What’s new in prostate cancer? A lot. It’s worth doing your research and understanding your options. If your PSA is going up, here are some things to consider:

Obtain a prostate MRI prior to seeing a Urologist.

Historically, primary care physicians (PCP) will refer you to a Urologist if they are concerned your PSA is going up. The urologist will then decide if you need a trial of medication +/- a biopsy of the prostate. The biopsy is a procedure, where around 12 pieces of tissue (“cores”) will be removed and sent to a lab to see if there are cancer cells present. Basically, the Urologist takes a random sampling from both sides of the prostate. It sorta looks like this, 6 samples on each side of the prostate gland (see inset).

And here’s the thing, if you’re over 70 years old, the pathology report will likely find some prostate cancer and then you and your team of physicians have to decide if that cancer is significant enough to warrant treatment. Spoiler alert- not all prostate cancer requires treatment.

So, if you get an MRI prior to seeing a Urologist, a radiologist can tell if there is “clinically significant” prostate cancer and some radiologists can even estimate the Gleason Score (how aggressive the tumor is). The MRI also can show us if there’s any tumor bulging at the edge of the prostate and if any tumor is invading the glands at the top of the prostate called the seminal vesicles. Lymph nodes and the hip bones are evaluated as well.

If you are fortunate and live in an area where there are trained radiologists, the radiologist can biopsy the tumor they see and identify as the most aggressive. MRI-guided biopsies are more accurate than the random biopsies done by Urologists because the needle is going into the most aggressive tumor identified on MRI.

Or if you are really lucky, the MRI will be negative for any obvious cancer, and you can avoid a biopsy and cancer diagnosis.

I recommend getting a prostate MRI prior to seeing a Urologist. Here’s the New England Journal of Medicine article recommending the same thing.

In conclusion, in men with a clinical suspicion of prostate cancer, we found that a diagnostic pathway including risk assessment with MRI before biopsy and MRI-targeted biopsy in the presence of a lesion suggestive of cancer was superior to the diagnostic pathway of standard transrectal ultrasonography–guided biopsy.

Make sure you see both a Radiation Oncologist and a Urologist to discuss options

While a cancer diagnosis can be scary and you may feel the urge to rush into treatment, please take the time to investigate surgery as well as radiation options. There are many new techniques in both fields and it’s important to decide what works best for you.

Radiation and Surgery have similar cure rates, so you have to decide which side-effects you can live with. Which leads me to…

Radiation courses are much shorter these days

Radiation treatment for prostate cancer used to require 40-44 treatments delivered Monday-Friday for a total of 8-8.5 weeks. Fortunately, we now have scientific studies showing that many men can receive much shorter treatment schedules, 20-28 treatments. Some men can be cured of prostate cancer in only 5 treatments!

In order to determine the total number of radiation treatments, your Radiation Oncologist will need your:

  • PSA
  • MRI results – is all the cancer confined to the prostate gland itself? Is there any concern for cancer has grown through the prostate capsule or invaded into the seminal vesicles which are located on top of the prostate?
  • Pathology report – showing that cancer was found in the prostate gland, where the cancer was located in the gland, how much cancer as well as the Gleason score.

You will also be asked questions regarding your urination habits and if you are having any problems urinating or having bowel movements. Your radiation oncologist will then discuss which treatment schedule works best for you.


Patient-focused treatment, and an individualized approach to oncology means Dr. Norleena Gullett is not just treating cancer, she's treating the whole person.