29000 Men Comment
I’m now going into my 6th year as a prostate cancer survivor, and I have done a great deal of research over those years. Following is Part I of a three part series that I believe is some of the best information I have found. I will follow with Parts II and III in later posts. I can’t recommend the source enough: LISTSERV@LISTSERV.ACOR.ORG.
Date: Fri, 29 Jan 2010 07:01:15 -0500
From: Nancy Peress <nperess@CHARTER.NET>
Subject: Ron Koster’s Updated “WELCOME NEWCOMER!” — Part 1 of 2
Several weeks before his death on August 11, 2005, Ron asked me to go
on sending out his weekly Welcome Newcomer message for him. It’s my
honor to continue posting his message each week as one small example
of his dedication to helping men with prostate cancer. As Ron often
signed his emails, “Sometimes, it takes just one person to work a
miracle.” Ron was one of the miracle workers.
Revised and updated December 1, 2009 by Mike Scott (with we hope
Ron’s complete approval).
In spite of the fact that almost everything about prostate cancer
(PCa) is controversial, you’ve found an excellent source of
information. Be patient, and don’t give up just because this resource
may frequently be dominated by irrelevant, repetitious, or esoteric
notes which may not be particularly helpful to the newcomer!
Risk for PCa is assessed primarily through a combination of two widely
used tests: the prostate specific antigen (PSA) test and the digital
rectal exam (DRE).
A normal PSA for a 50-year-old man is usually less than 2.5 ng/ml,
but there is no specific PSA value that is predictive of risk for
prostate cancer. A higher PSA level by itself does not necessarily
mean that you have PCa, and a lower PSA level does not necessarily
mean that you don’t have PCa.
The DRE enables your doctor to feel the size, shape, and texture of
your prostate to determine if you have a clinically normal or abnormal
prostate. However, you can have PCa without having a palpable
(feelable) tumor, and palpable nodules or abnormalities are not always PCa.
Even though much of the testing is extremely controversial, most PCa
survivors prefer and recommend that all men of about 40 be tested
early and regularly in the hope that early diagnosis will give greater
choice of treatment and cure with fewer side or after effects. Men
with a family history of prostate cancer or other risk factors may
want to get a first (baseline) PSA test at an even younger age.
High PSA levels may be cause by PCa, by benign prostatic hyperplasia
(BPH), or by a urinary tract infection such as prostatitis. However,
NO PSA ASSAY IS PERFECT and no specific PSA level is diagnostic for
prostate cancer! At 58 years of age, when I was diagnosed, my own PSA
was 3.6 ng/ml, my Gleason score was 7, and I was subsequently shown to
be pathological stage T2a (after surgery).
Other tests which your doctor may want to perform on a blood or urine
sample (or which you can ask him to carry out) include the PSA II or
Free PSA test, which can be used to rule out prostatitis and/or benign
prostatic hyperplasia (BPH) and the so-called PCA3 test, which can
help to predict risk for more aggressive forms of prostate cancer.
Older tests that are less commonly used today include the serum acid
phosphate test, the alkaline phosphatase test, and the prostatic acid
phosphatase (PAP) test.
The results of a PSA test and a DRE (and the PCA3 test) can be used,
in combination with information about your family history of prostate
cancer and other medical information, to assess your risk for PCa
using the Risk of Biopsy-Detectable Risk Calculator, which you can find at
The results of these tests, including a suspicious DRE, may give you
and your doctor good cause to decide you need a prostate biopsy. An
initial biopsy, today, usually consists of the removal of 8 to 12
biopsy cores using a specialized procedure under ultrasound biopsy.
If PCa is found in the tissue removed at biopsy, the pathologist who
examines the biopsy cores will assign what is known as a Gleason
score. It will be someplace between 6 and 10, the higher number
indicating a more aggressive form of PCa. The Gleason score has two
components, the GRADE and the SUM or SCORE. The GRADE is based on how
the individual cells look under the microscope. The Gleason grades
used to range from 1 to 5, with 1 being the closest to normal and 5
being bad. However, today, it is normal for all Gleason grades to
range only from 3 to 5 if cancer is thought to be present because
Gleason grades of 1 or 2 are considered not to be cancer. There are
both general and specific guidelines for each grade, but examining
prostate biopsy cores to establish the presence of cancer and the
Gleason grades of that cancer is difficult. The experience of the
pathologist is key — which is why a second opinion on the biopsied
tissue is often a good approach.
When the pathologist reads a specimen, s/he looks at it to determine
the most common grade of tumor seen: that is the first number of the
SUM. Then the pathologist determines the next most common tumor area
and assigns a Gleason grade to it. This is the second number of the
Gleason SUM or SCORE. The two numbers, when added together, give the
SUM. Close reading of the pathology report, will often indicate both
the Gleason grades and the percentage of each grade, which may make
you feel better or worse than knowing the Gleason SUM or SCORE) — but
the Gleason SCORE is what is reported in most of the medical
literature and used for comparisons. So a Gleason score of 3 + 4 = 7
means more grade 3 than grade 4 and a Gleason score of 4 + 3 = 7 is
just the opposite, meaning more grade 4 than grade 3.
It is VERY IMPORTANT, however, to understand that a “clean” or
negative pathology report of the prostatic tissue taken at a normal
8- or 12-core biopsy is no guarantee at all that PCa doesn’t exist in
If you are diagnosed with prostate cancer, BEFORE treatment, your
doctor will also assign a CLINICAL STAGE for your cancer. This
clinical stage will be based on the so-called TNM staging system,
where T refers to the primary tumor (in your prostate), N refers to
the evidence that there may be cancer that has extended to your lymph
nodes, and M refers to the evidence that the cancer has metastasized
(spread) to other areas in your body (usually, at first, bones like
your hips and your spine).
The following is the standard (AJCC) CLINICAL staging nomenclature for
prostate cancer, last updated in 2002:
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Clinically inapparent tumor not palpable nor visible by imaging
T1a Tumor incidental histologic finding in 5% or less of tissue
resected by TURP.
T1b Tumor incidental histologic finding in more than 5% of tissue
resected by TURP.
T1c Tumor identified by needle biopsy (e.g. because of elevated PSA)
T2 Palpable tumor but confined within the prostate
T2a Tumor involves one half of one lobe or less.
T2b Tumor involves more than half one lobe, but not both lobes.
T2c The tumor involves both lobes.
T3 Tumor extends through the prostatic capsule
T3a Extracapsular extension on one or both sides of the prostate
T3b Tumor invades one or both the seminal vesicles
T4 Tumor is fixed to or invades adjacent structures other than
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or smaller
N2 Metastasis to one or more lymph nodes 2 cm or larger, but none
larger than 5 cm in greatest diameter
N3 Metastasis to a lymph node greater than 5 cm in greatest diameter.
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis to any site
M1a Distant metastasis to non-regional lymph nodes
M1b Distant metastasis to the bone(s)
You should know that if you decide to have a surgical treatment for
your prostate cancer, then it will be possible for your surgeon to
obtain a post-surgical PATHOLOGICAL stage for your prostate cancer
which will usually be slightly different that the CLINICAL stage.
Pathological staging is only possibly after surgical treatment.
If you initially shown to have prostate cancer on a biopsy, your
doctor may want you to have one or more imaging tests to try to
identify whether your cancer has escaped from the prostate
(metastasized) to other parts of your pelvic region or even to other
organs. These imaging tests can include color Doppler ultrasound
scans, computerized tomography (CT) scans, magnetic resonance imaging
(MRI) scans, bone scans, and the ProstaScint test. Some of these tests
involve injecting a radioisotope into the blood-stream. Absolutely
none of these tests or procedures is 100% accurate.
(please see part 2)