of the body to which the tumors can migrate. PSMA PET is ideal for men who are initially diagnosed with prostate cancer or for men who were previously treated but have experienced cancer recurrence. More about PSMA PET Imaging >
The UCLA Genitourinary Cancer Genetic Risk Assessment Program focuses on investigation into the potential genetic causes of an individual’s urologic cancer. Up to 5-10% of cancers are related to a genetic predisposition. If you have been diagnosed with a urologic cancer, UCLA’s team has specific referral criteria to determine if you should pursue genetic risk assessment to evaluate for a genetic cause of cancer. For those at greatest risk, often this knowledge can more precisely tailor a treatment plan that is optimal for you.
Targeted biopsy is being used at UCLA’s Prostate Cancer Program to diagnose prostate cancer. Targeted prostate biopsy refers to using advanced MRI (and occasionally PET) imaging techniques to identify areas of the prostate suspicious for cancer, and then directly biopsying them. This leads to more accurate detection and diagnosis of prostate cancer. More about Targeted Biopsy >
If cancer is confirmed by the biopsy, the tumor’s aggressiveness can be characterized using the Gleason grading system. Looking at the cellular structure of the tumor, a pathologist will assign a Gleason score based on whether it is likely to grow quickly and spread outside the prostate. Further tests can help determine whether the tumor remains confined to the prostate or, if not, the extent to which it has already spread. This process is called staging.
The Gleason grading system assigns a grade to each of the two largest areas of cancer in the tissue samples. Grades range from 1 to 5, with 1 being the least aggressive and 5 the most aggressive. The two grades are then added together to produce a Gleason score. A score of 2 to 6 is considered low grade; 7, intermediate grade; and 8 through 10, high grade. A tumor with a low Gleason score (6) typically grows slowly enough that it may not pose a significant threat to the patient in his lifetime. A newer grading system that more clearly delineates aggressive from nonaggressive tumors is also increasingly used. The system grades cancers on a scale of 1 through 5, with 1 being indolent and 5 being the most aggressive. A score of 1 correlates with Gleason grade 3+3=6, while 5 is equivalent to Gleason score of 5+5=10. Your physician will help you to understand the risk your tumor poses.
In order to help better determine potential treatment options for men diagnosed with cancer confined to the prostate, further analysis of the tissue obtained by biopsy can be performed. Oncotype DX and Decipher are two commercially available tests that are frequently ordered in men with low to intermediate risk prostate cancer. These tests analyze the genetic make-up of your cancer and provide more information about the aggressiveness of the tumor. This information is particularly useful in men considering active surveillance or if additional therapy after surgery is needed.
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