fbpx Prostate Cancer: The Appointment and Diagnosis

Prostate Cancer: The Appointment and Diagnosis

You've been referred to a urologist because an exam revealed something. What comes next?
Kurtis Bright
Written by

Kurtis Bright

Every journey has an embarkation: You climb in the car or get on a plane, and you're off.

But the trip often doesn't really begin until you've been traveling for a while. Your car breaks down, or you witness some oddball roadside tableau and bam—now you really know you're on the road.

So it is with prostate cancer. As we've learned in the previous installments of this series on a man's journey through prostate cancer, a vast and complex group of factors determine who will develop this potentially deadly disease. Men are often on their way to getting prostate cancer years before they have a clue about what's coming.

It's probably fair to say the true prostate cancer journey doesn't really commence until you get a referral to see a specialist, which usually occurs after an exam with your family physician.

If you're heading to a specialist, it will help to know what the appointment might entail, how the diagnosis process is likely to occur and how to prepare for what's next.

The appointment
Illustration by Jaelen Brock
Illustration by Jaelen Brock

As we learned in the installment on prostate cancer risk factors, the clearest predictors of a man's chances of getting prostate cancer usually come from his close family members, genetic lineage and age. So when you see a specialist, the first step they're likely to take is to get a thorough personal and medical history.

"So let's say that a man has a rectal exam with his primary care doctor that doesn't look normal, or a PSA [prostate-specific antigen] test that doesn't look normal," said Petar Bajic, M.D., a urologist and men's health specialist with the Cleveland Clinic. "He might be referred to a urologist like myself for further evaluation. That visit would entail asking a lot of questions about the man's medical history and urinary and sexual issues, and then performing a physical exam that would include a rectal exam. And if the man has had a PSA, we'd check that."

The digital rectal exam (DRE)

The digital rectal exam (DRE) for prostate disease is the butt of a million jokes, so to speak. However, it's important—and quite serious—when you consider DREs are relatively inexpensive and easy to obtain, and the results often provide the first indication that something is wrong.

The doctor has you remove your pants and underwear, lie on a table on your side with your top knee pulled to your chest, or you may stand and bend over the exam table, resting on your elbows. Then the doctor inserts a gloved, lubricated finger into your anus to press on the prostate gland through the front of the rectum wall. The entire process takes a minute or two.

The goal of the DRE is to try to detect unusual lumps, nodules or hard spots that might indicate a tumor. It's not a perfect test by any means and is mainly used as a very rough guide.

While the test is still very common as a front-line check of prostate health, many urologists these days aren't relying as much on the DRE for general screening of men who are at average risk. The American Urological Association (AUA) guidelines state the efficacy of the DRE is more relevant to cancer detection in higher-risk men than true average-risk population screening.

"[The DRE] is falling more and more out of favor," said Jayram Krishnan, D.O., who specializes in urologic oncology with the Cleveland Clinic. "We typically don't do it when I have a new visit. We've found that our detection sensitivity from our rectal exam is not very good or not good enough to detect if there's even anything wrong."

The prostate-specific antigen (PSA) test

Probably the most frequently ordered and useful early-detection test in the urologist toolkit is the PSA, or prostate-specific antigen, test. It involves a blood draw that's sent to a lab where technicians check for unusually high levels of a certain protein that may indicate something is wrong with the prostate.

However, it's important to understand that PSA is produced by both healthy and diseased prostate glands; PSA levels are often higher in men with prostate cancer. If your initial PSA test comes back elevated, don't panic yet.

When dramatically elevated levels of PSA are detected or there is a significant change in levels from one PSA test to another, your healthcare provider will likely order a second PSA test to ensure accuracy. The number may be high for many potential reasons, including but not limited to other prostate conditions, such as prostatitis or enlarged prostate, riding a bike that day, having recently ejaculated or even the DRE itself.

But the PSA test also has problematic issues and isn't considered conclusive. Even a few short years ago, an elevated PSA level might have meant immediately making preparations for a prostatectomy. These days, however, urological specialists approach diagnosis and treatment with a much wider range of options—not to mention more caution and deliberation than they did 30 years ago.

"There's a little bit of interpretation we have to do based on other possible reasons why a man's PSA might be elevated, because it's not a perfect test," Bajic said. "It can be elevated for a wide variety of reasons, and prostate cancer is only one of those reasons. So one of the important things that we like to do is monitor the PSA and see how it is over time. If someone's never had the test before and they're a hair over what's considered normal, but they have other issues like, let's say, benign prostate enlargement or a urinary infection, there may be other things we need to consider that may be elevating that number."

Where you go from here
Illustration by Jaelen Brock
Illustration by Jaelen Brock

The possible immediate outcomes of the referral appointment to a prostate specialist can vary greatly.

It's important to note the PSA test and the DRE are far from the only screenings used to diagnose prostate cancer, nor are they the end of the diagnostic process.

In the next installment of this series, we'll go into more depth on other tests and procedures that may be employed following elevated PSA results. But here are a few possible directions your practitioner might recommend immediately following your appointment.

Do nothing

You and your doctor may do nothing. Well, not exactly nothing, but nothing in the immediate future. If you have a PSA result that's just slightly elevated, you may be sent on your way and asked to schedule a follow-up visit in six months or a year. More important than any single PSA test result is the trend over time, according to experts.

"If it's steady in the average range year over year, and then all of a sudden it rises and remains elevated on a repeat test, that's much more concerning," Bajic said.

Repeating the PSA

As noted above, the PSA screening is a highly important, early, noninvasive test that men's health specialists rely on to help determine whether a man might have prostate cancer or to explain other prostate symptoms he might be experiencing.

However, it's far from conclusive. If you show an elevated PSA level and your doctor doesn't have results from previous tests for comparison, you may be asked to wait a couple of weeks and repeat the test. A second evaluation may give your doctor a clearer picture of whether your PSA is elevated to a worrying level, has changed a great deal or is even elevated at all.

Conducting a biopsy

If multiple PSA tests show levels that are elevated to a troubling degree, your doctor may recommend a prostate biopsy, a procedure that will be discussed in more detail in the next installment of this series. Rest assured that techniques have been refined to minimize the discomfort and maximize the effectiveness of the biopsy.

Illustration by Jaelen Brock
Illustration by Jaelen Brock

Most men's health specialists will likely emphasize that a preliminary prostate cancer testing appointment is nothing to be afraid of and will not cause significant discomfort.

What's more, receiving further evaluation right away if a test result indicates something may not be right could be crucial to ensuring you have the best outcome possible.

Prostate cancer is a slow-developing disease most of the time, and can often be left alone under watchful care for long periods of time. However, if fast-growing and aggressive types aren't dealt with swiftly, they can spread quickly and wreak havoc on your life.

Get checked according to the guidelines for your age, family history and ethnic background, and stay healthy!