Have You Been Diagnosed?
According to the National Cancer Institute, prostate cancer is the second most common type of cancer among men in the United States. Men with certain risk factors are more likely than others to develop the disease.
Published data suggests that one of the most important factors in treating prostate cancer is early diagnosis and accurate treatment by experienced surgeons.
Before a treatment plan is determined, however, it is important to understand the disease and to research all the options available.
understanding your diagnosis
Typically, prostate cancer is diagnosed after closely examining biopsy cells through a microscope. There are several types of cells in the prostate, and each contributes in its own way to the prostate's development, architecture, and function. But cancer cells look different than normal prostate cells. Pathologists look for these differences first to detect the presence of cancer and then to determine the cancer "Grade" or Gleason Score.
Low-grade cancer cells tend to grow slowly, while high-grade cancer cells look abnormal and grow more quickly. For many years, the Gleason scoring system has been used for grading the tissue taken during a biopsy. All men with prostate cancer will have a Gleason score between 6 and 10. Your doctor will also consider how much cancer there is (its volume). For example, if you have one small area of cancer, your doctor would consider this a low-volume cancer. If you have a low-volume cancer that is also low grade, you might choose to have less aggressive management or treatment.
understanding your pathology report
If you have been diagnosed with prostate cancer it is important to understand as much as you can about your condition. Because every prostate cancer is different, knowledge about the underlying biology of your tumor may help personalize your treatment plan. Your physician will perform several tests on your tumor tissue to provide specific information about your cancer. These tests will result in a pathology report.
Your pathology report is one of the resources containing information about your tumor. This report will help guide your healthcare team in recommending an appropriate plan for you. Ask your doctor if there are additional tests you should consider ensuring you have the most complete understanding of your cancer.
Gross Description: Describes the color, weight and size of tissue as seen by the naked eye.
PSA level: Reflects the current level of prostate specific antigen (PSA) in your blood. In general, the higher the PSA, the higher the risk of cancer progression.
Gleason Score: A rating system that describes how the cancer cells look under the microscope. How the cells look is a very important predictor of how aggressive the cancer may be and very important for making management decisions.
Tumor Cell Type: The type of cancer cells in the tumor. The most common type (95% of prostate cancer) is an adenocarcinoma. Other types of prostate cancer, like small cell or signet cell, are rare and infrequently seen.
Number of cores: Specifies how many tissue samples, or cores, were removed during the biopsy. It is typical to report how many cores had cancer, along with what percentage of each core included cancerous tissue.
Location of cores: Identifies from which area in the prostate an individual tissue core was taken: apex (part of the prostate furthest from the bladder), mid-zone (middle), or base (part of the prostate nearest the bladder).
Lymphovascular/ Perineural Invasion: Specifies whether or not there are tumor cells near blood vessels or nerves, respectively.
Prostate Intraepithelial Neoplasia (PIN) or Atypical Small Acinar Proliferation (ASAP): These findings indicate abnormal cells that are not clearly cancerous. Although they are not cancer, some doctors will recommend a repeat biopsy if either of these are found.
Prostate cancer biomarkers
What is a prostate cancer biomarker?
A biomarker specific for prostate cancer is a biological molecule found in blood, urine, or tissues that is related to the presence of prostate cancer. It is also referred to as a molecular marker or a signature molecule.
Why are prostate cancer biomarkers important?
Prostate cancer biomarkers help to personailieze each patient care in the early detection, diagnosis, and treatment choices for prostate cancer. Through advanced science, researchers from many different institutions and companies have developed a variety of tests that look at each person’s genes or biomarkers and help to determine individual risk for having prostate cancer, the need for biopsies or repeat biopsies, and the best course of treatment.
What are the most frequently used biomarker tests for prostate cancer and how are they used?
Biomarkers have the following uses and benefits in each of the stages of prostate cancer screening and diagnosis:
Screening: Reduce the number of unnecessary (negative) biopsies performed as a result of elevated PSA levels
After a positive biopsy: Distinguish aggressive cancers that need treatment from non-aggressive ones that do not
After surgery: Determine if additional treatment is necessary
Currently, there are prostate cancer biomarkers in the following categories:
Urine-based biomarkers. The prostate sheds material that can be detected and measured in the urine. Urine tests can detect changes in genes and biomarkers that are specific to prostate cancer. The results of these new tests can help pinpoint whether a biopsy is necessary.
Tissue-based biomarkers. These tests use tissue from the prostate to look for specific gene markers that can help doctors distinguish between slow-growing and more aggressive forms of prostate cancer. These tests can even detect hidden cancers in men whose biopsies were negative.
Blood-based biomarkers. Cancer spreads when tumor cells break away, get swept up into the bloodstream, and start to grow in other parts of the body. These "liquid biopsies" use blood tests to capture and measure circulating tumor cells or proteins to diagnose and/or treat prostate cancer.
gleason grading
The Gleason grading system accounts for the five distinct patterns that prostate tumor cells tend to go through as they change from normal cells to tumor cells. The higher the Gleason score, the more aggressive the cancer, and the more likely it is to metastasize. The cells are scored on a scale from 1 to 5:
"Low-grade" tumor cells (those closest to 1) tend to look
very similar to normal cells."High-grade" tumor cells (closest to 5) have mutated
so much that they often barely resemble the normal cells.
These two grades are combined to create the Gleason Score, with the primary number reported first and the secondary number reported second (e.g. 3+3=6). A Gleason score can theoretically range from 2 to 10; however, a score of 5 or lower is rare so a Gleason score 3+3=6 cancer is generally the lowest grade of prostate cancer diagnosed.
The Gleason Score
The pathologist looking at the biopsy sample assigns one Gleason grade to the most similar pattern in your biopsy and a second Gleason grade to the second most similar pattern. The two grades added together determine your Gleason score (between 2 and 10).
Cancers with lower Gleason scores (2 - 4) tend to be less aggressive, while cancers with higher Gleason scores (7 – 10) tend to be more aggressive.
It's also important to know if any Gleason 5 is present, and most pathologists will report this. Having any Gleason 5 in your biopsy or prostate puts you at a higher risk of recurrence.
cancer stages
Some pathologists have started reporting on tertiary Gleason patterns when a very small number of cancer cells that appear different from the primary and secondary patterns. Not all pathologists use this additional classification, but some experts believe it helps to inform management decisions.
The Stage and What It Means
Stage 1 prostate cancer is limited to the prostate gland. The patient’s Gleason score is six or lower, and their PSA level is nine or lower.
Clinical Stage T1a-b: Cancer is diagnosed in prostate tissue removed during Transurethral Resection of the Prostate (TURP), a procedure for prostate enlargement.
Clinical Stage T1c: Cancer is diagnosed based on a biopsy performed due to elevated PSA in the absence of any abnormality of the prostate on DRE.
Stage II prostate cancer is still limited to the prostate gland, but the patient’s Gleason score is a seven or higher and their PSA level is 10 or higher.
Clinical Stage T2: The cancer is detected on DRE but appears to be confined to the prostate.
T2a involves less than one half of one side of the prostate
T2b involves more than one half of one side of the prostate
T2c involves both sides of the prostate
Stage III prostate cancer has spread beyond the outer layer of the prostate (for instance, it may have spread to the seminal vesicles). The patient’s PSA can be any level, and the Gleason score can be anywhere between two and 10.
Clinical Stage T3: The cancer is detected on DRE and appears to extend beyond the prostate, including into the seminal vesicles. T3a extends outside the prostate and T3b extends into the seminal vesicles.
Stage IV prostate cancer has spread to nearby lymph nodes, tissues or organs, or even distant parts of the body, such as the bones. Like stage III, stage IV prostate cancer can involve any PSA levels and Gleason scores that range between two and 10.
Clinical Stage T4: The cancer is detected on DRE and has invaded adjacent organs (e.g. bladder, rectum, pelvic wall).
Prostate Cancer Biomarkers Additional References:
https://archive.nytimes.com/www.nytimes.com/interactive/2013/03/26/business/new-ways-to-assess-prostate-cancer.html?ref=business.
https://www.health.harvard.edu/mens-health/biomarkers-for-better-prostate-cancer-screening
NCCN Clinical Practice Guidelines in Oncology, (NCCN Guidelines®) Prostate Cancer Early Detection. Version 2.2018 — April, 4, 2018, p. MS-16, 17.
Genomic Tools
Genomic tests measure the expression of genes that might influence the aggressiveness of your prostate cancer. These tests are playing an increasingly important role in the management of prostate cancer at all phases, from diagnosis to management decisions to post-treatment decisions about supplemental treatment.
Information from genomic tests can help guide decisions about the best management for your specific disease. For example, genomic tests might be done after PSA screening to judge whether high PSA levels indicate cancer; after a biopsy to gauge whether the biopsy is an accurate reflection of the prostate tumor; or after surgery, to determine the likelihood of the cancer coming back.
Oncotype DX® Genomic Prostate Score
One such genomic test, the Oncotype DX Genomic Prostate Score (GPS), is intended for men recently diagnosed with very low-risk, low-risk, and select cases of intermediate-risk prostate cancer. The Oncotype DX GPS examines expression of specific genes in the prostate tumor to help predict the likelihood of high risk disease not detected through a biopsy2. The information provided by the Oncotype DX prostate cancer test is used in conjunction with the NCCN risk groups and may help you and your doctor determine the most appropriate management option for you based on the biology of your individual cancer.
SelectMDx®
A non-invasive urine test (“liquid biopsy”), SelectMDx measures the expression of two mRNA cancer-related biomarkers (HOXC6 and DLX1). The test provides binary results that, when combined with the patient’s clinical risk factors, help the physician determine whether:
The patient may benefit from a biopsy and early prostate detection, or
The patient can avoid a biopsy and return to routine screening
ConfirmMDx®
A tissue test to improve the identification of men at risk for undetected clinically significant prostate cancer. Independently published clinical studies have shown that for men who have received a negative prostate biopsy result, ConfirmMDx is the single most significant predictor of patient outcome among all currently available clinical factors, such as age, PSA level, and DRE results.1,2 This test can:
“Rule-in” high-risk men who have had a previous negative biopsy result, may be harboring undetected cancer (a false-negative biopsy result), and therefore may benefit from a repeat biopsy and appropriate treatment.
“Rule-out” otherwise cancer-free men from undergoing unnecessary repeat biopsies and screening procedures, helping to reduce complications, patient anxiety, and excessive healthcare expenses associated with these procedures.
Other Genomic Tests
There are other genomic tests available such as ®Decipher3 and ®Prolaris4 that assess tumor aggressiveness. Both Decipher and Prolaris are available for patients who have already gone through a radical prostatectomy (surgical removal of the prostate) and in men who have had a biopsy that shows prostate cancer. These tests are validated as predictors of outcomes in prostate cancer but were not developed specifically for very low-risk, low-risk, and low intermediate-risk prostate cancer patients. Ask your physician about the best test option for you.
To Treat or not to treat?
Men diagnosed with prostate cancer have many different options available, and there is no one-size-fits-all approach to prostate cancer.
Prostate cancer grows at different rates in different individuals. Ideally, these very low-risk, low-risk, and even some select intermediate risk cancers may be managed with active surveillance - strict, regular monitoring of the cancer by your healthcare team with a decision to treat if/when the cancer shows more aggressive features.
Unfortunately, traditional clinical tests (biopsy, PSA, DRE) are not perfect predictors of how aggressive a given tumor will be. For some patients, doctors may recommend a biopsy-based genomic test that can be used in conjunction with traditional measures to help determine the true biological aggressiveness of a cancer.
Aggressive prostate cancers that have a high risk of growing and spreading should be treated in a timely manner. Your doctor may suggest treatment including surgery (radical prostatectomy), radiation therapy, cryosurgery, hormonal therapy, chemotherapy, and emerging new drugs or investigational agents. For each man, the potential benefits versus risks and side effects of treatment should be considered. Understanding your unique diagnosis will help you and your healthcare team determine which options will work best for you.
You should consult with your doctor regarding your screening or diagnosis and be empowered with your physician to make the move that is best for your specific case. Take your health care into your own hands, as no one can be as strong an advocate for you as you or your family can.
