Locally Advanced Disease (Stage T3–T4)

Locally advanced disease refers to prostate cancer that is no longer confined to the prostate and has started to invade nearby organs such as the seminal vesicles, but where there is no evidence of spread to distant sites such as the bone (T3–T4). This may also include those patients with biochemical failure following curative treatment, patients with N+ disease and those who are surgical margin positive after radical prostatectomy.

The aim of treatment for locally advanced disease is to reduce the risk of metastatic spread and tissue invasion and thereby prolong survival (Table 3.3). There are several possible treatment alternatives for patients with this early stage of prostate cancer. Some patients may be cured.


Radiotherapy + Hormonal Therapy

Neoadjuvant hormonal treatment prior to radiation therapy

Neoadjuvant hormonal therapy, used in combination with radiotherapy, is generally administered to reduce prostatic size/symptoms. The term neoadjuvant is used to describe a treatment is given before the primary treatment. Examples of neoadjuvant therapy may include hormone therapy commenced prior to radiation therapy.

EBRT (External beam radiotherapy) is often sufficient to suppress PSA levels to within normal ranges and delay disease progression. However, EBRT following neo-adjuvant hormonal therapy has been shown to produce better local control of disease and effect greater reductions in the risk of clinical or PSA relapse than EBRT alone.

The RTOG 86-10 trial investigated the use of MAB (goserelin – ZOLADEX plus flutamide) given for 4 months, starting 2 months before and continuing for 2 months during radiation therapy in T2–T4 disease. Disease free survival at 8 years was significantly improved (33%) in patients receiving neoadjuvant therapy compared to 21% in patients receiving radiation therapy alone.

Overall survival was improved in patients with a Gleason score of 2-6, although survival in all patients was not improved. In addition such neoadjuvant therapy reduces the number of patients requiring salvage therapy (Pilepich MV et al. Int J Radiat Oncol Biol Phys 2001; 50: 1243–52).

Figure 3.10. RTOG – 86-10 - Disease-free survival, all patients

Keyhole Surgery?

I have been thinking lately about the procedure that (hopefully) awaits me sometime in the new year - i.e. 'Keyhole Surgery'!

I say hopefully because the early results (PSA, Gleason Score, Biopsy and CT Scan) seemed to rule out this option. Let me explain.

All of the tests mentioned above, indicated that the cancer had spread beyond the 'capsule' of the prostate. This meant that 'cure' by removal of the tumour was not an option. The best case scenario, meant that I would undergo 'hormone therapy' and could look forward to 3-5 years of life!

Well ... something amazing occured from the time of the Bone Scan which followed only days after the CT Scan. No evidence of the cancer spreading beyond the capsule was found! This meant that a 'cure' became a possibility.

A subsequent blood test showed a 71% reduction in my PSA level even though the treatment was only a few weeks old!

If all goes well and according to plan; the hormone therapy will continue to reduce the size of the tumour and force it into remission. At some subsequent stage, a course of radiotherapy will be introduced to 'kill' the cancer and make surgery a viable option for a cure!

Given that my Urologist prefers to utilise a 'laproscopic surgical procedure' I reasoned that I should conduct some research on this technique. What follows is a video depicting the procedure itself and the benefits it entails. Prostate Cancer - Video

Prostate Cancer - A Glossary

Updated: Now includes an extensive 'online' glossary and also an online acronym and abbreviations decipher.

Researching Prostate Cancer, as a lay person, proved to be rather difficult at first. I really had no point of reference or basis for understanding (or remembering) either the medical terms or the anatomical names!

So, my solution, was to find a glossary of terms that would assist me on my endeavour until such times that the terms etc, became familiar to me by virtue of common usage. It is with this in mind, I offer the following as an aid to other lay persons who find themselves on the same journey.

Ablation - Removal or separation of something.

Adrenal glands - Small glands lying on top of the kidneys which produce a small amount of male hormone.

Androgens - Male hormones. The most active male hormone, testosterone, is produced by the testicles. Other male hormones are produced by the adrenal glands.

Anti-androgens - Drugs which block the effects of male hormones.

Asymptomatic - Not having symptoms, symptom-free.

Benign - Non-cancerous (not cancer).

Benign prostate enlargement - Non-cancerous enlargement of the prostate.

BPH - Benign Prostatic Hyperplasia. A condition causing non-cancerous enlargement of the prostate.

Biopsy of the prostate - Removal of small pieces of tissue, in this case, from the prostate gland. Tissue samples are taken from different areas of the prostate, and then examined under the microscope to see if they are cancerous.

Brachytherapy - A type of prostate radiotherapy - involves the insertion of radioactive seeds or rods directly into the prostate.

CAT (CT) scan - CAT stands for Computerised Axial Tomography. A series of x-ray pictures are taken in a circle around the body and are processed by a computer.

Chemotherapy - Usually refers to the killing of cancer cells with cytotoxic chemicals (cytotoxic means toxic to cells.)

Cystitis - Inflammation of the bladder, often caused by infection.

Cystoscope - A tiny tube with a lighted end which slides along the urethra and is used to examine the bladder.

Digital Rectal Examination (DRE) - An examination of the prostate through the rectum wall. The doctor inserts a finger in the rectum and feels the shape of the prostate. Irregularities may be caused by cancer.

Dry ejaculation - Also called reverse or retrograde ejaculation. After surgery on the prostate, a man may achieve orgasm, but produce no ejaculate. This is because of either the removal of a muscular valve which prevents the ejaculate from going backwards into the bladder (in the case of surgery called a TURP), or because the glands which produce much of the fluid in the ejaculate are also removed (in the case of a radical prostatectomy).

Ejaculate - Fluid produced at ejaculation which contains sperm and secretions from glands such as the prostate, seminal vesicles and testicles.

Gleason score - A way of grading cancer cells. Low grade cancers (Gleason score 2,3,4) are slower growing than high grade (Gleason scores 8,9,10) cancers.

Grade - A way of describing how abnormal the cancer cells look, and consequently how aggressive or fast-growing the cancer is likely to be. The most commonly used grading system is the Gleason score, which ranges from 2-10.

Hot flush - A sudden rush of heat to the face, neck, sometimes chest and back. It can be associated with hormonal therapy for prostate cancer.

Hormone resistance - Prostate cancer cells are dependent on testosterone or male hormone for growth. Withdrawal of male hormone by surgery or by means of drugs is therefore a means of controlling its growth. However cancer cells may develop which do not need testosterone for growth. The cancer is then said to be ‘hormone resistant’.

Hyperthermia - Higher than normal temperature. In the case of prostate cancer, a way of destroying tissue by heating.

Impotence - Inability to achieve an erection.

Indolent - Means ‘lazy’, usually referring to the type of cancer cells which grow only slowly.

Incontinence - Inability to hold urine or control urine loss.

Lymph nodes - Small glands which filter tissue fluid before it returns to the blood stream. This means that they often capture cancer cells which have escaped from the main tumour and have started to spread to other parts of the body.

LHRH - Luteinising Hormone Releasing Hormone. It is produced by the hypothalamus in the brain and stimulates the pituitary (another part of the brain) to produce LH (Luteinising Hormone). This, in turn causes cells in the testicles to produce testosterone, the male hormone.

LHRH agonists - Drugs which interfere with the production of LH (see above) by the pituitary.

Libido - Sex drive.

Margin-positive - See surgical margins.

Metastasis - A piece of cancer which has broken off from the main cancer and become established in a different part of the body. Prostate cancer metastases often occur in lymph glands, bone or in the lungs.

MRI - Magnetic Resonance Imaging. A way of imaging the inside of the body without using X-rays.

Nodules - Small lumps.

Oncologist - A doctor who specialises in treating cancer.

Orchidectomy - (Also Orchiectomy) A type of operation which removes the testicles, but usually leaves the scrotal sac or scrotum.

Pelvis/pelvic - The area of the body below the waist and surrounded by the hip and pubic bones.

Pituitary - Part of the brain which produces hormones which stimulate the testicles to produce testosterone (male hormone) and other hormones.

Prostatitis - Inflammation of the prostate. It can be caused by bacteria.

Prostatectomy - Operation to remove all or part of the prostate.

PSA - Prostate Specific Antigen. It can be used as a test for prostate cancer or to monitor its recurrence.

Radical prostatectomy - An operation which removes the prostate and the seminal vesicles. This may be done through a cut in the abdomen or the perineum (the area of skin between the rectum & scrotum).

Rectum - The last part of the bowel, leading to the anus, and through which stool passes.

Retrograde - Also called reverse ejaculation. This may occur after surgery for benign enlargement of the prostate. The ejaculate travels back into the bladder instead of exiting out through the penis. This means a man is infertile, but he can still achieve orgasm.

Scrotum - A pouch of skin which contains the testicles and some other parts of the male repro-ductive system. It hangs outside the body and below the penis.

Seminal vesicles - Glands which lie very close to the prostate and produce secretions which form part of the ejaculate.

Staging - A way of describing how far the cancer has spread.

Stricture - Scar tissue which obstructs fluid flow; in the case of a urethral stricture, urine flow is obstructed.

Surgical margins - After a radical prostatectomy, the edges of the tissue which has been removed are examined to see if cancer cells are present. If they are not (negative surgical margins) the chance is higher that all of the cancer has been removed.

Testicles - Glands which produce sperm and the male hormone, testosterone. They are found in the scrotum.

Testosterone - The major male hormone. It is produced by the testicles.

TRUS - Trans-Rectal Ultra-Sound. A means of imaging the prostate in order to locate cancer. The ultrasound probe is placed in the rectum.

TURP - Trans-Urethral Resection of the Prostate. An instrument is inserted, under anaesthetic, along the urethra (urine tube) and removes prostate tissue which may be blocking the flow of urine. It is a common operation for benign enlargement of the prostate, but only occasionally used to treat prostate cancer.

Urethra - Tube which carries urine and ejaculate along the length of the penis and to the outside.

Online Glossary: Acronyms and Abbreviations: Courtesy of: Prostate Cancer research Institute

Is Cancer Confined to the Prostate Gland?

The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) in the hope readers may become more informed. I would encourage all our readers to visit the author's website.

These tables may help you and your doctor to predict the chance of organ confined prostate cancer.

Find the table headed with your PSA level. Next, read down the left column to your Gleason score. Then read across to the column headed by your clinical stage (e.g T2a).

Where the row for your Gleason meets the column for your clinical stage is a number. This number, e.g. 66, is a percentage - 66%. Your number gives you a rough idea of how many chances out of a hundred a patient with your PSA level, Gleason score and Clinical Stage has of organ confined disease.


The higher this number, the better. Remember you're NOT an "average" number!

PSA 0.0 - 4.0 ng/mL

Clinical Stage___ T1a ---- T1b ---- T1c ---- T2a ---- T2b ---- T2c ---- T3a

Gleason Score ----% Probability (that cancer is organ-confined)

-- 2-4 ---------------------90 ------80 -------89 -------81 -------72 -------77

-- 5 ------------------------82 ------66 -------81 -------68 -------57 -------62 -------40

-- 6 ------------------------78 ------61 -------78 -------64 -------52 -------57 -------35

-- 7 ----------------------------------43 -------63 -------47 -------34 -------38 -------19

-- 8-10 ------------------------------31 -------52 -------36 -------24 -------27

_______________________________________________________________

PSA 4.1 - 10.0 ng/mL

Clinical Stage___ T1a ---- T1b ---- T1c ---- T2a ---- T2b ---- T2c ---- T3a

Gleason score --------------------------% Probability

--2-4 ---------------------84 ---- --70 -------83 -------71 -------61 ------66 --------43

--5 ------------------------72 -------53 -------71 --------55 ------43 ------49 --------27

--6 ------------------------67 -------47 -------67 -------51 -------38 ------43 --------23

--7 ------------------------49 -------29 -------49 -------33 -------22 ------25 --------11

--8-10 --------------------35 ------18 --------37 -------23 -------14 ------15 ---------6

_______________________________________________________________

PSA 10.1 - 20.0 ng/mL

Clinical Stage___ T1a ---- T1b ---- T1c ---- T2a ---- T2b ---- T2c ---- T3a

Gleason score ---------------------------% Probability

--2-4 ----------------------76 ------58 ------75 -------60 -------48 --------53

--5 -------------------------61 ------40 ------60 -------43 -------32 --------36 ------18

--6------------------------------------33 -------55 -------38 -------26 --------31 ------14

--7 -------------------------33 ------17 ------35 -------22 -------13 ---------15 -------6

--8-10 --------------------------------9 -------23 -------14 ------- 7 ----------8 --------3

________________________________________________________________

PSA above 20.0 ng/mL

Clinical Stage___ T1a ---- T1b ---- T1c ---- T2a ---- T2b ---- T2c ---- T3a

Gleason score ---------------------------% Probability

--2-4 -------------------------------38 --------58 -------41 ------29

--5 ----------------------------------23 --------40 -------26 ------17 --------19 ------8

--6 ----------------------------------17 --------35 -------22 ------13 --------15 ------6

--7 ----------------------------------------------18 --------10 -------5 ----------6 ------2

--8-10 -------------------------------3 --------10 --------5 --------3 ----------3 ------1
________________________________________________________________

Making Decisions at Time of Diagnosis

The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) in the hope readers may become more informed. I would encourage all our readers to visit the author's website.

Slow down and take a breath before making any decisions about treatment. Prostate cancer can develop into a deadly disease. But for most men at time of diagnosis today, prostate cancer is not usually in need of immediate, emergency treatment. Most likely, you'll have time -- days, weeks and in some cases months -- to gather information and to decide among several treatment options.

Even so, a recent study found that men with stage T2 prostate cancer who had to wait nine weeks or more before receiving treatment by radiotherapy had a higher rate of recurrence unless they received a higher dose of radiation.

Your first task, with your doctors' help, is to get information about your Gleason grade and stage of prostate cancer and your PSA velocity.

Your second task is learn about which treatments offer you best outcomes in long-term survival and side effects.

Medical information about prostate cancer may be new to you. Your body is on the line, and new information may be hard to absorb. This may be the most complex decision you've ever made. Do what you can to make it easier on yourself.


A few practical steps will help you to get organized and on track:

* Bring someone with you to your appointments.

* Bring a notepad and tape recorder to the appointments.

* At home, set up a calendar, a phone number book and a file box (or file drawer) and a loose-leaf ring binder.

* Use the file for your new medical records, medical bills and health insurance papers, and for print-outs from reliable sources like medical journals.

* Use the binder to list your own questions and to jot down your doctors' replies. If you prefer to use a small notebook in the doctor's office, tape your notes into the binder when you get home.

* If you wish, jot down or clip and paste in info from sources like books, pamphlets and computer print outs. Family, friends and support group members may be able to help you gather and sift information.

* Select the most important points that may affect you. These are points you want to discuss with your doctors.

* Nothing is too dumb (or too clever) to ask.

* If you need privacy to talk to your doctor about impact of various treatments on sexual desire, lovemaking and erections, or bladder and bowel control, say so.

* Expect any doctor you would care to allow to treat you to be interested in your overall health and well being and to see you as an individual with cancer not as a statistic or person of a certain age.

* Don't underestimate the value of statistics and "cancer numerology." Graphs and studies tell a story about human beings.

*Seek a second opinion about your biopsy.

*Seek second opinions and, if needed, third opinions or more about your treatment options.

*If you're considering either surgery or radiotherapy (external beam or brachytherapy), find a practitioner who has done the procedure many times. Usually, this means going to a major hospital recognized as a national cancer center. Prostate cancer has no single best treatment. But evidence has shown that some practitioners are "artists" and quantity of experience also counts. Quality of equipment used (especially for external beam radiation) is key. Urologists (surgeons) and radiologists who are leaders in their field and who have treated the most patients do a better job.

* Take some time to consider the information you have been given before you make a final decision.

In many situations in life we don't make optimal choices, "we choose the first reasonable option, a strategy known as satisficing." Satisficing is OK if there's no big penalty for choosing wrong.

In life and death situations, many people do not carefully gather all available information and come to a rational decision. A study of fire commanders found that they "took the first reasonable plan that came to mind and did a quick mental test for problems. If they didn't find any, they had their plan of action."

Some of the best cancer doctors are trained to be able to "take the first reasonable plan," do the quick mental test for problems and, if none jump out, to sell that plan of action to the patient.

But these people already know most of the available information.

Reflection

After you've gathered and studied a full range of good information, it's fine to sleep on it and let the decision come naturally.

A Dutch study has found that people can think unconsciously and -- surprisingly -- that for complex decisions unconscious thought is actually superior.

Lead researcher Dr Ap Dijksterhuis told the BBC: "The take-home message is that when you have to make a decision, the first step should be to get all the information necessary for the decision.

"Once you have the information, you have to decide, and this is best done with conscious thought for simple decisions, but left to unconscious thought - to 'sleep on it' - when the decision is complex."

It's your body and your life. You want to stay healthy, productive and active for as long as you can. More than one type of treatment might work equally well for you. For some men, no immediate treatment may be the best decision. But don't lose sight of the fact that you probably have just one good chance of a cure. It's worth bucking the urge to "satisfice" too soon. Keep reading and asking questions. Do the best that you can to make the right choice for yourself. Don't sell yourself short. Then, when you wake up with the decision "made" by your gut, or your unconscious mind, you can accept that and go forward without looking back.

The following video may prove useful in trying to understand the range of options available for treating Prostate Cancer today.

Diagnosis and Treatment of Prostate Cancer

More on the Gleason Index

The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) in the hope readers may become more informed. I would encourage all our readers to visit the author's website.

This is used to grade how far prostate tissue is from normal, healthy tissue. After the doctor has taken biopsy samples of your prostate tissue, he or she sends them to a pathology lab. The pathologist looks at the samples under a microscope and grades the tissue on a scale of 1 to 5. The low number, 1, is for cells that look almost normal (very slow growing cancer). The high number, 5, is for cells that are least like normal prostate cells. Grades 2 to 4 fall in between.

Prostate cancer tumors often have areas of various grades. The pathologist identifies the two most prevalent grades. These are then added together to make the Gleason score (also called Gleason sum).

A result may look like one of these (not all possible combinations are displayed here):

3 + 2 = 5 or
2 + 3 = 5

3 + 3 = 6

3 + 4 = 7 or
4 + 3 = 7

4 + 4 = 8 or
3 + 5 = 8

4 + 5 = 9 or
5 + 4 = 9


(The order of the numbers matters and can affect treatment outcomes)

The Gleason grading system is named after Dr Donald F Gleason, the doctor who formulated it along with members of the Veterans Administration Cooperative Urological Research Group.

Normal body tissue cells are well-formed and differentiated to fit the functions of the specific body part. As you see in this image above, cells at the far right end (5) are quite shapeless and random compared to the moderately differentiated cells in the middle and the quite regular-looking cells at the left (1).

A small tumor with nearly normal structure (well differentiated) will behave in a more normal biological way. It may grow very slowly, with a doubling time of many years, and might never become a serious threat to health. A tumor that is moderately differentiated or undifferentiated is faster growing and more likely to spread.

High-grade tumor cells, having lost the special structure, or "architecture," that made them work as part of the prostate gland, may not even put out much PSA. This is one reason the Gleason grade and score are such key pieces of information for making treatment decisions.

CT and Bone Scans Explained

Attended the Urologist's Surgery in St Leonards to receive an indication of the best way forward in light of the recent CT and Bone Scans. The earlier CT Scan, raised the possibility that the cancer had spread to the bones (pelvis); however, the subsequent Bone scan ruled that out.

This is of course is good news; but there remains a likelihood that the cancer is not contained in the prostate - largely because of the very high PSA reading of 84.8 and the '9' (out of 10) recorded on the Gleason index - '9' being a very agressive cancer.


Gleason Score

Utilising the 'Gleason Grade', the Urologist rated the two most common types of cancer cells present in the samples, numbering each type from 1 for the least affected up to 5 for the most affected.


Gleason Score Agressiveness of prostate cancer

2-4 Low
5-6 Moderate
7 Intermediate
8-10 High

A score of 2 to 5 indicates the cancer is relatively slow growing and probably not very agressive. A score from 5 to 7 indicates the cancer is faster growing and moderately aggressive. A score of 8 or higher indicates an aggressive cancer.


Hormone Therapy

This being the case, the recommended treatment is Hormone therapy - surgery is ruled out. Hormone therapy will involve four weeks of taking a medication which slows the production of testosterone. Since Prostate cancer relies upon testosterone to grow, the cancer often shrinks and goes into temporary remission sometimes for years.

Half way (two weeks) into this treatment, an injection of a luteinising hormone-releasing hormone (LHRH) is given to control the production of testosterone. LHRH is then given 3 monthly by injection to continue this treatment.

LHRH Agonists

LHRH, or luteinizing-hormone releasing hormone, is one of the key hormones released by the body before testosterone is produced. (Note that LHRH is sometimes called GnRH, or gonadotropin-releasing hormone.) Blocking the release of LHRH through the use of LHRH agonists or LHRH analogues is one of the most common hormone therapies used in men with prostate cancer.

Drugs in this class, including leuprolide (Eligard, Lupron, and Viadur), goserelin (Zoladex), and triptorelin (Trelstar), are given in the form of regular shots: once a month, once every three months, once every four months, or once per year.

The success of this treatment (in my case Goserelin 10.8mg every 3 months) will be monitored by regular blood tests which look specifically at the Prostate Specific Antigen (PSA) readings. A lower PSA indicates that the treatment is working.

Subsequent to this treatment and dependent upon how my body reacts to the LHRH, radiotherapy will then be considered.

As with most things, there is a down side to this treatment. Men receiving Hormone therapy may have side effects from the withdrawal of testosterone. This could include: increased tiredness, erection problems, reduced sex drive, weight gain, hot flushes, breast tenderness, depression, and loss of bone strength (osteoporosis).

These side effects can significantly affect the way a man functions, however there are treatments that can minimise the impact of the side effects.

In order to monitor the progress of the Hormone Treatment, I have been scheduled to have two further blood tests (December and February) with the expectation that my PSA readings will go down. At present my PSA is 84.8. Normal readings for someone my age would be between 0 and 3.5 - still a way to go!

Biopsy Explained

Thursday 25/10/2007 - 4:30pm.

Attended the Urologist's Surgery to receive the results of the transrectal biopsy. As predicted, the cancer was not contained in the prostate. I was then given the shattering news that I had 'advanced and incurable prostate cancer' and was told that the only real treatment option was hormone therapy.

I was told that the cancer was very agressive with a 'Gleason Score' of 9. The Gleason score (the most commonly used biopsy grading system) indicates whether the cancer is slow or fast growing depending on a score out of 10. The higher the score, the faster (more agressive) the cancer.

After pressing for a prognosis that I could understand i.e. 'how long have I got'; I was told the following:-

Under a 'best case' scenario, I was informed that I could expect to live for a further 3 to 5 years. However, if the 'worst case' scenario were in play then I could look forward to just 12 to 18 months.

It was then determined that further tests be undertaken, including a CT scan and a Bone Scan, in order to determine the most appropriate treatment options.

Testing for Prostate Cancer

The following is excerpt from the Prostate Cancer Foundation's website. I have reproduced the information here, but encourage all readers to visit the above website.

Caught in its early stages prostate cancer can be cured especially when the cancer is still confined within the prostate gland. Testing through a blood test - the Prostate Specific Antigen (PSA ) or DRE (digital rectal examination) offers the best opportunity to determine the presence of cancer.

Early detection is the key to enabling better outcomes and potential cure of prostate cancer. Accordingly, it is recommended that men at 50 with no family history of prostate cancer, and men at 40 with a family history, should seek voluntary annual assessments in the form of a Prostate Specific Antigen (PSA) blood test together with a Digital Rectal Examination (DRE). It can be life threatening to wait for symptoms before seeking assessment.


What are the common reasons to get tested

Most men will seek testing for prostate cancer for the following reasons:

(1) As part of a general check up - usually after 50 years of age.

(2) Due to a recent experience with a relative or friend who has suffered from prostate cancer.

(3) A family history of prostate cancer.

(4) A recent onset of urinary symptoms

Some men, when enquiring about prostate cancer, may be confused by conflicting views expressed about methods of diagnosing and treating the disease. Perhaps the most controversial is the view, that it would be better for men not to know whether they have the disease and therefore they should not be tested be treated.


The thinking behind this is...

(1) Because the disease can be relatively slow to develop, most men would die
with, rather than of, the disease.

(2) Because treatment has potentially serious side effects such as impotence and incontinence, treatment may be worse than the disease. It as the right of all men to make decisions for themselves about whether to be tested. It is your choice.


What Test Could I Have?

The PSA

The PSA blood test looks for the presence in the blood of a protein that is produced specifically by prostate cells called Prostate Specific Antigen.

The result of a PSA test needs expert evaluation by an experienced doctor but the following provides a guide in regards to PSA levels.

* Below a PSA of 4 the chance of prostate cancer being confined to the prostate gland is 65%.

* Between 4 and 10, the chance is 50%.

* Between 10 and 20, 35% and,

* Beyond 20, 20% and less.

Once the PSA is above 30, it is very likely the cancer has spread beyond the prostate and therefore cannot be cured surgically. If your test reveals a slightly elevated PSA, your doctor may recommend the test be repeated from time to time to establish the rate of change, if any, before recommending a biopsy.


The DRE

About 90% of all prostate cancers arise in the outer part of the prostate where they may be detected by a digital rectal exam (DRE), which is the simplest and most widely-performed screening procedure. The doctor inserts a gloved and lubricated finger into the patient's rectum and feels the prostate for bumps or other abnormalities. The exam is quick and painless but some men find it embarrassing. It is not very accurate in detecting early cancers, but studies indicate that regular DREs still save lives.

Biopsy

A Biopsy is a small tissue sample taken with a spring loaded needle. This normally conducted by a urologist. A small probe containing an ultrasound generator and sampling needles (known as Trans Rectal Ultra Sound or TRUS) is inserted in the anus. The ultrasound generates an image of the prostate on a computer screen and guides the doctor to insert the sampling needles into selected areas of the prostate. Your doctor may recommend an anaesthetic for the procedure and a course of antibiotics before or afterwards.

The biopsy samples will be analysed by a pathologist to determine the stage and grade of the cancer. If cancer is detected, two further assessments will be made:


Biopsy outcomes

There are four likely results...

* The tissue is normal benign prostate tissue.

* A condition called atypia or dyspalasia where the cells do not look typical of either normal or cancerous cells.

* Prostatic interpitelial neoplasia (PIN) where the cells appear to be in the transitional stage between normal and cancer.

* Prostate cancer - which are currently graded on a numerical scoring system call the Gleason Score and the Stage of cancer.

Gleason Score

Utilising the 'Gleason Grade', the Urologist rated the two most common types of cancer cells present in the samples, numbering each type from 1 for the least affected up to 5 for the most affected.


Gleason Score Agressiveness of prostate cancer

2-4 Low
5-6 Moderate
7 Intermediate
8-10 High

A score of 2 to 5 indicates the cancer is relatively slow growing and probably not very agressive. A score from 5 to 7 indicates the cancer is faster growing and moderately aggressive. A score of 8 or higher indicates an aggressive cancer.


Stage - how far the cancer has developed.

Stage 1 - The cancer is small and contained within the prostate.

Stage 2 - The cancer is larger and may be in both lobes of the prostate, but is still confined to the organ.

Stage 3 - The cancer has spread beyond the prostate and may have invaded the adjacent lymph glands or seminal vesicles.

Stage 4 - The cancer has spread to other organs, or to bone.

Note:

Each stage has up to 4 sub-groupings (a, b, c, & d) for more accurate definition. Frequently the letter “T” (for tumour) is placed before the stage number, which then appears, for example, as T2(c), or similar. If in doubt, ask your doctor to explain the meaning to you fully. It is vital information for you to understand.

If you have the misfortune to be diagnosed, be sure to ask your doctor for the exact grade and stage of your cancer and discuss their meaning and implications. Be sure to note this information for future reference, as stage and grade are important indicators when choosing treatment. Your doctor may call for additional tests like a bone scan, CT scan and a MRI to check the extent of the disease.