YANA
- YOU ARE NOT ALONE NOW
PROSTATE CANCER SUPPORT SITE
AN
INFORMATION GUIDE
TO
PROSTATE CANCER
This is part 2 of a 5 part Information Guide. Introduction:Index
Going
through the process of diagnosis is a frightening experience for most. Tests
are ordered, often without any apparent reason or explanation; results are given
in language that is difficult to interpret or understand; and all the time the
fear grows. Hopefully, this section will take some of that fear away from the
process. There is also often a feeling that time is limited, that a decision
regarding treatment must be made very soon after diagnosis. For the vast majority
of men the window of opportunity for successful treatment is a wide one and
decision-making may take some months.
The first important fact about all medical tests
No test is 100% accurate. Diagnosis is not an exact science.
The degree of error can vary considerably, depending on the complexity of the
test - and some tests are very complex indeed. Sophisticated machinery is used
for some - the maintenance of the machinery can alter the result. Chemicals
are used in other tests - the use-by date of these chemical agents can alter
results. Technicians run the tests - their training can alter results. The outcome
of all tests needs to be interpreted by a specialist - their expertise can vary.
All this adds up to a degree of uncertainty and explains why it is very important
to have all results checked by the most knowledgeable person available - and
why second opinions should be sought automatically.
The second important fact about many medical tests
The value of many of the medical tests lies in measuring the change in the results,
not in the results themselves. Thus for PSA tests, it is important to measure
the size and speed of any change, since this gives an indication of the aggressiveness
of the disease. To get this measurement it is necessary to have a series of
tests at regular intervals. This may mean delaying the start of treatment but
the information is invaluable.
And the third important fact - mistakes can be made
The medical world is no different to any other place. Human beings run it and
they can make mistakes. Ensure all test results are yours. If an unusual result
does not relate to other results, have a re-test in case a mistake has been
made.
Collect
and keep the paperwork
Studies show that people who take an interest in the diagnosis and details of
their disease and who involve themselves in the process of selecting the most
suitable treatment have the best chance of recovery.
Appointments with medical advisors are often confusing, and sometimes rather
rushed, affairs. Many people feel they do not want to waste their doctor's time
and sometimes doctors give the impression their patients are indeed doing just
that. But whether the time with the medical people is long or short, the information
will often be bewildering or overwhelming. It is considered to be a good idea
therefore to:
· Make notes before the appointment of all the issues you want to discuss or ask about;
· Attend all appointments with a companion - two heads being better than one for the interpretation of the information;
· Take a portable tape recorder to the appointment and record what is said, if the doctor is agreeable - you will then have time to gain a greater understanding of what was said when you play back the tape;· Not be reticent in expressing reservations, asking for the rationale for a suggested course of action or determining the likely side effects. Ensure that you receive all the information you will need to make your decision.
It is very important to obtain, study and keep copies of all medical reports.
Try to understand what they say and what they mean. If anything isn't clear,
ask for more information and keep asking until you understand. It may be difficult
for a medical person to reduce the complexities of a diagnosis to simple, non-medical
terms, but you are entitled to this, so keep plugging away.
If you have access to the Internet, get onto one of the email discussion lists
and ask questions there. The knowledge of the men and women on these lists is
enormous and very few questions cannot be answered. Above all, never be concerned
about appearing 'stupid' in asking a question. There are no 'stupid' questions.
It is also a good idea to check reports for factual errors. Even typing errors
can be a cause for concern and lead to misunderstandings. It may not be of great
importance if the report records your age incorrectly. Whether a man is circumcised
or uncircumcised does not affect the diagnosis or choice of treatment. But if
this type of detail is wrong, there may be other errors, on the technical side,
that are not so obvious.
GETTING STARTED - THE PROCESS
DRE - Digital Rectal Examination
The first step in the process of getting to the Strange Place is usually what
is referred to as a DRE. This stands for Digital Rectal Examination and is dreaded
by most men. Many refuse to even consider it. Most women cannot understand what
the fuss is about. It is a simple procedure and there is no discomfort when
it is done well - and if the man is relaxed. The examination does not take very
long - usually less than 30 seconds.
If you have an understanding of where the prostate is located, it is pretty
obvious that the only way it can be reached practically is via the rectum. The
doctor inserts a finger to feel the prostate. In doing so, he is trying to establish
whether there is anything unusual about the gland: a firmness perhaps, or nodules,
or roughness on the surface. A biopsy may well be ordered if the DRE reveals
any abnormal features.
In days gone by the DRE was virtually the only way in which prostate cancer
was diagnosed, unless there were symptoms. This method of diagnosis is not very
accurate because of the limits imposed by the examination. For one thing the
doctor can only feel one side of the gland; for another, the examining finger
is clad in a glove.
The DRE is usually a standard item on an inclusive health checklist for men
over 50 years old, or for men over 40 years of age if they are 'at risk' - for
example if breast or prostate cancer has been diagnosed in parents, aunts or
siblings. In the US Afro-American men are seen to be at risk because of the
high incidence of prostate cancer amongst these men. There are no statistics
available for South African men of any race.
PSA - Prostate Specific Antigen
This is the most widely used test for detecting prostate cancer today. It is
simple to do. A small sample of blood is taken, usually from a vein in the arm,
and is tested for the presence of PSA (Prostate Specific Antigen). This is an
enzyme at one time thought to be formed only by the prostate gland - hence "prostate
specific". It is now known that very small quantities of the enzyme are produced
by other glands - and even by women.
The laboratory testing the blood will report a number, which reflects the level
of PSA in the blood in nanograms per millilitre (ng/ml). A nanogram is one thousand
millionth of a gram. The method used to measure these very small amounts differs
between the manufacturers of the testing equipment and the results produced
vary considerably. Although all manufacturers have agreed to calibrate their
equipment to produce comparable results, this is often not done in practice.
It is best if you can have all tests run by the same laboratory using the same
equipment. Most laboratories will only guarantee accuracy to within 80%.
The scale of measurement is unlimited and PSA readings of over 1 000 ng/ml are
not unheard of. One man in the United States had a PSA reading of 3 552 ng/ml
in 1991, which climbed to 12 600 ng/ml in 1992. In 1999 his PSA was 109 ng/ml
and he was still working as a commercial pilot on a large American cargo airline.
It is unusual for a man to survive so long with such high levels of PSA because
this level is usually associated with a very aggressive tumour.
When the PSA test was introduced in 1990, a reading of more than 10 ng/ml required
further investigation. This figure was subsequently reduced to 4 ng/ml, which
is regarded as "normal" in South Africa. In the US the measure has now moved
down to 2,6 ng/ml and there is a move to go to 1,25 ng/ml as a "standard". Roughly
35% of men with a PSA higher than 2.6 ng/ml will be found to have prostate cancer,
although in many cases the tumour will be regarded as "insignificant".
There is another PSA test - the fPSA, PSA II or Free PSA test. This test refers
to the amount of what is referred to as "unbound" or "free" PSA in a sample
of blood and is discussed below.
Important Information on PSA levels
PSA is not a prostate cancer specific marker. Although a PSA level of 4 ng/ml
is regarded as "normal" in South Africa, a reading higher than that will only
signify prostate cancer in a minority of men. PSA levels can be elevated by
a number of causes, from infection to physical activities. For this reason it
is very important to investigate the cause of any elevated PSA reported and
not to assume that it is prostate cancer. In one reported case, a man with a
PSA of 362 ng/ml was found not to have prostate cancer, but an infection that
responded to treatment.
The most common causes of an elevated PSA are prostatitis (an infection of the
prostate), a bladder infection, or BPH (Benign Prostate Hyperplasia). This last
condition affects most men over 50 years of age and is not deadly. There is
little which can be done to reduce the effect of BPH on the PSA level, but any
infection should be treated before a second PSA test is carried out. Acute prostatitis
can cause the PSA levels to rise to five to seven times the normal level for
up to six weeks. Infections of the bladder and prostate are often very difficult
to deal with.
It is recommended that blood for PSA testing should be drawn as early in the
day as is convenient and preferably before eating. Physical activities can affect
the PSA level, and these should be avoided before drawing the blood. Examples
of physical activities to avoid include:
· DRE (Digital Rectal Examination). Although doctors often carry out the DRE before drawing blood, they should reverse these procedures.
· Sexual activity: Ejaculation can elevate PSA levels for up to 48 hours after it has taken place.
· Cycling or motor cycling: This can increase levels up to three times for up to a week, depending on how strenuous the cycling is. This includes use of an exercise bicycle.
· Alcohol and coffee: Both can irritate the prostate and should be avoided for 48 hours prior to blood being drawn.
If any PSA result is between 4 and 10 ng/ml, and provided there has been no
treatment, a second test should be run - the so-called fPSA, PSA II or Free
PSA test. Some laboratories will do this automatically, while others require
a specific request since the cost of the fPSA test is higher than the PSA test
alone. The result of this test will be shown as a percentage of the total PSA
measured and is invaluable as part of the diagnostic process. The risk of cancer
being present varies in inverse proportion to the percentage shown. So the higher
the percentage, the less chance of the PSA being caused by prostate cancer.
An fPSA of over 25% would mean that the most likely cause of the elevated PSA
is not prostate cancer; an fPSA level of under 15% will point to prostate cancer
as being potentially the main cause of the elevated PSA. If the fPSA level is
high, alternative causes of the elevated total PSA level should be investigated
before a biopsy is undertaken, since there are some risks associated with biopsy.
PSA levels can also vary significantly for no obvious reason. It is therefore
usually important to have a series of PSA tests done to establish the average
level before moving on to the next important test, which is the biopsy. Many
men monitor their PSA levels for some years, watching for any upward trend in
the numbers. One of the measures is referred to as PSADT (PSA Doubling Time).
As the title implies it measures the time the PSA has taken to double or it
projects an estimated doubling time. The more rapid the PSADT, the more likely
it is that prostate cancer is the cause of the high PSA result. So, a PSADT
measured in months certainly requires investigation; a PSADT measured in years
may be watched closely for some time further without any further direct intervention.
Biopsy
If the DRE (Digital Rectal Examination) and/or the PSA tests indicate the possibility
of cancer cells being in the prostate, the next step is to take samples from
the gland to examine them under a microscope. This is known as a biopsy. As
already mentioned, the only convenient way to reach the prostate gland is via
the rectum. So the material for the biopsy is usually collected by way of what
is often referred to as a "TRUS guided sextant needle procedure". This means
that the six very fine needles used to gather the samples will by guided by
transrectal ultrasound (TRUS). Occasionally more than six needles - up to twelve
- are used.
The procedure is uncomfortable, but usually no more than that, although some
men have reported considerable pain from the procedure. The ultrasound device
is activated to check out the condition of the prostate in an effort to establish
whether there are any specific areas to be investigated. If any are identified,
the biopsy "gun" (a small spring-loaded device which is inserted in the rectum)
is guided to these areas. If there is no specific target, the samples are taken
in a random pattern, three from each side of the gland. For men who have played
a contact sport like rugby or, perhaps, served in the armed forces, the procedure
is rather like being kicked in the backside six times.
Many men are concerned about side effects from the biopsy procedure. There are
some short-term side effects and, more rarely, some long-term side effects.
Because the prostate will bleed after the procedure, both urine and ejaculate
will usually be bloody for some time. Initially - the day after the procedure
- the urine will often be the colour of Pinotage, but will fade to Rosé. The
long-term side effects can include erectile dysfunction, but, as said previously,
they are very rarely reported. One study puts their incidence at less than 3%.
There is some speculation that the entry of the needles might cause any cancer
to spread. There is no firm evidence, but considerable discussion, of this happening.
It is clear that there can be an increase of cancer cells in circulation in
the bloodstream after a biopsy. The unresolved argument concerns the possibility
of these cells lodging in other parts of the body and establishing a metastasised
disease.
Because the biopsy needles pass through the lower bowel on their way to the
prostate, there is a chance of infection so it is important to take the antibiotics,
which will be prescribed before the procedure is carried out.
Samples are also submitted for analysis when men have the procedure known as
a TURP (Transurethral Resection of the Prostate), which is a common way of dealing
with BPH (Benign Prostatic Hyperplasia). The material from the procedure is
examined for cancer cells and if any are present they are graded in the same
way as the material from the sextant needle procedure described above. If there
is a positive diagnosis following a TURP, the material will have come from the
transitional zone of the gland. The majority of tumours in this area have low
Gleason scores and will probably not progress. This may make the man a candidate
for conservative management or watchful waiting.
Gleason Grades
The biopsy samples are examined in a pathology laboratory. The pathologist or
technician will be looking for abnormal cells - cells that have lost their natural
shape and have created unusual glandular patterns. The first focus is on the
abnormal patterns making up more than 50% of the sample. The second focus is
on abnormal glandular patterns that make up less than 50% of the sample. Not
all abnormalities are identified as cancer - there is a condition known as PIN
(Prostatic Intraepithelial Neoplasia), for example, that can be confused with
adenocarcinoma, the most common form of prostate cancer. Reference is also sometimes
made to 'atypical' cells. This merely means that they are not normal, but does
not necessarily mean they are cancerous.
Any cells appearing to be cancerous are evaluated using a scale known as the
Gleason Grade (GG). Very poorly differentiated patterns get a grade of 5 on
this scale: very well differentiated patterns get a grade of 1. Healthy glandular
tissue is well differentiated, so a Gleason Grade of 5 is bad news: a Grade
of 1 is good news.
After each focus is graded, the two Gleason Grades are added together to establish
a Gleason Score (GS). The Gleason Score therefore runs from 1+1=2 (good) to
5+5=10 (bad). Typical examples of Gleason Scores (and the most common) would
be shown as GS 3+3=6 or GS 3+2=5. A score of 6 is the mid-point in the aggressiveness
rating. The lower the score the better. Gleason Scores below 5 are comparatively
rare and are often associated with material recovered in the process of carrying
out a TURP (Transurethral Resection of the Prostate). Gleason Scores of 8 and
above are also rare but usually indicate that the tumour is particularly aggressive.
The most controversial Gleason Grade to deal with is a GG 7 - either 3+4 or
4+3. There is a view that the 3+4 diagnosis is marginally better than the 4+3
one because there are less grade 4 cells in a Gleason 3+4.
Note the difference between a Gleason Grade and a Gleason Score (which is the
sum of the two grades.)
Important Information on Biopsy and Gleason Grades
It is important for the samples collected in the biopsy procedure to be clearly
labelled so, if any cancerous cells are found, the area where they were collected
can be identified. This makes focussed treatment easier. Some laboratories do
not do this automatically, so it is worth insisting upon it when arranging for
the biopsy.
The process of grading abnormal cells is a subjective one, so accuracy of the
result will depend on a number of things, including the experience of the person
doing the grading. Since the grading of any tumour has a significant influence
on the chosen method of treatment, it is very important that any Gleason Score
be verified by at least one independent laboratory. In other words, get at least
one second opinion on any biopsy report, preferably from the laboratory with
the most expertise.
Unfortunately there are no standard procedures for reporting on biopsy results.
A good report will show a good deal of detail including:
· The part of the prostate where the material being reported on was collected;
· The amount of abnormal material in the total sample;
· The percentages of material which relates to the Gleason Grades reported;
· Any evidence of neural invasion or spread to tissue beyond the prostate capsule;
· The presence or absence of PIN (prostatic intraepithelial neoplasia).
The reference above to PIN is important. PIN can occur in a prostate and because
it is similar in structure to adenocarcinoma (prostate cancer) it is sometimes
mistaken for that condition. PIN is not malignant. There is a view in some parts
of the medical profession that PIN may be a forerunner to prostate cancer but
this has not yet been demonstrated conclusively.
Additional Tests: Blood Tests and Scans
If the results from the biopsy are positive - meaning that prostate cancer has
been reported - then it is customary to have a series of further tests. Some
additional tests suggested are not really diagnostic but are useful to establish
a base line for tracking future developments. Others are done to try to establish
if the disease has spread beyond the capsule of the prostate gland.
It is important to try to establish if the disease has spread since treatment
options vary depending on whether the disease is contained within the gland
or has spread. One of the ways of trying to estimate the likelihood of such
spread having occurred, either into adjacent tissue or as distant metastases
is to use the Partin Tables that are described further on.
At this stage it might is valuable to have a quick overview of how prostate
cancer spreads.
Diversion - Metastasis, or how prostate cancer
spreads
The normal progression of prostate cancer is to move out of the prostate as
the cancer grows. The first step is often to penetrate the capsule of soft tissue
surrounding the prostate gland. This may be accomplished by the cancer tracking
the nerves, in much the same way as the roots of a tree will follow pipes. Having
penetrated the capsule, the spread will often be into adjacent tissue, specifically
the seminal vesicles (glands on each side of the bladder) and the lymph nodes
(an integral part of the immune system).
From these sites the disease can migrate to other organs, although the normal
target is the bone, specifically the pelvic girdle and spine. The process of
this spreading of the disease beyond the capsule is called metastasis. Commonly
a metastasised tumour is simply referred to as "mets" as in "mets to the bone"
or "liver mets".
Back to the additional tests.
Blood Tests
PAP (Prostatic Acid Phosphatase)
This test should not be confused with the better-known Pap Smear women have
for the detection of cervical cancer. It is a test measuring an enzyme in the
blood.
Many specialists recommend a PAP (Prostatic Acid Phosphatase) test after diagnosis.
It is not very accurate but it can give an indication of the possibility of
the tumour having spread beyond the capsule - the soft tissue that surrounds
the gland. The test, like the PSA test, is affected by sexual activity. It should
not be done within 48 hours of ejaculation and not until at least six weeks
after any biopsy.
There is no universally accepted standard regarding the calibration of results,
so if PAP results are used for tracking any developments, the blood should always
be sent to the same laboratory. Although there is a high number of false negatives
- about 25% of men with metastases do not have elevated PAP numbers - anyone
with an elevated PAP score should be aware that this may make surgery a poor
choice. Studies indicate men with high PAP scores can have up to four times
the risk of a relapse after surgery.
Other markers
The presence of higher than normal levels of CGA (Chromagranin A) in the blood
can be an indicator of a more aggressive form of prostate cancer. This is especially
true if it is found in conjunction with elevated scores in other markers such
as NSE (Neuron Specific Enolase) or CEA (Carcinoembryonic antigen). These markers
are often used to track the effectiveness of treatment and it is important to
view them as a series and not to take one isolated elevated score as a poor
indicator.
Scans - X-rays, bone scans, CAT scans and MRI
Scans are done in order to try to see what, if any, spread there is beyond the
capsule. The value of some of these scans is doubtful in many cases. Some leading
practitioners consider the automatic ordering of CAT and bone scans, which occurs
frequently, as a waste of money. Their necessity should be established before
the scans are undertaken.
The Partin Tables described below can help in making this decision. The chances
of there being metastases to the bone are remote with a small volume, low-grade
(Gleason Grade 5 or lower) tumour. However, there is a high correlation between
high Gleason Grades (7 and above), a large tumour and the extent of disease.
According to one leading authority there is virtually no possibility of metastasis
occurring until the tumour reaches a critical mass of about 12 ccs. The average
prostate gland is about 25 ccs, so in this view about half the gland would be
occupied by cancer cells before metastasis occurred. There would therefore usually
be a positive DRE (Digital Rectal Examination) and a palpable mass.
X-ray
The cost of X-rays is not high and they are usually undertaken as a matter of
course. However, the chances of any signs of spread being shown, using X-rays
alone, are slim. If any of the other scans are being run, there is probably
little point in having an X-ray. Many people strongly believe in avoiding any
unnecessary exposure to X-ray to minimise the chance of cell damage.
CAT (Computer Axial Tomography)
MRI (Magnetic Resonance Imaging)
Although these two scans use differing technology, they are similar in their
output. Both create a series of images, in effect showing views of the organ
being examined in "slices". The CAT scan uses X-rays to create the images. The
MRI scan uses a very strong magnetic field for this purpose. The MRI images
can be enhanced by the use of an endorectal coil. This is a small device inserted
into the rectum, which generates secondary fields.
Both examinations can be a little intimidating for those having them for the
first time. The person being scanned lies on a small trolley, which enables
them to be moved into a large cylindrical structure containing the scanning
machinery. There is very little room in the cylinder, especially for larger
men, and a feeling of claustrophobia can result. The MRI scanning process is
a noisy one and the operators should provide earplugs or headphones. There is
nothing painful about the procedure however - just a degree of discomfort from
remaining immobilised during the scan, and the noise.
Some experts feel that CAT scans are only of value in the diagnostic process
of advanced prostate cancer, which is usually associated with PSA readings of
50 ng/ml or higher and Gleason Scores greater than 8. CAT scans are highly insensitive
in detecting disease in the lymph nodes, and valueless in most patients in detecting
penetration of the capsule, which is usually the first stage of progression
of the disease.
MRI scans with the endorectal coil can be much more useful but even then will
only be associated with an accuracy rate of between 75% and 90%.
Bone Scans
Bone scans fall under the general term of nuclear medicine. The way in which
the bone scan works is the reverse of a CAT scan or an X-ray. In conventional
X-ray or CAT scan examinations, the radiation comes out of a machine and then
passes through the patient's body. Nuclear medicine examinations, however, use
the opposite approach. A radioactive material is introduced into the patient's
body (usually by injection), and is then detected by a machine called a gamma
camera. The test is very expensive.
Bone metastases are usually associated with advanced prostate cancer, so bone
scans are not considered essential for early stage disease. For men with a PSA
of less than 10 and a Gleason Grade of 6 or less, the chances of the disease
having metastasised to the bone has been estimated at less than 1%.
The procedure for a bone scan involves nuclear material injected into a vein
(usually in the arm). There is a wait of two to three hours for the material
to circulate in the system. The person being examined then lies on a special
table and the gamma cameras (one above and one below) slowly track down the
length of the body. The entire procedure takes between 30 and 60 minutes.
Some people are concerned about the introduction of nuclear material into the
body, but it is said that the radiation from this procedure is similar to that
from a normal X-ray. The material is quickly cleared from the body. There is
nothing painful about the procedure - apart from the injection, but the table
upon which the person lies is made of metal and can be very cold, especially
in winter, which creates a degree of discomfort.
Important point regarding bone scans
The procedure is not cancer specific. It highlights local changes in bone metabolism,
not cancer as such. So it will also highlight old fracture sites and even arthritis.
Author Michael Korda, in his book Man To Man, describes the fear a positive
bone scan raised. This showed what seemed to be clear signs of metastasis to
his collarbone. It was only some time later that he remembered he had fractured
his collarbone years before.
STAGING AND DIAGNOSIS
The final step in this part of the journey through the Forest of Fear is to
stage the disease. This summarises the results of all the tests and results
in the Diagnosis. It is very important to achieve as accurate a staging as possible
because, as will be seen, some forms of treatment are more suitable for some
stages than for others.
Until fairly recently there were many systems of staging. The best known was
probably the Whitmore-Jewett system, which showed four stages defined as A,
B, C, D. The current system, used almost universally, is referred to as the
TNM system.
There are four T stages, which are then subdivided into a number of sub-sets.
These are followed by the N and M stages, which are also subdivided. The main
divisions are as shown below, although there may be some variations in some
definitions:
|
Stage
T1
|
The tumour is discovered "incidentally". This is usually in connection with a TURP (Transurethral Resection of the Prostate) done to relieve the symptoms of BPH (Benign Prostate Hyperplasia). The material produced by the TURP is subjected to pathology analysis and if cancer is detected, the disease is staged as T1a or T1b depending on the amount of material exhibiting malignancy and the Gleason Score. If the tumour is discovered in the course of a biopsy following an elevated PSA test and if there are no other symptoms, then the stage is T1c. |
|
Stage
T2
|
For this stage, the tumour must be palpable. This means that the doctor carrying out the DRE (Digital Rectal Examination) must be able to feel the tumour. If the tumour occupies less than half of one two lobes of the gland the disease is staged as T2a. If the tumour occupies more than half of one lobe, the disease is staged as T2b. When the disease can be felt in both lobes it is staged T2c.
|
|
Stage
T3
|
A diagnosis of stage T3 disease requires penetration of the capsule - the soft tissue surrounding the prostate. Stage T3a disease has no evidence of involvement of other tissue and has penetration on one side of the capsule only. Stage T3b is similar to T3a except there is penetration on both sides of the capsule. Stage T3c indicates penetration from one or both sides, but with the involvement of the seminal vesicles - located on either side of the bladder.
|
|
Stage
T4
|
In this stage, the tumour has escaped from the capsule and the seminal vesicles, although it is still contained in the immediate area of the prostate gland. A stage T4a disease will have invaded the bladder neck or sphincter or the rectum. A stage T4b disease will have invaded the levator muscles or may be fixed to the pelvic wall.
|
|
Stage
N+
|
Disease staged as N+ will have evidence of spread to the pelvic lymph nodes. If there is no sign of this spread the stage will be shown as N0. If the presence of the cancer in the lymph nodes cannot be assessed the staging will be NX. Sometimes three stages of N (N1, N2, N3) are used to denote the extent of the spread into the lymph nodes.
|
|
Stage
M+
|
Disease staged as M+ will have evidence of spread beyond the pelvic lymph nodes - in other words, the disease has metastasised. If there is no sign of this spread the stage will be shown as M0. If the presence of distant metastases cannot be assessed the staging will be MX. Sometimes three stages of M (M1, M2, M3) are used to denote the extent of the metastases.
|
And that's how to get to DIAGNOSIS. Anyone who has got here will be able to relate better to the denizens of this Strange Place because all will have the "numbers" that define their diagnosis. The normal sequence of these "numbers" is PSA, GS (Gleason Score), and Stage.
So a typical "number" might be PSA 7.2: GS 3+2=5: Stage T2bNXM0. This would relate to a man who has a slightly elevated PSA, a Gleason Grade that indicates a relatively non-aggressive tumour, but a tumour occupying more than half of one lobe of his prostate. It is not clear whether the tumour has spread to the lymph nodes but there is no sign of metastasis beyond the pelvic area. Simple now you know how to read the language!!
GO NOW to Part 3 - Beyond Diagnosis - The Desert of Doubt
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