A Patient Guide To Prostate Cancer Testing

“We have many new imaging technologies today,” Dr. Leonard Gomella, Chair of the Urology Department at Thomas Jefferson University’s Sidney Kimmel Comprehensive Cancer Center, tells SurvivorNet. “We have radiologic studies such as CT scan and MRI.

“One of the newer ones that’s out there is something called the PSMA scan, which is a nuclear medicine scan that is actually able to pick up spots of cancer that you may not see on a regular study such as MRI or CT scan,” he adds.

The diagnostic process usually begins because of one or more of the following:

• Abnormal PSA (prostate-specific antigen) test
• Abnormal digital rectal exam (DRE)
• Urinary symptoms like weak stream or frequent urination
• Family history or genetic risk
• Findings on imaging done for another reason

Not everyone who gets tested has symptoms. In fact, many early-stage prostate cancers are found in men who feel completely well. That’s why regular screening is so important.

Here, we break down of the different tests that may be a part of the prostate cancer diagnostic process.

PSA Test: A Key First Clue

The PSA test is a simple blood test that measures the level of prostate-specific antigen (PSA) in your blood. PSA is a protein made by both normal and cancerous prostate cells.

There’s no single “normal” PSA level, but generally:

• PSA under 4.0 ng/mL is considered low
• PSA between 4-10 ng/mL is borderline
• PSA above 10 ng/mL is more concerning for cancer

That said, many non-cancerous conditions can raise PSA levels, including an enlarged prostate, prostatitis or inflammation of the prostate, recent ejaculation, a urinary tract infection, or even something like vigorous bike riding.

If your PSA is elevated, your doctor may:

• Repeat the test to confirm
• Order additional tests like a free vs. total PSA ratio
• Proceed to imaging or biopsy based on risk

Digital Rectal Exam

This is a quick, in-office exam where the doctor gently inserts a gloved finger into the rectum to feel the back of the prostate.

They’re checking for:

• Lumps or hard areas
• Asymmetry
• Enlargement

While some cancers can be felt through a digital rectal exam, others may not. It’s often used along with the PSA test to guide the next steps.

Risk Assessment Tools

Your doctor may use a risk calculator or predictive model to combine your age, PSA, DRE findings, and other factors to estimate your risk of having prostate cancer.

Some patients may also undergo urine-based genetic tests (like PCA3 or SelectMDx) or blood tests (like the PHI or 4Kscore) that can refine risk further. These help decide whether a biopsy is needed, especially in borderline cases.

Prostate MRI: A More Precise View

In many cases, especially before biopsy, doctors now recommend a multiparametric MRI (mpMRI) of the prostate. This detailed scan provides a clearer view of the prostate and helps identify suspicious areas.

MRI can:

• Guide where to target biopsies
• Reduce unnecessary biopsies
• Detect more aggressive cancers

If the MRI doesn’t show any concerning areas and your PSA is only mildly elevated, your doctor may recommend continued monitoring instead of biopsy.

Prostate Biopsy: Confirming The Diagnosis

The only way to confirm prostate cancer is with a prostate biopsy, where small samples of prostate tissue are taken and examined under a microscope.

Most biopsies are done transrectally (through the rectum) or transperineally (through the skin between the scrotum and anus).

Local anesthesia is used, and the procedure takes about 20 minutes.

An ultrasound probe helps guide the needle, and often MRI images are fused with the ultrasound for better targeting.

Usually, 12 to 14 cores (small tissue samples) are taken. The pathologist then grades them using the Gleason score (more on what this means below).

Understanding Biopsy Results

If cancer is found, the pathology report will include several factors, including a Gleason score, the location of the cancer, and whether it has spread to nerves. Here’s a breakdown of what it all means:

• Gleason score (now called grade group): This describes how abnormal the cancer cells look. Grade group 1 (Gleason 6) is the least aggressive, grade group 2 and 3 (Gleason 7) are considered intermediate, and grade group 4 and 5 (Gleason 8-10) are the most aggressive.
• Cancer location: This includes how many of the biopsy cores were positive and where in the prostate they were found.
• Perineural invasion: This means the cancer is near or involving nerves, which can have implications for treatment planning.

Staging Tests: Has It Spread?

If the cancer appears to be intermediate- or high-risk, your doctor may order imaging tests to see whether the cancer has spread beyond the prostate.

Common Staging Tests Include:

• Prostate MRI: Assesses whether the tumor is confined or has spread locally
• Bone Scan: Looks for spread to the bones, especially in high PSA or high Gleason score cases
• CT or PET/CT Scans: Looks for lymph node or distant spread

Newer scans like PSMA PET are even more sensitive and increasingly used in high-risk patients.

“The PSMA scan … is a nuclear medicine scan that is actually able to pick up spots of cancer that you may not see on our regular studies such as MRI or CAT scan,” Dr. Gomella explains. “This is very important to us. This is really redefining how aggressive we need to be in treating a man with prostate cancer, depending on how extensive the spread of the cancer is.”

The scan can help doctors decide between recommending active surveillance and treatment and predict the risk of spread or recurrence. They’re not required for every patient but can provide helpful decision-making information.

Putting It All Together: Risk Stratification

Once all of your test results are in — PSA level, Gleason score (grade group), imaging studies, and possibly genomic testing — your healthcare team will determine the overall risk level of your prostate cancer. This is called risk stratification, and it helps guide decisions about treatment.

Doctors generally group prostate cancer into three main risk categories: low-risk, intermediate-risk, and high-risk.

If your PSA is under 10, your Gleason score is Grade Group 1 (also called Gleason 6), and the cancer is confined to the prostate with no signs of spread, you are likely in the low-risk group. These cancers often grow slowly, and some patients in this group may be candidates for active surveillance instead of immediate treatment.

The intermediate-risk group includes patients with a PSA between 10 and 20, or a Gleason score of Grade Group 2 or 3 (Gleason 7). These cancers may still be confined to the prostate, but they tend to grow faster than low-risk cancers and may require active treatment such as surgery or radiation.

The high-risk group includes patients with a PSA over 20, a Gleason score of grade group 4 or 5 (Gleason 8-10), or evidence that the tumor has grown beyond the prostate. High-risk cancers have a greater chance of spreading and typically need more aggressive treatment, sometimes involving a combination of therapies.

Your doctor will explain where you fall within these categories and what it means for your treatment plan and long-term outlook.

Tips For Patients

Professionals recommend the following to help you understand and interpret all of the information you’ll be given after a prostate cancer diagnosis:

• Bring a notebook to appointments to write down questions and answers
• Ask for copies of your test results and reports
• Seek a second opinion if you’re unsure about your diagnosis or treatment
• Include a loved one in conversations to help process information

Questions To Ask Your Doctor

• Which diagnostic tests do you recommend and why?
• Do I need a PSMA scan?
• What are the treatment options for someone in my risk group?
• What are the potential side effects for each option?

Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.

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