Prostate cancer diagnosis
Benign prostatic hyperplasia or cancer
As men get older, the prostate often undergoes changes: it may increase in size without necessarily indicating a disease. Benign enlargement of the prostate is common and should not be confused with prostate cancer.
Benign prostatic hyperplasia (BPH) usually develops in the central part of the prostate surrounding the urethra and may cause urinary symptoms, such as a weak urine stream or frequent urination. BPH can be effectively treated with medication or, when necessary, surgery.
Prostate cancer usually develops farther away from the urethra, in the outer (peripheral) part of the prostate, where it can remain unnoticed for a long time. Urinary problems often appear only later, when the tumor has already grown larger.
“If you notice changes in your urination, such as an increased urge to urinate or difficulty urinating, you should have them evaluated by a urologist. It is not possible to reliably determine on your own whether such changes are caused by a serious condition,” says Prof. Dr. Thomas Steiner, Chief Physician of Urology and Head of the Uro-Oncology Center at Helios Hospital Erfurt.
How does prostate cancer develop?
The growth and division of cells in the body are normally carefully regulated processes. Old cells die and are replaced by new ones. However, changes in the genetic material of individual cells (mutations) can disrupt this balance. As a result, cells may begin to grow uncontrollably, leading to the formation of a tumor.
Prostate cancer develops as a result of such malignant changes in the cells of the prostate gland. It is not yet fully understood why prostate cancer develops in some men but not in others. However, several risk factors are known, including:
- older age;
- a family history of prostate cancer;
- certain genetic changes.
The risk of developing prostate cancer increases with age. Prostate cancer is rare in men under the age of 40 and is significantly more common from the age of 60 onward. The average age at diagnosis is approximately 71 years.
Why does prostate cancer often go unnoticed
Localized prostate cancer often causes no symptoms. Many men feel completely healthy even though a tumor is already present. This is precisely why early detection plays such an important role: when prostate cancer is detected before symptoms appear, there are often particularly good treatment options.
For men, this means that the absence of symptoms does not rule out the disease. Conversely, having symptoms does not necessarily mean that cancer is present. In particular, changes in urination are much more commonly caused by benign conditions such as an enlarged prostate (benign prostatic hyperplasia, BPH).
When Is early detection necessary
The current German S3 clinical guideline recommends that men from around the age of 45 be offered a PSA test as part of a consultation with their doctor.
“For men with a family history of prostate cancer or other risk factors, it may be advisable to discuss early detection with a doctor at a younger age, as their individual risk is higher,” says Prof. Dr. med. Friedrich von Rundstedt, Director of the Department of Urology and Pediatric Urology at Helios University Hospital Wuppertal.
An important consideration in the early detection of prostate cancer is what is known as overdiagnosis. This refers to the detection of tumors that grow very slowly and might never have caused any symptoms.
Therefore, not every tumor that is detected needs to be treated immediately. For less aggressive tumors, active surveillance may be an appropriate strategy. This involves regularly monitoring the disease without starting treatment right away.
The aim is to avoid unnecessary treatment and potential side effects while ensuring that aggressive tumors are not overlooked.
Prostate cancer diagnostic methods
Today, prostate cancer is diagnosed using modern diagnostic methods through a series of carefully coordinated steps. A thorough interpretation of all findings in their overall clinical context is essential to establish an accurate diagnosis and, when necessary, initiate the appropriate treatment in a timely manner.
Palpation
The digital rectal examination (DRE), in which the prostate is examined by palpation through the rectum, was for many years a key part of early prostate cancer detection. According to the current German S3 clinical guideline, digital rectal examination is no longer recommended as a stand-alone method for early detection. However, as part of a urological examination, it can still provide additional diagnostic information.
PSA test
The PSA test is now considered the most important tool for the early detection of prostate cancer. PSA stands for “prostate-specific antigen,” a protein produced by the prostate that can be measured in the blood. How often PSA levels should be retested depends on the patient’s age and previous PSA level. For a 45-year-old man, the German S3 clinical guideline recommends the following intervals:
- PSA < 1.5 ng/mL: low risk — repeat testing in five years;
- PSA between 1.5 and 3.0 ng/mL: intermediate risk — repeat testing in two years;
- PSA ≥ 3 ng/mL: increased risk — the PSA level should initially be retested within three months. If the elevated level is confirmed, further diagnostic evaluation is recommended.
What does an elevated PSA level mean
An elevated PSA level can have various causes, including benign prostate enlargement, inflammation, or prostate cancer. Therefore, it is important to consider not only the PSA level itself, but also how it changes over time, as well as the patient’s individual circumstances, such as age or a family history of prostate cancer.
Importantly, an elevated PSA level does not automatically mean prostate cancer. Conversely, a low PSA level cannot rule out a tumor with absolute certainty. The PSA test provides important diagnostic information, but it does not establish a diagnosis on its own.
Prostate MRI
MRI is becoming a key component of prostate cancer diagnostics. It allows the prostate to be visualized in great detail and helps identify suspicious areas. This imaging method enables physicians to assess the risk more accurately and make an informed decision about whether a biopsy is necessary.
“If the MRI shows no suspicious findings and the overall risk is considered low, a biopsy may initially be avoided in some cases. This is particularly applicable when PSA levels are only slightly elevated without any concerning changes over time and additional risk factors, such as a family history of prostate cancer, are absent,” says Prof. Dr. med. Chris Protzel, Chief Physician of Urology at Helios Hospital Schwerin.
This approach is known as risk-adapted diagnostics, meaning that diagnostic examinations are tailored to the individual patient’s circumstances and risk profile.
Currently, most Helios hospitals are equipped with state-of-the-art MRI scanners, enabling highly precise examination of the prostate. This advanced technology makes it possible to visualize even very small tumor areas within the prostate and to detect changes in tumor tissue at the molecular level. Physicians can identify suspicious areas on the images and mark them digitally for further evaluation.
MRI-guided prostate biopsy
A prostate biopsy is recommended when there is a well-founded suspicion of prostate cancer. This may be the case, for example, when PSA levels are significantly elevated or show concerning changes over time (above 3 ng/mL), when suspicious findings are detected on MRI, or when there is a strong family history of prostate cancer, such as several family members having been diagnosed with the disease. The decision to perform a biopsy is always made on an individual basis, taking into account all available examination results.
A prostate biopsy involves taking tissue samples from the prostate gland. It can reliably determine whether cancer cells are present and assess the aggressiveness of the tumor. The biopsy findings therefore provide an important basis for all subsequent treatment decisions.
During the procedure, several small tissue samples are taken from the prostate using thin hollow needles. The MRI images are fused with real-time ultrasound images, precisely superimposing the two sets of images to create an accurate 3D model of the prostate. This allows the physician to monitor the path of the biopsy needle and precisely target suspicious areas.
As part of an MRI-guided prostate biopsy, tissue samples are also taken from different areas of the prostate. The biopsy procedure itself is similar to a standard biopsy and can be performed either through the rectum (transrectally) or through the perineum (transperineally). The tissue samples obtained are examined by experienced pathologists, who provide a detailed pathology report upon completion of the analysis.
The newly created 3D image of the prostate can also be useful for subsequent biopsies, for example as part of active surveillance, allowing suspicious areas to be accurately monitored and targeted again during follow-up biopsies.
If diagnostic findings indicate cancer
If histological examination shows that the tumor is malignant, two additional aspects are assessed: the aggressiveness of the tumor and the extent of the disease.
Tumor aggressiveness is determined using the Gleason Score and the ISUP Grade Group. With the Gleason scoring system, the two most common patterns of tumor tissue are each graded on a scale from 1 to 5 and then added together, for example: 3 + 4 = 7. The ISUP Grade Group ranges from 1 to 5: Grade Group 1 indicates low aggressiveness, while Grade Group 5 indicates high aggressiveness. Both systems are based on the same principle: they describe how much the cancer cells differ from healthy tissue. The ISUP Grade Group translates the Gleason Score into a classification that is easier to understand and interpret.
The pathology report also indicates whether the tumor is confined to the prostate or has already spread beyond it. If necessary — for example, in cases of a high Gleason Score or a PSA level above 20 ng/mL — additional examinations such as PSMA PET/CT may be required.
“Both of these factors are crucial for determining the appropriate treatment, which is usually planned by a multidisciplinary tumor board involving specialists from different medical disciplines,” says Professor Protzel.
If prostate cancer is confirmed
If a malignant prostate tumor is confirmed, an appropriate treatment strategy is developed. The choice of treatment depends on numerous factors assessed by the treating physician and, when necessary, by a multidisciplinary tumor board.
Helios hospitals throughout Germany follow modern protocols for prostate cancer diagnosis and treatment, with many centers holding official certifications from relevant urological and oncological organizations. If you require diagnostic examinations, a medical consultation, or treatment by experienced Helios physicians, you can submit a request using the contact form or the email address provided at the top of the website.
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