1.2 Digital Rectal Exam

What is a Digital Rectal Exam (DRE) 1?

Doctors use a Digital Rectal Exam (DRE) to screen for cancer. This procedure is completed to examine the health of the prostate gland and to check for abnormalities and prostate cancer. The prostate can be felt through the side of the rectal wall. Please note that not all parts of the prostate can be felt on this exam.

What can you expect with a DRE?

A DRE is an in-office examination where your doctor or nurse gently inserts a lubricated, gloved finger into the anus to estimate the size of the prostate and feel for lumps or other abnormalities. Due to the additional pressure on the prostate, some men may feel discomfort or the urge to urinate during the exam.

If the PSA or DRE tests are suspicious for prostate cancer, your primary care doctor will likely refer you to a urologist who will request further testing such as prostate biopsy and/or imaging.

Chapter 2 - A prostate biopsy

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2.1 Biopsy

As mentioned, rising PSA levels and an abnormal DRE may suggest cancer is present. To confirm the presence of prostate cancer, your urologist will order a prostate biopsy. A biopsy is the small sampling of tissues from the prostate to be reviewed by a pathologist to determine if cancer is present.

What can you expect before and during a biopsy?

To prepare for the biopsy, the doctor may do the following:

• Ask you to stop taking certain medications

• Prescribe antibiotics to prevent infection

• Order an at home enema

• Have a clear liquid diet and avoid heavy meals in the days leading to the procedure

It's crucial that you talk with your doctor about the full list of instructions before your biopsy. During the biopsy procedure, the doctor will use either the Transrectal (TRUS) or Transperineal (TPUS) approach, mentioned below, to guide a thin hollow needle into the prostate. In some instances, the doctor will order an MRI before the biopsy to locate abnormalities within the prostate that may represent prostate cancer. The needle retrieves several thin cylindrical sections, or cores, of prostate tissue. Most urologists take 6-12 core samples in total from different areas of the prostate.

Some doctors may recommend imaging guidance during the prostate biopsy procedure to help ensure that the best samples are being removed. Transrectal Ultrasound (TRUS) is a form of imaging guidance.

What is a Transrectal Ultrasound (TRUS)?

A small probe, about the width of a finger, is inserted into the rectum. The probe emits soundwaves that enter the prostate and create echoes. Those echoes are picked up by the probe and sent to a computer that turns them into an image of the prostate. This procedure often takes less than 10 minutes and is done in a doctor’s office or outpatient clinic.

What is a Transperineal Ultrasound (TPUS)?

This approach differs from TRUS because the biopsy needles enter between the anus and scrotum, called the perineum, using an ultrasound imaging for guidance to the prostate. You should discuss the differing biopsy approaches and risks with your urologist as your might prefer one procedure over another.

What happens after the biopsy is performed?

Biopsy samples will be sent to a lab and examined by a pathologist for cancer cells by looking under a microscope. If the pathologist can see cancer, a grade will be assigned. This grade is called the Gleason grade. Prostate cancer Gleason grades range from 1 to 5. Higher Gleason grades usually represent more aggressive prostate cancer. The Gleason grades will be available in the pathology report.

But because pathology includes looking at your biopsy slides under a microscope, the interpretation can vary between pathologists.

3.1 What is Gleason Scoring?

Pathologists review biopsy tissue under a microscope and assign it a Gleason grade based on the appearance of the cells. If cancer is present, it will be assigned two Gleason grades ranging from 1 to 5. The primary grade, or first number shown, is the most common Gleason pattern (grade) found in the biopsy. The second number is the second most common Gleason pattern (grade). These two numbers are added together for a Gleason score. Gleason scores range from 2 to 10 with most prostate cancer ranging from 6 to 10. An example of a Gleason score is 3+4=7. In this example, 3 is the primary pattern, and 4 is the secondary. When added together they equal 7.

Another term you may hear regarding Gleason scores is Grade Groups. Gleason scores have been divided into groups ranging from 1 to 5. Gleason score and Gleason grades determine the Gleason group.

Gleason Group Break Down

Poorly differentiated/ Anaplastic

Limitations of Gleason Scoring

Gleason scores play a vital role in determining treatment decisions. First developed in the 1970s, Gleason scores have been used to assess the aggressiveness of patients’ prostate cancer. Because Gleason is based off looking at cancer tissue under a microscope, there can sometimes be a difference of opinions between diagnosing pathologists. Additional testing can be done to get a more accurate assessment of your cancer’s aggressiveness. Certain genomic tests like the Prolaris ® test combine clinical and pathologic features (findings on DRE, PSA and Gleason score) with personalized information about how aggressive your tumor is—giving you a complete picture of your prostate cancer prognosis.