1. What information does the PSA blood test give my doctor?

A:  The PSA test is a blood test that reports the level of prostate-specific antigen (PSA) in the blood. The PSA level is one tool that helps your doctor monitor your prostate health.  An elevated PSA may be an indicator of BPH (benign enlargement of the prostate), infection, inflammation or prostate cancer. PSA is measured in nanograms per millimeter of blood. Normal PSA range is between 1 and 4 ng/ml. Anything higher can be an indication of prostate cancer and should be monitored by an urologist.  A single PSA score, however, is not enough information to indicate prostate cancer. The rate at which PSA increases is a greater indicator of a problem than one single score. This is the reason that it is recommended that men between the age of 40 and 75 have annual prostate screenings consisting of a PSA blood test and digital rectal exam (DRE). Click here for information about free prostate cancer screenings offered by the Prostate Cancer Center at Saint Joseph's.

2. What is Free PSA and what information does it give my doctor? 

A:   The free PSA test measures the amount of PSA that is not attached to other substances (free-floating) in the blood. The total PSA test measures both the amount of PSA that is attached to proteins in the blood and PSA that is in the free-floating form. Once both tests are completed, a doctor compares the free PSA result to the total PSA result to determine the percent-free PSA. The percent-free PSA, combined with the total PSA value and a DRE, helps determine whether a prostate biopsy is needed to rule out the risk (in percent) of cancer. The smaller the percent-free PSA, the more likely the patient is to have prostate cancer. The use of percent-free PSA is expected to reduce the number of unnecessary biopsies, while identifying those men who have an increased probability of having prostate cancer.  Source: Food and Drug Administration. Learn More>> FDA website.

3. Do I need to have a digital rectal exam (DRE) as part of routine screening for prostate cancer?

A:   The digital rectal exam (DRE) is a manual (by hand) examination that involves the healthcare provider putting a gloved, lubricated finger into the rectum to feel for any irregularities or nodules on the prostate. Abnormal prostate findings by examination include: (1) Nodules, and (2) Asymmetry or induration (firmness). In combination with a blood test for prostate-specific antigen (PSA), DRE is an important part of screening for prostate cancer.

4. I've been told I need a prostate biopsy but I need to better understand what is involved.

A: A prostate biopsy is an outpatient procedure that involves using an ultrasound probe to visualize the prostate through the rectum. Through this probe, a small needle is inserted and biopsy samples of the prostate are taken. The number of samples can range anywhere from 6-24. It is generally well tolerated and most men feel little to no pain. Based on the most current research, the protocol followed by the Prostate Cancer Center at Saint Joseph's is to remove a minimum of 12 prostate samples during a prostate biopsy.  For more information or to schedule a consultation for a prostate biopsy at Saint Joseph's, please contact Renee Sevy-Hasterok, our Prostate Cancer Center Patient Navigator at (678) 843-5665 or renee.sevy@emoryhealthcare.org.  She can help guide you through the process and answer any questions that you may have.

5. What additional imaging tests are typically done after a diagnosis of prostate cancer to determine extent of the cancer?

A:  Based on several criteria (i.e. age, clinical stage, PSA, general health, life expectancy) imaging tests that may be recommended include: Bone scan, pelvic computed tomography (CT) scan or magnetic resonance imaging (MRI). American Urological Association (AUA) Best Practice Statement (2009 Update) suggests that routine use of bone scan is not required for staging asymptomatic (no symptoms) men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL. CT or MRI scans may be considered for the staging of men with high-risk clinically localized prostate cancer when the PSA is greater than 20.0 ng/mL or when locally advanced, or the Gleason score is greater than or equal to 8. 

Other imaging that may be recommended: 

Endorectal MRI: An endorectal MRI provides the most extensive cross-sectional imaging available and has shown to be superior to conventional MRI for imaging the prostate. Much of the clinical information obtained will have already been provided by needle core biopsy results. MRI is most useful when assessing prostatic capsular involvement in patients at high risk of extracapsular extension (Gleason score, 8–10; PSA value, 20 ng/ml; greater than 50% positive cores; advanced clinical stage). Because of the PSA value, most newly diagnosed prostate cancers are clinically localized, which limits the utility of the endorectal MRI (Lacy, 2007). Source:  © Oncology Nursing Society, ONS University, Site Specific Series: Prostate Cancer, 2010.

ProstaScint® (EUSA Pharma, Inc.): ProstaScint is an imaging agent that can help locate and identify the extent of prostate cancer. It also helps identify previously diagnosed prostate cancer that has spread (metastasized) to other areas within the body, such as the lymph nodes, adjacent tissue and bone. ProstaScint is a single clone (monoclonal) antibody that is combined with a small amount of radioactive material called Indium 111. Given by injection into a vein, ProstaScint circulates throughout the body and attaches to an antigen called PSMA (Prostate Specific Membrane Antigen), which is located on prostate cancer cells. Pictures or images are then taken with a special device called a gamma camera that can detect radiation given off by the Indium 111. Using this technology, pictures or images will be produced showing prostate cancer. ProstaScint can be used in newly-diagnosed prostate cancer patients with biopsy-proven prostate cancer, who are at high-risk for pelvic lymph node cancer growth. ProstaScint is also recommended for use in post-prostatectomy patients with a rising PSA (Prostate Specific Antigen) in whom there is a high medical suspicion of metastatic disease. Source: Information provided by EUSA Pharma, Inc.

A review of ProstaScint’s ability to predict nodal disease demonstrated a 60%–70% sensitivity and specificity (Lange, 2001; Rosenthal, 2001). At this time, the evidence does not support routine use in low-risk patients, but the ProstaScint scan may have a role for use in high-risk patents. Source:  © Oncology Nursing Society, ONS University, Site Specific Series: Prostate Cancer, 2010.

6. What is a Gleason score and what does it mean?

A: Gleason score is the way that prostate cancer is graded on a microscopic level. Certain microscopic features, that only a pathologist can identify, categorizes prostate cancer as either low grade (Gleason 6) moderate grade (Gleason 7) or high grade (Gleason 8, 9, 10). Information on prognosis and risk of recurrence is gained from knowing the Gleason score.  Learn More>> The following articles offer expanded information on the role and significance of Gleason scores.

-  Prostate Cancer Research Institute: The Gleason Score: A Significant Biologic Manifestation of Prostate Cancer Aggressiveness On Biopsy

-  Journal of Clinical Oncology (July 20, 2009):  Gleason Score and Lethal Prostate Cancer: Does 3 + 4 = 4 + 3?

We encourage you to contact our Patient Navigator at (678) 843-5665 or rsevy@sjha.org with any questions you have relating to screening and diagnosis of prostate cancer.

7. Does low testosterone cause prostate cancer?  If I am on hormone replacement therapy for loe testosterone, can I resume this therapy after prostate cancer treatment? 

A:  Low testosterone can be caused by injury (e.g., trauma, castration,radiation or chemotherapy), hormonal disorders (e.g., pituitary tumors or diseases, high levels of prolactin), or other diseases (e.g., mumps). Some medications, HIV/AIDS and several genetic conditions (e.g., Klinefelter syndrome, hemochromatosis, Kallmann syndrome, Prader-Willi syndrome, and mytonic dystrophy) also can cause low testosterone. In many cases, however, the cause is not known. Testosterone replacement therapy can improve sexual interest, erectile function, mood and energy, body hair growth, bone density, and muscle mass. There are risks with long-term use of any testosterone delivery method for men over 50. Possible Risks of Testosterone Treatment:

-  A high red blood cell count

-  Occasional stopping of breathing during sleep (sleepapnea)

-  An increase in prostate enlargement or prostate cancergrowth

-  Fluid build-up (rarely)

African American men and men over 40 years of age who have close relatives with prostate cancer, and all men over 50 years of age should be carefully monitored for prostate cancer during testosterone treatment. Men with breast cancer or known or suspected prostate cancer should not receive testosterone replacement therapy. Men who have known prostate cancer should not receive testosterone replacement therapy as it is believed that testosterone feeds cancer growth.

Source: Journal of Clinical Endocrinology and Metabolism. Learn more>>  Medline Plus, a service of the U.S. National Library of Medicine and the National Institutes of Health offers health informationin both video or article formats.

Information on this page is provided collaboratively by the team at the Prostate Cancer Center at Saint Joseph's and has been medically reviewed by Rajesh G. Laungani, MD, 2010. The PCC follows American Urological Association and  National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for the treatment of prostate cancer.

Last Updated: October 18, 2010 (RSH