Tests That Help You and Your Doctor Make Treatment Decisions
A prostate biopsy is currently the only sure way for your doctor to confirm whether you have prostate cancer. After you and your doctor decide to move forward with a prostate biopsy, you will have a follow-up clinic visit to talk about the results. If the biopsy shows prostate cancer, your doctor will look at several things, including:
- Your PSA level (a blood test that measures prostate-specific antigen, a protein made by the prostate),
- Your Gleason score (how aggressive the cancer looks under the microscope)
- Your overall health
Using this information, your doctor may recommend:
- Treatment, such as surgery to remove the prostate or radiation therapy, or
- Active surveillance (watching the cancer closely with regular tests and visits instead of treating it right away).
Sometimes, you and your doctor may want more detailed information about your cancer to help decide which plan is best for you. One option is to use special lab tests called biomarkers on the tissue from your biopsy. These tests can help show how aggressive your cancer is and how likely it is to come back after treatment.
Most of these biomarker tests are done on the small pieces of prostate tissue taken during your biopsy, and sometimes on the whole prostate that is removed during surgery. The biomarker tests listed below may help guide how closely you are monitored and which treatments you and your doctor choose after a biopsy. Not all these tests are listed in major treatment guidelines, and not every doctor will use them. We include them here to help you know what is available and what your treatment team might talk to you about:
Decipher
Decipher is a lab test that looks at the activity of certain genes in your prostate cancer tissue. This test helps estimate how likely your cancer is to spread or come back in the future.
Decipher can be done on tissue from your prostate biopsy and on the prostate that is removed during surgery (radical prostatectomy, an operation to remove the prostate gland). If you have Gleason 3+3 prostate cancer (often called low-risk cancer), a Decipher test can help show whether active surveillance is likely to be safe for you or if whether you are more likely to need treatment soon. If you have a small amount of Gleason 3+4 prostate cancer (sometimes called “favorable‑intermediate risk”), Decipher can also help you and your doctor decide whether close monitoring is still a good option or if it is safer to move ahead with treatment. Decipher can also help men who are planning their first treatment or who have already had surgery to remove the prostate.
For men who have had surgery, the test can give important information, such as:
- How likely it is that you might need radiation after surgery and how soon that might be needed.
- How likely it is that the cancer will spread outside the prostate area in the future if your PSA starts to rise after surgery. This rise if PSA after treatment is called biochemical recurrence.
- The chance that cancer will spread to other parts of your body (called metastases, when cancer cells travel and grow in other organs or bones) within 5 to 10 years after surgery if your cancer looked high-risk under the microscope.
ArteraAI Prostate Test
The ArteraAI Prostate Test uses computer technology (artificial intelligence) to analyze digital pictures of your biopsy tissue together with information like your PSA and Gleason score. This test helps estimate how your prostate cancer may behave over time and who might benefit most from certain treatments. There are several key scenarios where the ArteraAI Prostate Test can provide additional information:
- Helping to show whether adding short-term hormone therapy (also called androgen deprivation therapy, or ADT) to radiation is likely to give you extra benefit.
- Estimating your long-term outlook, including the chance that the cancer may spread to other parts of the body or cause serious problems in the future.
- Supporting decisions about active surveillance for men with low-risk or favorable- intermediate risk disease by estimating the chance of finding more aggressive cancer if the prostate were removed.
- After surgery, if your PSA begins to rise, helping estimate the chance that cancer will spread and whether adding hormone therapy to radiation might be helpful.
ConfirmMDx
ConfirmMDx is a test used when a man has had a biopsy that did not show cancer, but the doctor still has concerns. The test looks for subtle changes in the biopsy tissue called epigenetic changes (chemical "tags" on DNA that can turn genes on or off without changing the DNA sequence itself). These changes may suggest cancer could be present in parts of the prostate that were not sampled. This test helps your doctor decide whether you should have another biopsy.
Prolaris
Prolaris is a test that looks at how quickly your prostate cancer cells are growing and dividing. It combines information from many genes in the tumor to create a Prolaris Score that helps estimate how aggressive your cancer is. Prolaris can help you and your doctor decide whether active surveillance is a reasonable option or whether you are more likely to need treatment such as surgery or radiation.
Genomic Prostate Score (GPS) Test
The GPS test (formerly known as Oncotype DX Prostate) is a test that looks at the activity of certain genes in your prostate cancer to give a score from 0 to 100. After a biopsy, this score can help classify your cancer as lower or high risk. This test is performed on biopsy tissue, and the score helps estimate whether the cancer may be higher risk than it appears and how likely it is to grow or spread over time, supporting decisions about active surveillance versus treatment.
ProMark
ProMark is a test used in men with Gleason 3 + 3 or Gleason 3 + 4 prostate cancer on biopsy. It measures certain proteins in the cancer cells to estimate how aggressive the cancer is and gives a score between 0 and 1. This can help predict whether more serious cancer might be found if the prostate is removed.
| Biomarker | When to Consider this Biomarker? |
|---|---|
| Decipher Genomic Classifier | For men with intermediate-risk prostate cancer see how likely their cancer is to spread, and whether it is safer to choose active surveillance or move ahead with stronger treatment. |
| ArteraAI Prostate Test | For men with intermediate-risk prostate cancer to estimate long-term outlook and whether adding hormone therapy to radiation is likely to help. |
| ConfirmMDx | For men whose first biopsy did not show cancer, but there is still concern, to help decide if another biopsy is needed. |
| Prolaris | For men with low or favorable-intermediate risk prostate cancer to understand their long-term risk and decide between monitoring and treatment. |
| Genomic Prostate Score (GPS) test | For men with low- or favorable-intermediate risk prostate cancer to predict whether more aggressive cancer might be found at surgery and to better define risk. |
| ProMark | For men with low- or favorable-intermediate risk prostate cancer to use protein markers in the tumor to help decide whether active surveillance is a good option. |
Other Newer Tests
There are also newer and more experimental tests that may or may not be useful in your specific situation. Examples include:
- PTEN loss: loss of a gene called PTEN is linked with more aggressive prostate cancer and may help doctors talk with you about how strongly to treat your cancer, especially in more advanced.
- Germline testing: a blood or saliva test that looks for inherited gene changes. These results can sometimes guide targeted treatments in advanced prostate cancer and can also give information about your family’s risk, including your children.
- Somatic testing: looks for gene changes only in the cancer cells themselves and can also help doctors choose targeted treatments in advanced prostate cancer.
Researchers are also studying other tests that look at patterns of gene activity in the tumor or a combination of many inherited gene changes. These tests are still being studied and are not yet part of routine care.
Making Decisions About These Tests
The decision to use one or more of these biomarker tests after a biopsy or after surgery should be made together by you and your doctor. These tests are most helpful when they could change:
- How closely you are monitored or
- Which treatments you choose.
Not all of these tests are available at every hospital or clinic, and insurance coverage can vary. Before having a test, ask your care team about the cost and whether there might be any out-of-pocket expenses for you.
What is Genomic Testing for Prostate Cancer?
Men with high-risk localized prostate cancer require intensive treatment of their cancer in order to diminish the risk of dying of prostate cancer. Over the last five to 10 years, genomic testing has evolved to try and “personalize” the treatment of prostate cancer.
Genomic testing takes on two forms:
(1) looking at the genes you were born with, that are found in every cell in your body (i.e., your DNA, or “what makes you who you are”), or
(2) looking at cancer genes in the prostate tumor itself. The first type of testing is called “germline testing” and the second type is called “somatic testing.” Germline testing is typically done from a blood test or a saliva sample, whereas somatic testing is done from biopsy tissue from the prostate or from one of the sites that prostate cancer has spread to (i.e., the bones, liver, lungs, lymph nodes). One of the most common germline genomic tests is the FoundationOne Liquid CDX test, which is an FDA-approved test that analyzes genes from a simple blood test, in addition to being the only approved blood test to analyze over 300 genes.
Genomic testing helps doctors see how DNA and genes work within the cell and can suggest a path to better treat your cancer. Furthermore, genomic testing may be able to answer other questions, such as:
- Will your cancer grow slowly or will it get worse quickly?
- Is your cancer likely to spread?
- What types of treatment should we use to treat your prostate cancer?
In other articles, we discuss how genomics makes up the basis for pre- and post-prostate biopsy biomarkers. In this article, we focus on genomic testing that identifies certain genes that may provide further information for cancer aggressiveness and for guiding treatment. It is important to understand who is most likely to benefit from either germline or somatic genomic testing. The National Comprehensive Cancer Network (NCCN) suggests that all of the following men with prostate cancer should be considered for genomic testing:
- A family history of prostate cancer
- High and very high risk localized prostate cancer
- Locally advanced and metastatic prostate cancer
- Ashkenazi Jewish ancestry
- Intraductal or cribriform (particularly aggressive cells on microscopic examination on prostate biopsy tissue) prostate cancer
Furthermore, it is important to understand how genomic testing may guide treatment plans. For men who have had surgery, it may help with understanding their risk of recurrence in the future. This may be important to guide the early use of subsequent treatments (like radiation or hormone therapy). For men with advanced prostate cancer (specifically metastatic castration-resistant prostate cancer (mCRPC), medications called PARP inhibitors (specifically called olaparib and rucaparib) are FDA-approved for those patients who have certain genetic mutations in genes that repair damaged DNA, including mutations in BRCA1 and BRCA2. These genetic mutations may sound familiar, as they are famously known for their association with aggressive breast and ovarian cancer. They also are associated with aggressive prostate cancer. For men with MSI-high mutations in their prostate tumor (which is quite rare, with only ~3% of prostate cancers having this mutation), the immunotherapy agent pembrolizumab is approved for these patients, which is typically associated with the mCRPC disease state.
In conclusion, men with high risk-localized prostate cancer should discuss with their cancer doctors the utility of genomic testing. Based on real-world studies, unfortunately, genomic testing of a patient’s blood or their tumors has not had the uptake that would be expected, thus it is important for patients to specifically ask their doctor if genomic testing is appropriate for them. As highlighted above, genomic testing may be important for personalizing treatment, particularly for men with advanced prostate cancer.
Magnetic resonance imaging (MRI) is a type of imaging, or way to take pictures of the inside of the body. It creates images with a magnetic field and computer-generated radio waves. The MRI machine is a large tube-shaped structure that you lie inside. For prostate cancer imaging, the machine will take pictures of your pelvis (lower abdomen), including your prostate gland.
Why would I get a prostate MRI?
There are several reasons why your doctor may order an MRI to help them with staging and planning treatment for your prostate cancer.
When Considering Prostate Biopsy After an Elevated PSA
If your PSA blood test (a screening test for prostate cancer) is elevated or high, your urologist may order a prostate MRI before considering a prostate biopsy (to see if you have prostate cancer). There are several large clinical studies that show that men who have an elevated PSA and receive an MRI before getting a biopsy benefit in at least two ways.
First, some men may have such a good result from their MRI that a biopsy is not needed right away. However, a “normal” MRI does not guarantee there is no prostate cancer. So, you should still talk with your urologist about whether or not you need a prostate biopsy.
Second, the MRI provides a “map of the prostate” to guide a urologist to perform targeted biopsies of those areas most likely to have prostate cancer. As a result, these studies have shown that clinically significant prostate cancer (that which requires treatment) is more likely to be found in men who have an MRI before biopsy.
During Active Surveillance for Low-Grade/Low Volume Prostate Cancer
There are many protocols that doctors may follow when patients are on active surveillance. However, nearly all modern protocols use prostate MRI at some point in the active surveillance journey. Patients that are being considered for active surveillance most often have an MRI soon after their first biopsy. This is done to see if there are areas in the prostate that should be targeted at the time of the second, or confirmation, biopsy. For men that have been on active surveillance, most doctors will perform an MRI every one to two years to make sure there are no changes in how the prostate looks on MRI.
Local Staging for High-Risk Prostate Cancer
Prior to local therapy (i.e., surgery or radiotherapy) for high-risk prostate cancer, your doctor may order an MRI to get a better look at the anatomy of the prostate. The MRI will also help your doctor see the areas around the prostate, such as any enlarged lymph nodes (which is a common location for prostate cancer to spread).
Specifically, for patients who will have surgery, a prostate MRI may allow your urologist to see if prostate cancer is close to the prostate capsule (the wall of the prostate gland). This information can help your urologist to plan how much nerve-sparing can or should be done for each side of the prostate gland during the operation. Your urologist can be better prepared to do the cancer operation and provide you with the best chance to return to your normal life as much as possible.
What does a prostate MRI involve?
During an MRI, you will lie on the narrow bed of the MRI machine while it moves in and out of the MRI tube. This process takes about 30 minutes. In most cases, you will receive contrast dye through an I.V. during the scan.
Some men are claustrophobic (afraid of small spaces) and may find being in the MRI “tube” hard to tolerate. If you are claustrophobic, you should mention this to your doctor. They may prescribe a light sedative or a medication (i.e., Valium) to help ease the anxiety of the MRI.
Before the MRI you must remove any clothing with snaps or zippers. You likely will be asked to wear a hospital gown in the MRI scanner. Additionally, you should take off any jewelry or metal, including hearing aids.
There are several absolute contraindications (i.e., reasons why you should NOT have an MRI) to receiving an MRI. These include having a cardiac implantable electronic device (CIED) such as a pacemaker, an implantable cardioverter defibrillator (ICDs), and cardiac resynchronization therapy (CRT) device. Patients who have one of these devices are at risk of device malfunction (not working right), device heating/movement, and possible irregular heartbeat (arrhythmia) during an MRI.
If you have an elevated or high PSA test, an MRI may help your urologist to check to see if and where cancer may be in your prostate. The results of the MRI will help your urologist plan the next steps of your prostate cancer journey, and guide you and your loved ones in shared decision-making.