Welcome back for part 3 of 3 of Amanda Saltzman’s M.D. series on prostate cancer screening. So far, she has reviewed the basics of prostate cancer screening and the controversy surrounding screening recommendations. Find out now what happens next-
Well, this gets complicated, and again, each of the governing bodies differs slightly on what they recommend. There are essentially 4 options:
1. Your PSA is within normal range, your DRE was normal and you aren’t in the high risk category
- You passed the test!
- No further testing is necessary
- You will discuss the interval of repeat screening with your physician (by convention, most suggest yearly or every other year)
2. Your DRE was abnormal
- You need a prostate biopsy as this finding is suggestive of cancer
3. Your DRE was normal, but your PSA is elevated and/or your doctor thinks you may be in the high risk category
- Historically, doctors used a cut off PSA of 4 ng/mL for prostate biopsy
- However, there is no PSA level below which a man can be reassured that prostate cancer does not exist
- Because of this, the consideration of other factors becomes important (free PSA, patient age, family history, ethnicity, prior biopsy results, comorbidities)
- Based on your individual situation, your doctor will recommend either prostate biopsy or repeat screening
4. Your PSA velocity is >0.75 ng/mL regardless of the total PSA level
- PSA velocity measures how quickly your PSA has risen, and if it’s too quick we get worried
- In order to calculate PSA velocity, you need to have at least 3 PSA measurements over 18 months
- You will likely need a prostate biopsy
What’s a prostate biopsy?
A prostate biopsy is a procedure by which your physician collects pieces of prostate tissue to look for cancer under a microscope. Whenever a physician is trying to exclude or diagnose cancer, we have to take a piece of tissue to have a definitive answer.
A prostate biopsy is also called a TRUS biopsy. TRUS stands for trans-rectal ultrasound, which is the imaging modality physicians use to see the prostate so they know what to biopsy.
How do you do a TRUS biopsy?
I’ll be honest, this procedure is not the most comfortable procedure in medicine, but it sounds worse than it is. A urologist performs this procedure in the office. An ultrasound probe (shaped like a banana, but skinnier and a bit longer) is placed into the rectum. Because of the anatomic relationship between the prostate and the rectum (the prostate is just in front of the rectal wall), the ultrasound allows your physician to see the prostate the easiest, even if it’s not the most comfortable option. The urologist will then measure the size of the prostate gland and look for any suspicious areas. Then he or she will numb the prostate with local anesthetic, by introducing a long needle via the ultrasound probe. This is usually not painful, just uncomfortable.
Then the urologist will take a sampling of prostate tissue to look for any cancer. He or she usually takes 8-12 samples from both sides of the back parts of the prostate that cancer develops from first. Most men feel some pressure during this, but rarely is it painful. Once this is finished the urologist removes the probe and you are finished. The samples he or she takes are then sent to the pathologist to be analyzed under the microscope by experts.
What do I have to do to prepare for a TRUS biopsy?
To prepare for a TRUS biopsy you need to take antibiotics a few days before and after the procedure. Some physicians ask patients to take a mini bowel prep (enema or suppository) before the procedure, but it is unclear if it decreases the rate of infection.
What can I expect after the TRUS biopsy?
After the biopsy you can expect to see some blood in your stool and urine for a few days. Men often notice blood in their semen, and this can last up to a month.
Things you need to be concerned about are fevers, infection and significant bleeding after the procedure. This could be because of bacteria getting into your bloodstream, which is dangerous, so you need to call the urologist right away. These complications are rare, affecting between 1 and 4% of patients undergoing TRUS biopsy.
Now you are an expert in understanding the prostate cancer screening process. Knowledge no doubt eases fear! Take care of yourself, get screened and stay healthy!