“You have prostate cancer.” About 1 in 9 American men will hear those words at some point during their lifetime. Today, screening helps doctors find most prostate cancers at least five years earlier than in the past. If you, or a loved one, are facing a potential prostate cancer diagnosis, you may be wondering what happens next. Everyone’s case is unique, but the main steps are: Diagnostic testing Biopsy Cancer grading Cancer staging Treatment Diagnostic Testing When a screening test suggests a potential prostate problem, your doctor will start the diagnostic process. You may have already been through this part of the diagnosis. It involves having a transrectal ultrasound (TRUS). For this imaging exam, a wand-like transducer is inserted into the rectum. It is not painful, but it can be uncomfortable. The ultrasound helps your doctor measure the size of the prostate gland. This information can also assist your doctor in deciding which treatment options for prostate cancer you have. Biopsy A biopsy is often the next step in a prostate cancer diagnosis. You may have already been through this part, as well. It is the only way to know for certain whether or not you have prostate cancer and provides additional information about the cells themselves, which is necessary for certain treatment recommendations. It involves taking a sample of prostate cells and examining them under a microscope. For prostate biopsies, doctors most commonly use a core needle biopsy. This technique uses a hollow needle to remove a tiny cylinder—or core—of tissue. After numbing the area, your doctor will use TRUS to locate the area for biopsy. Using a spring-loaded tool, your doctor will painlessly advance the needle through the wall of your rectum directly into the prostate. The process of taking the core sample is very quick with the spring-loaded tool. Doctors usually take several cores. A pathologist will analyze the cores to determine if cancer is present. Grading the Cancer Pathology testing also will tell your doctor your cancer’s grade. Grade is essentially a measure of how aggressive the cancer is. Doctors determine this by looking at the cells—the closer the cells look to normal cells, the lower the grade; the more abnormal the cells look, the higher the grade. High-grade, aggressive cancers are more likely to grow and spread. Most prostate cancers are slow-growing and low-grade. Grading prostate cancer is somewhat complex, but understanding your grade can help you make a shared treatment decision with your doctor. There are five grades for prostate cancer using the numbers 1 to 5. However, prostate cancers are not always uniform. The tumor tends to have areas with different grades. So, doctors use what’s known as a ‘Gleason score’ to describe the aggressiveness of prostate cancer. The Gleason score takes the two most common grades in the cancer—from the set of core samples—and combines them. For example, if the most common grade is 3 and the next most common is 4, the Gleason score is 3+4 = 7. If the grade is the same throughout the tumor, the same number is added to itself. For example, 3+3 = 6. The highest possible score is 10 (5+5). Doctors may group Gleason scores as follows: Gleason score of 6 or less: low-grade. A pathology report may say these are ‘well differentiated,’ meaning they look close to normal prostate cells. These cancers are not aggressive and are less likely to spread. Gleason score of 7: intermediate-grade or moderately differentiated. Gleason score of 8 to 10: high-grade or poorly differentiated. These cancers are aggressive. However, you may also see an actual grade number of 1 to 5 on the pathology report. This is because doctors have realized the Gleason score groups can be too broad. For example, a score of 7 can be either 3+4 or 4+3 depending on which grade is most common. If 3 is most common, men tend to have a better prognosis than when 4 is most common. So, an overall grade is often more helpful: Grade 1: Gleason 6 or less Grade 2: Gleason 3+4 = 7 Grade 3: Gleason 4+3 = 7 Grade 4: Gleason 8 Grade 5: Gleason 9 or 10 Staging the Cancer Cancer staging is the process of finding out how extensive the cancer is. There are four stages of prostate cancer using the Roman numerals I, II, III and IV. In general, lower—or early—stages have a more favorable outlook. Higher stages are more advanced. There are five criteria doctors use to determine the stage: T: extent of the tumor N: presence or absence of cancer cells in lymph nodes M: whether the cancer has spread—or metastasized PSA (prostate-specific antigen) level Gleason score Doctors will take biopsies from nearby lymph nodes to see if cancer is there—this is the N part of staging. They will use imaging tests to detect any cancer spread—this is the M part of staging. Doctors may use MRI (magnetic resonance imaging) for prostate cancer diagnosis, but you also may have ultrasounds, bone scans, CT (computed tomography), and PET (positron emission tomography) at different times after the initial diagnosis, throughout treatment, and after you finish treatment. Choosing Treatment Believe it or not, many prostate cancers do not need treatment right away. It is possible to have a very low-grade, early stage cancer. These cancers pose little threat to a man’s health. In fact, men with these cancers usually live a full life for years and eventually die from another unrelated cause. Watchful Waiting and Active Surveillance If treatment is not necessary, your doctor may recommend watchful waiting for prostate cancer. You delay treatment until you have symptoms, a change in symptoms, or there are other signs the cancer is growing or changing in some way. You will see your doctor regularly for PSA tests and other prostate cancer screening exams. You will have another biopsy and imaging tests one year from initial diagnosis. If there is no sign of a change, you and your doctor may extend the length of time in between tests. Active surveillance is sometimes used interchangeably with watchful waiting, but typically active surveillance involves more closely (and more frequently) monitoring the tumor by normal screening methods and biopsy—sometimes within six months of initial diagnosis. If your doctor uses either of these terms, ask for details on the types of tests you will have and how frequent they will be. Watchful waiting and surveillance can be stressful for some men because it does not involve active treatment. Talk with your doctor if this approach will not meet your physical and mental health needs. Active treatment may be a better option for your overall health. Active Treatment When active treatment is necessary, surgery and radiation therapy are the two main options. In early stages, prostate cancer surgery vs. radiation have similar cure rates. Each has risks and benefits. Your doctor is the best resource for weighing the options and choosing the right one for you. Hormone therapy and biologic therapy are additional options for more advanced prostate cancers. Making cancer treatment decisions can be difficult sometimes. This is especially true when treatment can result in problems, such as erectile dysfunction and urinary incontinence. If you are having trouble deciding, consider getting a second opinion. It is very common in the cancer diagnosis process to consult another doctor. In fact, your doctor may suggest it or your insurance company may even require it. Having another doctor’s perspective may lead you to a different decision. It may also solidify your original plan and give you peace of mind that you are making the right choice.