Prostate Cancer Diagnosis

Like some other types of cancer, the risk of developing prostate cancer is thought to be partly based on genetic factors. If your father or brother had prostate cancer, particularly at a young age, you may be at increased risk for the disease, and so your doctor may recommend genetic testing through our High-Risk Cancer Genetics Program.

At NYU Langone’s Perlmutter Cancer Center, our philosophy for diagnosing prostate cancer is based on the latest research, which indicates that diagnosing some prostate cancers can cause more harm through unnecessary testing and treatment than leaving it undiagnosed and untreated. Some prostate cancers grow slowly, and, depending on your age and other individual health factors, may not need to be treated immediately, if ever.

Our urologists are at the forefront of investigating how advances in detecting prostate cancer biomarkers and MRI can guide decisions about who needs a prostate biopsy, and how to more effectively use imaging to diagnose only those prostate cancers that are potentially lethal. Our specialists employ image-guided detection that more accurately locates tumors than traditional “random” biopsy, which can miss tumors that need attention or detect small, slow-growing tumors that don’t warrant treatment.

If screening tests reveal abnormal results, your urologist discusses the risks and benefits of additional testing with you based on your age, risk factors, and symptoms.

Early prostate cancer causes no symptoms. Prostate cancer may arise many years before symptoms appear or a doctor can feel it during a basic screening test, known as a digital rectal exam.

Noticeable symptoms that may indicate prostate cancer include difficulty urinating or ejaculating, or pain or bleeding with ejaculation. In most cases, these symptoms are caused by benign conditions, but if you are experiencing them, you should speak with your doctor, who may recommend certain tests.

At NYU Langone’s Smilow Comprehensive Prostate Cancer Center, part of Perlmutter Cancer Center, your doctor first performs a physical exam, which includes a digital rectal examination, and gathers a detailed medical history.

Your doctor may then perform the following tests to check for the presence of prostate cancer and to assess whether the cancer is growing slowly or may require more immediate treatment.

In a prostate-specific antigen, or PSA, test, a small amount of blood is drawn and sent to a laboratory for analysis. This is the same test that is used to screen for prostate cancer.

If your PSA is elevated but the risk of aggressive prostate cancer is low, your doctor may perform a type of blood test that measure prostate cancer biomarkers to determine whether a biopsy is necessary.

If your doctor feels a prostate irregularity during the digital rectal exam, or if more than one PSA test result indicates elevated levels of the protein in the blood, your doctor may recommend an MRI scan of the prostate. MRI uses magnets and computers to create two- and three-dimensional images of the body. This allows your doctor to view the prostate in detail and to check for areas that appear suspicious for cancer.

In the past decade, NYU Langone doctors have been recognized internationally for developing and improving techniques for MRI scanning of the prostate. Our radiologists use the latest technology to interpret images for this advanced method of MRI testing. If you have had an MRI scan of the prostate elsewhere, our doctors can reassess it. If they believe it’s necessary, they may order a second scan to better evaluate the likelihood that you have prostate cancer.

Our MRI techniques include measuring blood flow and the movement of water in the tissues of the prostate to identify regions that appear suspicious for cancer. Water molecules move differently within noncancerous cells than in cancerous tissue, helping doctors to identify tumors.

MRI can also help doctors identify cancerous tumors by the presence of abnormal blood vessels. This is because blood vessels that feed prostate cancer take up contrast material, an injected dye that rapidly helps makes cancer more visible on scans. This is known as early contrast enhancement. The contrast material also leaves those abnormal blood vessels more quickly.

Our radiologists typically score any areas of suspicion on a scale from 1 to 5. This suspicion score indicates how confident the radiologist is that there may be cancer in the area.

An MRI scan typically takes about 30 minutes to complete. Following the scan, your doctor assesses the results to decide whether a biopsy of the prostate is necessary. For instance, our doctors may recommend that some men who have normal MRI results and elevated and rising PSA levels or prominent family history get a biopsy, whereas older men with the same results may instead be monitored for any further elevation in PSA levels. In other cases, your doctor may order a test that detects prostate cancer biomarkers to determine whether a prostate biopsy is necessary.

A biopsy—a series of tissue samples collected from the prostate—can allow your doctor to confirm a diagnosis of prostate cancer. Urologists may recommend biopsy if previous tests have shown abnormalities. Several types of biopsy techniques exist; the type your doctor performs depends on your test results.

Transrectal Ultrasound–Guided Biopsy

A traditional prostate biopsy is known as a transrectal ultrasound–guided biopsy or 12-core systematic biopsy.

During the procedure your doctor first inserts an ultrasound probe—which produces sound waves that create images of the prostate—into the rectum to visualize the prostate. The probe contains a hollow needle that can quickly pass in and out of the prostate to obtain several thin sections of prostate tissue, which are sent to a laboratory for analysis. Twelve samples, or cores, of the prostate are typically collected as part of this biopsy.

Almost all prostate biopsies at Smilow Comprehensive Prostate Cancer Center are performed with local anesthesia, and men are able to return home about 30 minutes after the procedure.

After a transrectal biopsy, you may experience mild discomfort, bleeding from the rectum, or blood in urine or semen. These effects generally subside after a few days. To reduce the risk of infection after biopsy, your doctor prescribes an antibiotic taken by mouth the day before the procedure and another injected into a muscle immediately before the procedure.

Transrectal ultrasound–guided biopsy is a valuable tool in diagnosing prostate cancer, but because alone it may miss aggressive cancers in areas of the prostate that are not sampled, NYU Langone doctors typically pair it with MRI imaging.

Image-Guided Biopsy

As urologists have become more aware that many early prostate cancers are slow growing and may never harm men, the goal of biopsy has changed. Now, urologists use biopsy to identify aggressive cancers while minimizing the likelihood of finding small, slow-growing cancers that don’t require treatment.

In the past few years, researchers, including those at the Smilow Comprehensive Prostate Cancer Center, have been working to identify the most effective strategy for prostate biopsy. This includes combining imaging techniques, such as MRI and ultrasound—which produces sound waves that create images of the prostate—to help target the most suspicious areas of the gland for biopsy, rather than selecting areas at random.

Our doctors are among the country’s most experienced in using a state-of-the-art technology called MRI–ultrasound fusion targeted biopsy, which combines MRI with ultrasound to create a three-dimensional biopsy image of the prostate. This allows doctors to align the biopsy needle with the suspicious regions found on MRI. As a result, our urologists diagnose more cases of aggressive cancers and fewer cases of low-risk cancers.

Because this technology greatly reduces under-sampling of areas where aggressive cancers reside, additional biopsies are less likely to be required later. Image-guided biopsy also helps doctors identify harmful prostate cancers and to avoid detecting small, nonaggressive cancers that don’t require treatment.

Computerized Template Biopsy

A computerized template biopsy uses ultrasound imaging to create a three-dimensional map of the prostate. The template allows urologists to obtain more precise tissue samples, making it more accurate than a traditional biopsy.

NYU Langone doctors were among the first in the country to implement a computerized template biopsy and to lead national multicenter studies on its use. A study led by NYU Langone researchers demonstrated that this type of biopsy may more accurately predict where cancer is located in the prostate.

If doctors suspect cancer has spread, they may order a prostate-specific membrane antigen PET/MRI or PET/CT scan—a CT scan uses a series of X-ray images and computer software to create three-dimensional, cross-sectional images. CT scans are typically better at detecting cancer in the bone than MRI scans.
 
For the PET/MRI or PET/CT scan, doctors use a radioactive tracer drug that attaches to receptors, or proteins known as prostate-specific membrane antigens (PSMAs) that may sit on the surface of prostate cancer cells. If these proteins are present, patients may be eligible for radionuclide therapy if they have not responded to other systemic therapies.