When prostate cancer is suspected, either from the results of a digital rectal exam (DRE), a PSA (prostate specific antigen) test, or both, a prostate biopsy is then performed. The procedure involves taking samples of prostate tissue and having a pathologist examine them under a microscope for the presence of cancer.
A pathologist is a medical doctor who examines tissues and takes on the responsibility for the accuracy of laboratory tests for the approximately 800,000 men who have a prostate biopsy each year in this country. Do you want to know what a prostate tissue specimen looks like under the microscope to a pathologist? Imagine a splotchy work of modern art, with countless shades of gray, some black, and variations of black and white shades all swirled together. Within this mass are some normal cells and some that probably are not. From this sample, it's the pathologist's job to determine if there is cancer present and, if yes, how much.
Many patients are unaware of the position of the pathologist in the cancer-detection process, yet these medical specialists play a vital role on the patient's primary health care team.
The pathologist interprets the biopsy results, sending back information that is critical for the patient's diagnosis, decision-making process, and ultimate recovery.
When looking at a prostate biopsy sample, what the pathologist is checking for are specific patterns of prostate cancer cells. Interspersed among healthy cells, prostate cancer cells grow in five recognizable patterns that allow for their identification, or Gleason grade.
By adding the number of the most common pattern to the second most common pattern, a Gleason score is determined. For example 4 + 3 = 7, or 2 + 3 = 5. The Gleason score is the best way that we can assess the aggressiveness of prostate cancer cells. Most men diagnosed with prostate cancer have Gleason scores of 5, 6, and 7. Only 8% of men with prostate cancer have high-grade Gleason scores of 8, 9, and 10.
Getting a Biopsy
The most common prostate biopsy method is transrectal ultrasound-guided biopsy, also known as TRUS. The procedure is typically performed in a urologist's office and takes about 20 minutes. While the patient is lying on his side, an ultrasound probe is inserted into the rectum to visualize the prostate. Fitted to the probe is a special biopsy gun that drives ultra-fine needles (usually about 1/2-inch long and 1/16-inch wide) through the wall of the rectum and into the prostate. In less than a second, the hollow needle removes a small tissue sample called a core. Usually, 8 to 12 tissue samples (cores) are taken from the right and left side of the gland and at the back of the outer peripheral zone of the prostate. It is here, extending along the sides like a shallow horseshoe, that most cancers are found.
After the procedure, the tissue samples are sent to a medical laboratory to be examined by a pathologist. The results are usually ready in three to five days. Nearly 75% of the time, no prostate cancer is detected in the samples, generally because the elevated PSA levels that prompted the biopsy were due to another prostate condition (such as BPH or prostatitis) or a nonmedical reason (such as recent sexual activity).
Many men worry that prostate biopsy will be painful, but the exam usually causes only minor discomfort, provided they are done properly. A local anesthetic is used by many urologists to numb the area and diminish any possible pain symptoms. Antibiotics are necessary to reduce risk of sepsis. Also, it's important not to be taking aspirin or blood thinners before the biopsy to avoid risk of bleeding.
Common biopsy side effects may include minor rectal bleeding; blood in the stool, urine, or semen; and soreness in the biopsied area. All of these side effects disappear over time. Sometimes bleeding can be severe and may require treatment in the immediate follow- up period, so someone who has a biopsy should be sure they have the doctor's contact number should problems develop.
Rendering a Definitive Diagnosis
Looking at and diagnosing limited prostate cancer on biopsy is one of the most difficult diagnoses in pathology. For starters, prostate cancer is often very tiny on a needle biopsy.
While some other cancers in the body are obvious in terms of their malignancy and how they appear under the microscope, the findings of malignant prostate cancer tend to be extremely subtle. Put these factors together and you can end up with problems interpreting the slides, with both under-diagnosis and over-diagnosis as possible outcomes.
The problem with under-diagnosis relates to the limited cancer and subtle findings in the sample. Problems with over-diagnosis relate to a lot of mimickers of prostate cancer that are viewed under the microscope. These benign cells closely resemble prostate cancer. Add an inexperienced pathologist to the mix and the results can be greatly skewed.
The biggest mistake made by a pathologist is calling something cancer when it's benign— and that happens anywhere from 1.3 to 1.5% of the time each year. That may not seem like a lot, but when you think that such a grave error can lead a man to undergo
Mistakes are also made in the grade (Gleason score) of the cancer, which could ultimately influence decision making, ranging from surgery versus radiation, and the type of radiation used. About 20% of the time, there is a significant change in the grade following a second opinion of the biopsy sample.
Differences of opinion come when pathologists say they really don't know what they are seeing under the microscope. This finding is called suspicious of cancer. This diagnosis is given about 5% of the time. However, when those biopsy samples are sent to Johns Hopkins for a second opinion, the pathologist ends up agreeing with the original suspicious label about 30% of the time. The other 70% of the time the sample is called definitively cancer or definitively benign.
Your Pathology Report
It is recommended that you obtain a copy of your pathology report from your urologist.
This is your medical information and you have every right to have it. Take the time to find out what the report means, and don't be scared by the findings. Currently, it's estimated that only about half of the men get a hold of their reports.
Once you have the report, confer with your doctor, and go over the salient points with him
While the urologist should tell his patient what is on the report, some just don't take the time.
Insist that your urologist explain the findings of your pathology report to you.
Now that you know what's involved in diagnosing prostate cancer, you are ready for
Key #2 — soliciting other opinions to help make your treatment decision.
KEY 2 is titled: Get A Second (and Third or Fourth) Opinion about Your Prostate Cancer Diagnosis and Prostate Cancer Treatment
Visit this link to get a downloadable PDF copy of the full special report:
.
