Blood Tests For Cancer

What should people know about cancer of the colon and rectum?
Colorectal cancer (cancer of the colon and rectum) is one of the most common cancers among New Yorkers.
The colon and rectum are part of the body’s digestive system. The colon (large intestine) and rectum (the last 7-8 inches of the intestines) absorb water and eliminate waste products from digestion.
Nationally, excluding skin cancers, colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in men and women. It is estimated that one in 18 people will develop colorectal cancer sometime during their life.
Who gets cancer of the colon and rectum?
Colorectal cancer is more common in older people. Over 75% of people newly diagnosed with cancer of the colon and rectum are age 65 and over. At all ages, men are more likely to get colorectal cancer than women.
What causes cancer of the colon and rectum?
At this time, scientists do not know exactly what causes colorectal cancer. We do know that certain risk factors increase a person’s risk of developing this disease. These risk factors include:
* increasing age – age is the most important risk factor for getting colorectal cancer.
* family history – people with certain inherited diseases (familial adenomatous polyposis and hereditary nonpolyposis colon cancer) are more likely to get cancer of the colon and rectum.
* personal factors – people with a history of colon cancer, intestinal polyps, or inflammatory bowel disease are more likely to develop colorectal cancer.
* diet – diets high in animal fats (such as red meats) increase a person’s risk for getting cancer of the colon and rectum, while a diet high in vegetables, fruit and fiber may reduce risk.
* being overweight, leading an inactive lifestyle, smoking and heavy alcohol consumption also may increase risk.
What can I do to reduce my chances of getting cancer of the colon and rectum?
Some cancers of the colon and rectum can be prevented by removing polyps. In addition, colorectal cancers are more treatable when found early, before the cancer has spread to other parts of the body. To increase the chances of prevention or diagnosing colorectal cancer early, men and women at average risk over the age of 50 should be screened. People at higher risk should talk with the doctor about beginning screening sooner.
Some research studies show that participation in regular physical activity may reduce the risk of getting cancer of the colon and rectum. Men and women who use aspirin regularly and hormone replacement therapy in women after menopause may also decrease the risk of getting colorectal cancer. Because hormone replacement therapy may increase the risk of other disease, women should discuss using hormone replacement therapy with their health care provider.

What is Skin Cancer?
Skin cancer is a disease in which malignant (cancer) cells form in the tissue of the skin. Skin cancer can occur anywhere on the body. The skin has several layers; the two main ones are the epidermis (upper or outer layer) and the dermis (lower or inner layer). Skin cancer begins in the epidermis, which is made up of three kinds of cells: squamous, (thin and flat cells forming the top of the epidermis); basal (round cells that are the middle layer of the epidermis) and melanocytes (the bottom layer of the epidermis). The melanocytes give skin its color and cause the skin to darken when exposed to the sun. Skin cancer is the most commonly occurring cancer with over one million cases a year.
Is There More Than One Type of Skin Cancer?
There are three kinds of skin cancer: squamous, basal and melanoma. Melanoma is a form of skin cancer that begins in melanocytes (the cells that make the pigment melanin). Melanoma usually begins in a mole. Because melanoma tends to rapidly spread to other organs, it causes most skin cancer deaths, even though it currently accounts for only 4% of skin cancer cases. An estimated 8000 people die annually of melanoma. The number of new cases of melanoma in the US is on the rise and melanoma is the most common cancer in young women aged 25-29. (For more information on skin cancer, visit the National Cancer Institute’s Web site.)
What Causes Skin Cancer?
The exact cause of skin cancer is not known, but we do know that certain risk factors are linked to the disease. Too much exposure to ultraviolet (UV) radiation is the main risk factor for skin cancer. Some physical characteristics, including having light skin that burns and freckles easily and having naturally red or blond hair, also increase the risk of developing skin cancer.
Once My Sunburn or Tan Fades is there Still a Risk of Developing Skin Cancer?
Sunburned or tanned skin is damaged skin. Most of a person’s lifetime skin damage, which increases the risk for skin cancer, occurs before the age of 18. Therefore, even if a child’s sunburn or tan fades, the damage caused by that tan or burn does not and the effects cannot be reversed. The damage keeps adding up with each sunburn or tan and may one day result in skin cancer. So, it is important that both children and adults protect their skin.
How Can Skin Cancer be Prevented?
Reducing behaviors that can cause skin cancer may lower your chance of developing the disease. Therefore, you should avoid unnecessary unprotected exposure to the sun and artificial sources of UV light, such as tanning booths or sun lamps. When you are in the sun, protect yourself by following these simple measures:
* Cover your head with a wide brimmed hat. Wear long-sleeved shirts and long pants whenever possible.
* Use a sunscreen labeled “broad-spectrum” with a sun protection factor (SPF) rating of 15 or higher. SPF 15 blocks out 93% of UV rays, while an SPF 30 blocks out 97% of UV rays.
* Apply the sunscreen to dry skin 15-30 minutes before going outdoors and again after swimming or perspiring.
* One ounce of sunscreen, enough to fill a shot glass, is considered the amount needed to completely cover the exposed areas of the body.
* Avoid direct sun at midday, between 10 a.m. and 4 p.m., when the sun’s rays are strongest.
Do I Have to Worry About Sun Exposure on Cloudy Days?
Clouds do not block most UV rays; therefore you should use sunscreen and cover up your skin in order to protect yourself even on cloudy days.

Ovarian cancer can develop in one or both ovaries. About 1 in 55 women are diagnosed with ovarian cancer in their lifetime (compared with 1 in 9 diagnosed with breast cancer). However, because it is often not discovered until it has spread beyond the ovary, it is the fourth leading cause of cancer death among women (after lung, breast, and colon cancer).
What are the risks for ovarian cancer?
A family history of ovarian cancer: Having a relative with ovarian cancer increases a woman’s risk of getting it herself. Generally, the closer the relative, the greater the risk. However, only about 10% of all ovarian cancers can be linked to a family history of the disease.
Breast cancer: Women who have had breast cancer are twice as likely to develop ovarian cancer.
No pregnancies: Women who have not been pregnant are more likely to develop ovarian cancer.
Possible risks: One study suggests that women who have taken the fertility drug clomiphene citrate (Clomid) may have an increased risk of ovarian cancer. Other possible risks being studied are a diet high in fat; exposure to asbestos; and the use of talc (a mineral substance found in talcum powder) near the vaginal area.
What are the symptoms of ovarian cancer?
Often there are no symptoms until the disease has spread throughout the abdomen. Even then, the symptoms are often vague and can be confused with other conditions. They include:
* Feeling bloated;
* Abdominal discomfort and/or backaches;
* Gas or indigestion that can’t otherwise be explained;
* A feeling of fullness, even after a light meal;
* Nausea or loss of appetite;
* Shortness of breath or difficulty breathing;
* Pain during sexual intercourse;
* Change in menstrual flow;
* Feeling tired;
* Slight fever.
As the tumor grows, it can cause pressure on other organs and may cause frequent urination, constipation and weight change. However, these symptoms can also be caused by fibroids and other non-cancerous conditions.
Are there tests for ovarian cancer?
There is no single test. If a woman has ovarian cancer in her family history, or if she is having symptoms, she should be checked with a combination of tests. They include:
* A rectovaginal pelvic exam, so the doctor can feel if there is any mass or growth in the abdomen. The doctor will insert one finger into your vagina and one finger into your rectum and press down on your abdomen with the other hand.
* A transvaginal sonogram (also called an ultrasound). This painless test uses sound waves to check for growths inside the pelvis.
* A CA-125 test. CA-125 is a substance often found in the blood and urine of women with ovarian cancer. However, other, non-cancerous conditions can also cause an increase in CA-125, so a cancer diagnosis cannot be made from this test alone.
What if ovarian cancer runs in my family?
An inherited risk of ovarian cancer can be passed through either the father’s or mother’s side of the family. It may be caused by a defect in a gene that keeps tumors from growing.
Ask your relatives if any women in your family have had ovarian, breast, or colon cancer. (In some cases the risk for these cancers is linked.) If there is a family history, be sure to tell your gynecologist. You may need to be checked more often.
If there is ovarian cancer in my family, what can I do to protect myself?
Bring the information about your family history to your gynecologist or a gynecologic oncologist (a doctor who specializes in ovarian, vaginal, or uterine cancer). Depending on your risk, you may be advised to be checked every six months. If you are at very high risk, are over 35, and have completed your family, your doctor may advise you to have your ovaries surgically removed before they show any signs of disease.
I have no history of ovarian cancer in my family. What can I do to protect myself?
All women, regardless of their risk, should have regular rectovaginal pelvic examinations throughout their lives.
Talk to your doctor about oral contraceptives (birth control pills). Some studies suggest that they protect against ovarian cancer.
Avoid the use of powders (talc or cornstarch-based) and feminine deodorant sprays around your vaginal area.
Try to limit your fat intake.
Where can I get more information about ovarian cancer?
If you have a family history or other genetic concerns related to ovarian cancer, you can call the Gilda Radner Familial Ovarian Cancer Registry. The registry is named in honor of comedienne Gilda Radner, who died of ovarian cancer in 1989. Registry support staff offer advice and help for women who may be at risk for the disease. The number is 1-800-OVARIAN.

Prostate cancer is the second most common cancer in American men after skin cancer. African-American men have the highest rate of prostate cancer in the world. Men with family histories of the disease are also at greater risk. In addition, the risk for prostate cancer increases with age. It most often appears after age 50.
The prostate gland is part of the male reproductive system. It produces semen, the fluid that carries sperm. The prostate gland is found below the bladder and in front of the rectum. Normally, the prostate is about the size of a walnut. As a man gets older, the prostate often becomes enlarged. More than one-half of American men over the age of 60 have some enlargement of the prostate. This is not usually caused by cancer but could possibly cause other problems.
What Is Cancer Of The Prostate?
Prostate cancer is a cancer that starts in the prostate gland. Cancer causes cells in the body to change and grow out of control. Most types of cancer form a lump or a growth called a tumor. If there is a cancerous tumor in the prostate, a man may not know it. Most cases of prostate cancer develop very slowly. However, in some men, it can grow quickly and spread to other parts of the body.
What Causes Prostate Cancer?
While the exact causes of prostate cancer are not known, certain risk factors have been linked to prostate cancer. A risk factor is something that increases a person?s chance of getting a disease. Aging is the greatest risk factor for prostate cancer. Family history also plays a role. If a man?s father or brother has cancer of the prostate, his risk is two to three times greater than average. Diet may also be a factor. Men who eat large amounts of animal fat, particularly fats from red meat, may face a greater risk of prostate cancer than men who eat less animal fat.
What Are The Symptoms Of Prostate Cancer?
Often, there are NO symptoms in the early stages of prostate cancer. If symptoms DO occur, they can vary, depending on the size and exact location of the lump or the growth in the prostate. Since the prostate surrounds the urethra, the tube that carries urine and semen, any change in the prostate can cause problems with urination and ejaculation. However, similar symptoms can be caused by a number of things, including an infection or a non-cancerous condition called benign prostatic hyperplasia (BPH).
If a man has any problems with weak or interrupted flow or pain while urinating, painful ejaculation, blood in the urine or semen, or, a nagging pain in the back, hips or pelvis, he should see a health care provider or an urologist to find out what’s going on. A health care provider may order tests to determine the cause of the symptoms.
What Type Of Exam Is Used To Detect Prostate Cancer?
Your health care provider may feel for any unusual lumps or growths on the prostate by pressing on it or using a gloved finger inside the rectum (digital rectal exam or DRE). Your health care provider may also order a blood test. This blood test measures the level of prostate-specific antigen (PSA), a protein that is produced by the prostate. Higher than expected levels of PSA may mean that a tumor is present. However, high PSA levels may also be caused by an infection or an enlarged prostate. Talk with your health care provider about the tests that are right for you.
What Happens If They Find Something?
If your health care provider finds something suspicious, more tests may be needed. Often, the problem may be just an enlarged prostate or a simple infection. Further tests, including urinalysis, blood tests, x rays, ultrasound or a biopsy, may help diagnose your problem. Your health care provider may refer you to an urologist or other specialists for some of these tests and for any needed treatments.
What If I Am Told That I Have Prostate Cancer?
You should get a second opinion before undergoing any treatment. Second opinions are covered under most health insurance plans in New York State, including Medicare and Medicaid. Seek advice from a specialist (urologist, surgeon, radiologist or oncologist) who has extensive experience in the diagnosis and treatment of prostate cancer.
Not all treatments work for everyone. However, you have the right to know all the choices you have and to play an active part in treatment decisions.
Additional information is available to the public through the American Cancer Society 1-800-ACS-2345 and the National Cancer Institute?s (NCI) Cancer Information Service 1-800-4-CANCER. Many communities offer prostate cancer education and support programs that can provide you with help as you make your decisions and undergo treatment.
What Is The Treatment?
The earlier prostate cancer is detected, the more options that are available. Surgery, radiation therapy (either external beam or internal seed implants), hormone therapy or some combination of these are all commonly used. Depending on your age and condition, and your wishes, your health care provider may recommend only that you be watched and tested several times a year. Some urologists feel that, for men over age 70, the risks of surgery or radiation treatment outweigh any benefits. Therefore, they recommend ?watchful waiting?. If you are younger and in good health, your health care provider will be more likely to recommend that the cancer be treated. Any treatment may have side effects. Talk with your health care providers about your treatment options. Make sure you understand the risks, benefits and chances of success.
For More Information
For more information about prostate cancer or for an examination, see your health care provider. To learn more about any kind of cancer, call the NCI’s Cancer Information Service at 1-800-4-CANCER (or, visit their web site at www.nci.nih.gov) or the American Cancer Society at 1-800-ACS-2345 (or, visit their web site at www.cancer.org).

Screening and Early Detection Save Lives
By Lynne L. Hall
Imagine taking a fantastic voyage through the highways and byways of the human body. With a touch of a finger on the controls of your vehicle, you “fly” down strangely scenic routes and dark tunnels. Along the way, you note dangers and relay them back to technicians for future repair. Sound farfetched? Not really.
By using new computer-assisted technology, doctors can visualize a person’s colon just as if they were there. Called “virtual colonoscopy,” this screening test projects a three-dimensional image of the colon onto a computer screen. The physician “flies” through its length, searching for lumps that might be cancerous. The test is non-invasive and often involves much less discomfort than conventional methods of examining the colon. Sedation is seldom required, and the patient can go home immediately after the procedure.
“Virtual colonoscopy has the potential to revolutionize how we screen for colon cancer,” says Brian E. Harvey, M.D., a senior medical officer in the Food and Drug Administration’s Center for Devices and Radiological Health. “It’s very exciting, and once all the data are in, we may find we can screen the entire population over the age of 50, which can lead to early detection of more colonic polyps and colorectal cancer.”
When this technique is perfected, it will be added to the arsenal of tools used for the prevention and early diagnosis of colorectal cancer. Although this cancer remains a very scary disease, such new detection technologies improve the chance of finding the tumor early in its growth when it’s most curable. In addition, therapeutic advances offer new hope that, even if the cancer has spread, the diagnosis of colon cancer will not be fatal.
A Killer Disease and Its Risk Factors
Colorectal cancer–cancer of the large intestine and rectum–is second only to lung cancer in the number of cancer deaths it causes. The American Cancer Society estimates that more than 130,000 Americans will be diagnosed with colorectal cancer in 2000, and more than 56,000 will die from the disease this year. On average, one in 20 people will develop the disease in the course of a lifetime. Ninety percent of cases occur in patients over age 50, and the majority of cases–75 percent–occur in people with no known medical risk factors for colorectal cancer. But certain factors can sharply increase risk. They include:
* Family history. Having a first-degree relative–mother or father, for example–with colorectal cancer increases the lifetime risk of developing the disease to as high as eight-fold greater than people without a family history.
* History of bowel disease. Risk increases 30-fold in patients with a history of inflammatory bowel disorders, such as Crohn’s disease or ulcerative colitis.
* History of adenomatous polyps. Most colorectal cancers begin as small precancerous growths, called polyps, inside the colon or rectum. Villous adenomatous polyps are the most likely to become cancerous (up to 25 percent). Tubular adenomatous polyps are estimated to become malignant 1 to 5 percent of the time.
* Genetic traits. A genetic syndrome known as Familial Cancer Syndrome or Hereditary Non-Polyposis Colon Cancer markedly increases the risk for developing colorectal cancer at an earlier age than those patients at average risk.
Signs and Symptoms
The colon and rectum make up the large intestine, the end of the long tube of the gastrointestinal tract through which food passes during digestion. (This interconnected gastrointestinal organ system also includes the esophagus, stomach and small intestine.) The colon is the upper five or six feet of the large intestine, and the rectum is the last six to eight inches. Cancer begins to develop when cells in the colon multiply uncontrollably. These cell mutations result in precancerous polyps, small protrusions from the intestine’s lining.
There are several types of polyps, and they become increasingly common with age. By age 50, 10 percent of the population has polyps, but by age 65 that number grows to 30 percent. If left untreated, 8 to 12 percent of polyps will become cancerous. If allowed to grow, the tumor can invade nearby organs. Once the disease enters the lymph nodes or bloodstream, it most often spreads to the liver.
As with many cancers, there are usually no symptoms in the early stages. Polyps do sometimes bleed, and there may be some noticeable rectal bleeding. However, most of the time, this blood is invisible to the naked eye and is only detectable microscopically.
Patient symptoms begin to appear once the tumor is large enough to cause obstruction of the bowel. They include:
* anemia
* rectal bleeding with bright, red blood
* blood in the stool, characterized by black, “tarry” stools
* a change in bowel habits, such as recurrent diarrhea or worsening constipation
* persistent abdominal pain
* generalized weakness or fatigue
* unexplained weight loss
Early Detection Means Survival
If diagnosed and treated in its early stages, colorectal cancer is highly curable. Patients whose tumors are entirely localized to the bowel have an 80 to 90 percent chance of surviving for 10 years. With tumors that spread to the liver, however, the five-year survival rate is less than 5 percent.
The lack of symptoms in early stages may be one reason colorectal cancer has a high mortality rate. “By the time this disease becomes symptomatic, it’s often in the late stage,” says Robert Kurtz, M.D., chief of gastroenterology and nutrition at Memorial Sloan-Kettering Cancer Center in New York. “There’s no question that the earlier colon cancer is found, the more likely the patient will be cured with surgery.”
“In fact,” Kurtz says, “prevention is the best solution.” Because colorectal cancer begins as a slow-growing precancerous polyp, finding and removing these polyps can prevent cancerous changes from taking place. However, since there is no way to know if a polyp is precancerous without a biopsy, medical professionals generally agree that all polyps should be removed upon discovery.
FDA has approved or cleared several screening and diagnostic methods for colorectal cancer. When performed regularly, these tests allow the removal of polyps before they become cancerous, which can reduce the incidence of colon cancer by 40 percent. And, by preventing tumor formation, these tests can cut the death rate from colorectal cancer in half.
Screening for patients with no medical or family risk factors should begin at age 50 and be performed regularly. Available screenings include:
* Fecal occult blood test. Both colon cancer and polyps can cause bleeding, which will be passed into the stool. In this test, a small stool sample transferred to a collection card with a narrow stick is screened for the presence of blood. The sample can be collected at home by patients, who send the sample to their doctors, or by the doctor during a physical examination. Because other conditions, such as stomach ulcers and hemorrhoids, can cause blood in the stool, this test has a high rate of false positives and may result in unnecessary follow-up screenings. It may also fail to detect some tumors.
* Flexible sigmoidoscopy. A short, flexible fiber optic tube is inserted to inspect the rectum and part of the colon. Although this can be an effective diagnostic tool, it is limited in that it inspects only the lower third of the colon.
* Barium x-ray. In this test, a contrast material is infused through the rectum. This material expands the colon and allows a radiologist to see large polyps or cancers (greater than 10 millimeters) in the entire colon. The bowel must be cleansed by laxatives or enemas before the test is performed. This test involves some discomfort and often fails to detect small polyps.
* Colonoscopy. This is currently the most effective tool for detecting polyps and cancers. Additionally, it allows for removal of small polyps. After bowel preparation with laxatives and/or enemas, the patient is sedated. A long, flexible scope with a video chip is inserted into the entire length of the colon. The chip projects an image of the colon onto a video screen, allowing the physician to view the colon. Small, accessible polyps can be removed and examined for the presence of tumor cells.
The American Cancer Society recommends that patients over 50 have a fecal occult blood test yearly and a sigmoidoscopy every five years. Since Medicare and some insurance companies pay for barium x-ray screening, many physicians also recommend that this test be used in conjunction with the flexible sigmoidoscopy. A colonoscopy should be performed if any abnormalities are seen, or if the patient is experiencing symptoms. Patients with known medical risk factors should be screened more extensively and more often.
Despite the availability of screenings and their relative effectiveness, the mortality rate for colorectal cancer remains high. Experts say there are several reasons for this, including the fact that some screenings may fail to detect tumors. Another reason, according to David Ahlquist, M.D., professor of medicine and director of the Colorectal Neoplasia Clinic at the Mayo Clinic in Rochester, Minn., is a reluctance of patients to have the tests performed due to the discomfort and embarrassment involved. “We could have a much larger impact on this disease if the screening tools we have were more widely used,” Ahlquist says. “There’s a challenge for science to come up with screenings that are more accurate and more comfortable so more people will have them performed.”
Kim Vallarelli confirms that embarrassment was a factor in screening for her. “It’s such a private thing,” says the Harrison, N.Y., resident. “It just seemed too embarrassing to go through.” Vallarelli, however, was experiencing recurring symptoms, including bright red blood in the stool, bloating and persistent abdominal pain. Her doctor recommended a colonoscopy, which revealed a grapefruit-sized malignant tumor.
Vallarelli vividly recalls her terror at the news. “I was hosting my daughter’s birthday party the next day. I remember children laughing all around me,” she says, “but all I could feel was fear.”
Meeting the Challenge
Virtual colonoscopy is one way science can provide more accurate and more comfortable screening. FDA first cleared this computer-assisted technology in 1995. As in the early devices, updated versions use digital information to produce a three-dimensional reconstruction of internal hollow structures of the human body, including the colon.
Before performing virtual colonoscopy, the bowel is first cleansed with oral laxatives. A small tube is inserted into the rectum and the colon is inflated with air. A computerized axial tomography (CAT or CT) scan or magnetic resonance imaging (MRI or MR) is then performed. The entire procedure takes less than five minutes, and since sedation is usually unnecessary, the patient can leave immediately after the scanning is completed.
In earlier versions of these devices, the technician loaded the CAT or MRI images into a computer, where special software reconstructed the digital data into 3-D images. Now, with later versions, the digital data transfer and reconstruction are automated in “real time.” Medical professionals can now “fly” inside the images, identifying polyps, cancers or other structural abnormalities. Using a computer mouse or a joy-stick, the doctor controls the speed of the voyage, going forward and backward–even making a complete circle–at will. The technology is able to consistently identify polyps 10 millimeters in diameter–about the size of a blueberry–or larger. If an abnormality is found, the patient then undergoes a conventional colonoscopy so the polyp can be removed.
There are other potential benefits to this new technology. For example, it may reduce the number of conventional colonoscopies performed for diagnostic purposes, and increase the number performed therapeutically for the specific purpose of removing polyps. These procedures also can provide an electronic record that can be stored, transmitted to distant locations, and used for future analysis. As the technology becomes more sophisticated, a cleansing bowel preparation may no longer be necessary, making the test even more acceptable to patients.
FDA’s Harvey says that although the agency has cleared this new technology as a general radiological tool, there is not yet a Medicare coverage policy for virtual colonoscopy. In addition, many insurance companies do not currently pay for the procedure because outcome data from large patient groups are not yet available. Currently, virtual colonoscopy is most often performed in clinical trials designed to establish whether this type of testing is an effective method for colorectal cancer screening.
Other technologies may be available within the next several years, such as more accurate stool testing. These tests could be conducted in a manner similar to the current fecal occult blood tests. However, instead of testing for microscopic blood, these tests could detect DNA mutations in the cells that have been sloughed off by polyps and cancers. This approach promises to be more sensitive and specific in detecting abnormalities, and could result in fewer false positive tests.
According to the Mayo Clinic’s Ahlquist, the ability to detect polyps accurately through virtual colonoscopy and DNA testing can reduce the frequency of testing, and thereby reduce overall medical costs. “The transition from a flat [normal] colon lining to a polyp to a cancer takes seven to 10 years. That’s a large window of opportunity. If a diagnostic tool has the potential to detect the polyps, it probably does not need to be applied more frequently than every five years.”
Treating the Disease
The type and duration of colorectal cancer treatment depend upon the extent of the disease and when it is discovered. Treatments can include surgery, chemotherapy, radiation, or a combination of all three.
Surgery is the most commonly performed treatment for colorectal cancer. If the tumor is discovered before it has penetrated the bowel wall, removal of the cancer is usually all that is necessary for a complete cure. Specific surgical procedures may require the removal of a portion of the large bowel, which is reconstructed by sewing or stapling the two ends together. In part due to new surgical techniques and devices, a colostomy, where a portion of the colon is rerouted through the abdominal wall to the outside surface and a bag is worn to collect wastes, may not be necessary.
Small cancers localized to the rectum can be removed surgically, with radiation therapy follow up. For large cancers that have grown through the rectal wall, a technique called “mesorectal excision” can be performed. The procedure allows removal of all cancerous tissue, but avoids severing of nerves involved in sexual and urinary function. Large rectal tumors are often treated with chemotherapy and radiation before surgery.
If surgery reveals that the cancer has spread to the lymph nodes or other organs such as the liver, chemotherapy is usually prescribed. This was the case for cancer patient Vallarelli. Two days after her daughter’s birthday, she awoke from surgery to learn that the tumor had invaded her uterus, and the doctors had performed a hysterectomy. It was devastating news for the 30-year-old, but nothing compared to what came next. Her sister gently informed her that the cancer had spread to her liver. Her chances for survival were not good, but, she says, her sister would not let her give up.
Just 44 days following her first surgery, Vallarelli returned to the operating room to have the left half of her liver removed. She spent two weeks in the hospital, weakened by the two surgeries, but encouraged by tests showing there was no cancer in the remaining part of her liver. Then she underwent chemotherapy, in which she was given a regimen of intravenous drugs.
The main approved drug for colorectal cancer treatment is 5-fluorouracil (5-FU), which has been in use for more than 30 years. This drug works by inhibiting an important enzyme in cancer cells. The standard chemotherapy programs have used a combination of 5-FU and leucovorin (folinic acid), a drug that enhances the action of 5-FU. This therapy is commonly given intravenously daily for five days, every four to five weeks, for six months.
In April 2000, FDA approved Camptosar (irinotecan) to be used in combination with 5-FU and leucovorin as a primary treatment for advanced colorectal cancer. Previously, Camptosar was used only in patients who failed to respond to the 5-FU and leucovorin combination. Recent studies have shown that the addition of Camptosar significantly delays tumor progression and improves the chances of survival. Camptosar’s main side effect is diarrhea, which may be severe.
Vallarelli, whose chemotherapy took place before the approval of Camptosar as a primary treatment, says she experienced some weakness and diarrhea but was gratified that her hair loss was minimal.
An alternative method for the delivery of chemotherapy drugs is to use a pump and catheter. A small pump is implanted beneath the skin of the abdomen, and a catheter, a small, flexible tube, connects the pump to an artery that carries the drug directly to the tumor. After several weeks, the pump must be reloaded with chemotherapy by injecting more of the drug into the pump’s reservoir. This method provides a continuous supply of the chemotherapy agent, though it may still cause side effects in the patient.
Many drugs are being studied that may improve colorectal cancer treatment, including oral drugs that are analogs of 5-FU or that increase 5-FU absorption from the gastrointestinal tract. This oral treatment results in prolonged exposure to 5-FU. “In advanced disease, it’s been shown that prolonged exposure to 5-FU gives better results,” says Martin Cohen, M.D., an FDA medical officer.
Cohen cites another class of drugs in the early stages of study: matrix metalloproteinase inhibitors. “The idea behind these drugs is that they would prevent cancer cells from spreading and thus would allow you to live with the cancer,” he says. “It’s too early for real data, but they’re drawing much interest.”
Living with cancer is something survivor Vallarelli knows plenty about. She has been cancer-free for four years, though she awaits the five-year mark when doctors will tell her she’s likely to have beaten the disease. Meanwhile, she keeps a vigilant watch for signs of recurrence with periodic blood tests, CAT scans, and MRIs to screen for new growths.
“Going in for the testing every month is hard sometimes. It brings everything back to me. My strongest message to everyone is: Don’t put off screening because of embarrassment. A little embarrassment or discomfort is a small price to pay to save your life.”
Lynne L. Hall is a writer in Birmingham, Ala.
Lifestyle Changes Could Save Your Life
In June 1999, the Harvard Center for Cancer Prevention released a report summarizing the impact of diet and lifestyle factors on colon cancer. The report came to a startling conclusion: Half of all colon cancers can be prevented through lifestyle changes and widespread screening.
Behaviors recommended by the Harvard report for lowering colon cancer risk include:
* Regular screening after age 50. This can reduce the risk of dying from colon cancer by at least 33 percent.
* Regular exercise. Physically active adults are half as likely to develop colon cancer as sedentary adults. The report recommends a daily workout of 30 minutes of vigorous exercise or one hour of brisk walking.
* Cut down on red meat. Eating one serving per day of red meat is associated with a 50 percent increase in risk.
The report also recommended maintaining a healthy weight, eating more vegetables, limiting alcohol intake, and not smoking.
–L.L.H.
For More Information
American Cancer Society
1-800-ACS-2345 (1-800-227-2345)
www.cancer.org
American College of Gastroenterology
4900B South 31st St.
Arlington, VA 22206
fax: 703-931-4520
www.acg.gi.org
American Gastroenterological Association
www.gastro.org
American Digestive Health Foundation
1-800-668-5237
National Cancer Institute
Public Inquiries Office
Building 31, Room 10A03
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580
1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615
www.cancernet.nci.nih.gov
The Mayo Clinic
www.mayohealth.org/home?id=SP3.1.5.7
Harvard Center for Cancer Prevention
665 Huntington Ave.
Building 2, Room 105
Boston, MA 02115
617-432-0038
www.hsph.harvard.edu/cancer/
Oncology Tools Web page
Internet site with information about cancer and treatments
www.fda.gov/cder/cancer/

Key Points

* Hematopoietic or blood-forming stem cells are immature cells that can mature into blood cells. These stem cells are found in the bone marrow, bloodstream, or umbilical cord blood (see Question 1).
* Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are procedures that restore stem cells that were destroyed by high doses of chemotherapy and/or radiation therapy (see Questions 2 and 3).
* In general, patients are less likely to develop a complication known as graft-versus-host disease (GVHD) if the stem cells of the donor and patient are closely matched (see Question 5).
* After being treated with high-dose anticancer drugs and/or radiation, the patient receives the harvested stem cells, which travel to the bone marrow and begin to produce new blood cells (see Questions 11 to 13).
* A “mini-transplant” uses lower, less toxic doses of chemotherapy and/or radiation to prepare the patient for transplant (see Question 15).
* A “tandem transplant” involves two sequential courses of high-dose chemotherapy and stem cell transplant (see Question 16).
* The National Marrow Donor Program® (NMDP) maintains an international registry of volunteer stem cell donors (see Question 19).

1. What are bone marrow and hematopoietic stem cells?
Bone marrow is the soft, sponge-like material found inside bones. It contains immature cells known as hematopoietic or blood-forming stem cells. (Hematopoietic stem cells are different from embryonic stem cells. Embryonic stem cells can develop into every type of cell in the body.) Hematopoietic stem cells divide to form more blood-forming stem cells, or they mature into one of three types of blood cells: White blood cells, which fight infection; red blood cells, which carry oxygen; and platelets, which help the blood to clot. Most hematopoietic stem cells are found in the bone marrow, but some cells, called peripheral blood stem cells (PBSCs), are found in the bloodstream. Blood in the umbilical cord also contains hematopoietic stem cells. Cells from any of these sources can be used in transplants.
2. What are bone marrow transplantation and peripheral blood stem cell transplantation?
Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are procedures that restore stem cells that have been destroyed by high doses of chemotherapy and/or radiation therapy. There are three types of transplants:
* In autologous transplants, patients receive their own stem cells.
* In syngeneic transplants, patients receive stem cells from their identical twin.
* In allogeneic transplants, patients receive stem cells from their brother, sister, or     parent. A person who is not related to the patient (an unrelated donor) also may be used.
3. Why are BMT and PBSCT used in cancer treatment?
One reason BMT and PBSCT are used in cancer treatment is to make it possible for patients to receive very high doses of chemotherapy and/or radiation therapy. To understand more about why BMT and PBSCT are used, it is helpful to understand how chemotherapy and radiation therapy work.
Chemotherapy and radiation therapy generally affect cells that divide rapidly. They are used to treat cancer because cancer cells divide more often than most healthy cells. However, because bone marrow cells also divide frequently, high-dose treatments can severely damage or destroy the patient’s bone marrow. Without healthy bone marrow, the patient is no longer able to make the blood cells needed to carry oxygen, fight infection, and prevent bleeding. BMT and PBSCT replace stem cells destroyed by treatment. The healthy, transplanted stem cells can restore the bone marrow’s ability to produce the blood cells the patient needs.
In some types of leukemia, the graft-versus-tumor (GVT) effect that occurs after allogeneic BMT and PBSCT is crucial to the effectiveness of the treatment. GVT occurs when white blood cells from the donor (the graft) identify the cancer cells that remain in the patient’s body after the chemotherapy and/or radiation therapy (the tumor) as foreign and attack them. (A potential complication of allogeneic transplants called graft-versus-host disease is discussed in Questions 5 and 14.)
4. What types of cancer are treated with BMT and PBSCT?
BMT and PBSCT are most commonly used in the treatment of leukemia and lymphoma. They are most effective when the leukemia or lymphoma is in remission (the signs and symptoms of cancer have disappeared). BMT and PBSCT are also used to treat other cancers such as neuroblastoma (cancer that arises in immature nerve cells and affects mostly infants and children) and multiple myeloma. Researchers are evaluating BMT and PBSCT in clinical trials (research studies) for the treatment of various types of cancer.
5. How are the donor’s stem cells matched to the patient’s stem cells in allogeneic or syngeneic transplantation?
To minimize potential side effects, doctors most often use transplanted stem cells that match the patient’s own stem cells as closely as possible. People have different sets of proteins, called human leukocyte-associated (HLA) antigens, on the surface of their cells. The set of proteins, called the HLA type, is identified by a special blood test.
In most cases, the success of allogeneic transplantation depends in part on how well the HLA antigens of the donor’s stem cells match those of the recipient’s stem cells. The higher the number of matching HLA antigens, the greater the chance that the patient’s body will accept the donor’s stem cells. In general, patients are less likely to develop a complication known as graft-versus-host disease (GVHD) if the stem cells of the donor and patient are closely matched. GVHD is further described in Question 14.
Close relatives, especially brothers and sisters, are more likely than unrelated people to be HLA-matched. However, only 25 to 35 percent of patients have an HLA-matched sibling. The chances of obtaining HLA-matched stem cells from an unrelated donor are slightly better, approximately 50 percent. Among unrelated donors, HLA-matching is greatly improved when the donor and recipient have the same ethnic and racial background. Although the number of donors is increasing overall, individuals from certain ethnic and racial groups still have a lower chance of finding a matching donor. Large volunteer donor registries can assist in finding an appropriate unrelated donor (see Question 19).
Because identical twins have the same genes, they have the same set of HLA antigens. As a result, the patient’s body will accept a transplant from an identical twin. However, identical twins represent a small number of all births, so syngeneic transplantation is rare.
6. How is bone marrow obtained for transplantation?
The stem cells used in BMT come from the liquid center of the bone, called the marrow. In general, the procedure for obtaining bone marrow, which is called “harvesting,” is similar for all three types of BMTs (autologous, syngeneic, and allogeneic). The donor is given either general anesthesia, which puts the person to sleep during the procedure, or regional anesthesia, which causes loss of feeling below the waist. Needles are inserted through the skin over the pelvic (hip) bone or, in rare cases, the sternum (breastbone), and into the bone marrow to draw the marrow out of the bone. Harvesting the marrow takes about an hour.
The harvested bone marrow is then processed to remove blood and bone fragments. Harvested bone marrow can be combined with a preservative and frozen to keep the stem cells alive until they are needed. This technique is known as cryopreservation. Stem cells can be cryopreserved for many years.
7. How are PBSCs obtained for transplantation?
The stem cells used in PBSCT come from the bloodstream. A process called apheresis or leukapheresis is used to obtain PBSCs for transplantation. For 4 or 5 days before apheresis, the donor may be given a medication to increase the number of stem cells released into the bloodstream. In apheresis, blood is removed through a large vein in the arm or a central venous catheter (a flexible tube that is placed in a large vein in the neck, chest, or groin area). The blood goes through a machine that removes the stem cells. The blood is then returned to the donor and the collected cells are stored. Apheresis typically takes 4 to 6 hours. The stem cells are then frozen until they are given to the recipient.
8. How are umbilical cord stem cells obtained for transplantation?
Stem cells also may be retrieved from umbilical cord blood. For this to occur, the mother must contact a cord blood bank before the baby’s birth. The cord blood bank may request that she complete a questionnaire and give a small blood sample.
Cord blood banks may be public or commercial. Public cord blood banks accept donations of cord blood and may provide the donated stem cells to another matched individual in their network. In contrast, commercial cord blood banks will store the cord blood for the family, in case it is needed later for the child or another family member.
After the baby is born and the umbilical cord has been cut, blood is retrieved from the umbilical cord and placenta. This process poses minimal health risk to the mother or the child. If the mother agrees, the umbilical cord blood is processed and frozen for storage by the cord blood bank. Only a small amount of blood can be retrieved from the umbilical cord and placenta, so the collected stem cells are typically used for children or small adults.
9. Are any risks associated with donating bone marrow?
Because only a small amount of bone marrow is removed, donating usually does not pose any significant problems for the donor. The most serious risk associated with donating bone marrow involves the use of anesthesia during the procedure.
The area where the bone marrow was taken out may feel stiff or sore for a few days, and the donor may feel tired. Within a few weeks, the donor’s body replaces the donated marrow; however, the time required for a donor to recover varies. Some people are back to their usual routine within 2 or 3 days, while others may take up to 3 to 4 weeks to fully recover their strength.
10. Are any risks associated with donating PBSCs?
Apheresis usually causes minimal discomfort. During apheresis, the person may feel lightheadedness, chills, numbness around the lips, and cramping in the hands. Unlike bone marrow donation, PBSC donation does not require anesthesia. The medication that is given to stimulate the release of stem cells from the marrow into the bloodstream may cause bone and muscle aches, headaches, fatigue, nausea, vomiting, and/or difficulty sleeping. These side effects generally stop within 2 to 3 days of the last dose of the medication.
11. How does the patient receive the stem cells during the transplant?
After being treated with high-dose anticancer drugs and/or radiation, the patient receives the stem cells through an intravenous (IV) line just like a blood transfusion. This part of the transplant takes 1 to 5 hours.
12. Are any special measures taken when the cancer patient is also the donor (autologous transplant)?
The stem cells used for autologous transplantation must be relatively free of cancer cells. The harvested cells can sometimes be treated before transplantation in a process known as “purging” to get rid of cancer cells. This process can remove some cancer cells from the harvested cells and minimize the chance that cancer will come back. Because purging may damage some healthy stem cells, more cells are obtained from the patient before the transplant so that enough healthy stem cells will remain after purging.
13. What happens after the stem cells have been transplanted to the patient?
After entering the bloodstream, the stem cells travel to the bone marrow, where they begin to produce new white blood cells, red blood cells, and platelets in a process known as “engraftment.” Engraftment usually occurs within about 2 to 4 weeks after transplantation. Doctors monitor it by checking blood counts on a frequent basis. Complete recovery of immune function takes much longer, however—up to several months for autologous transplant recipients and 1 to 2 years for patients receiving allogeneic or syngeneic transplants. Doctors evaluate the results of various blood tests to confirm that new blood cells are being produced and that the cancer has not returned. Bone marrow aspiration (the removal of a small sample of bone marrow through a needle for examination under a microscope) can also help doctors determine how well the new marrow is working.
14. What are the possible side effects of BMT and PBSCT?
The major risk of both treatments is an increased susceptibility to infection and bleeding as a result of the high-dose cancer treatment. Doctors may give the patient antibiotics to prevent or treat infection. They may also give the patient transfusions of platelets to prevent bleeding and red blood cells to treat anemia. Patients who undergo BMT and PBSCT may experience short-term side effects such as nausea, vomiting, fatigue, loss of appetite, mouth sores, hair loss, and skin reactions.
Potential long-term risks include complications of the pretransplant chemotherapy and radiation therapy, such as infertility (the inability to produce children); cataracts (clouding of the lens of the eye, which causes loss of vision); secondary (new) cancers; and damage to the liver, kidneys, lungs, and/or heart.
With allogeneic transplants, a complication known as graft-versus-host disease (GVHD) sometimes develops. GVHD occurs when white blood cells from the donor (the graft) identify cells in the patient’s body (the host) as foreign and attack them. The most commonly damaged organs are the skin, liver, and intestines. This complication can develop within a few weeks of the transplant (acute GVHD) or much later (chronic GVHD). To prevent this complication, the patient may receive medications that suppress the immune system. Additionally, the donated stem cells can be treated to remove the white blood cells that cause GVHD in a process called “T-cell depletion.” If GVHD develops, it can be very serious and is treated with steroids or other immunosuppressive agents. GVHD can be difficult to treat, but some studies suggest that patients with leukemia who develop GVHD are less likely to have the cancer come back. Clinical trials are being conducted to find ways to prevent and treat GVHD.
The likelihood and severity of complications are specific to the patient’s treatment and should be discussed with the patient’s doctor.
15. What is a “mini-transplant”?
A “mini-transplant” (also called a non-myeloablative or reduced-intensity transplant) is a type of allogeneic transplant. This approach is being studied in clinical trials for the treatment of several types of cancer, including leukemia, lymphoma, multiple myeloma, and other cancers of the blood.
A mini-transplant uses lower, less toxic doses of chemotherapy and/or radiation to prepare the patient for an allogeneic transplant. The use of lower doses of anticancer drugs and radiation eliminates some, but not all, of the patient’s bone marrow. It also reduces the number of cancer cells and suppresses the patient’s immune system to prevent rejection of the transplant.
Unlike traditional BMT or PBSCT, cells from both the donor and the patient may exist in the patient’s body for some time after a mini-transplant. Once the cells from the donor begin to engraft, they may cause the graft-versus-tumor (GVT) effect and work to destroy the cancer cells that were not eliminated by the anticancer drugs and/or radiation. To boost the GVT effect, the patient may be given an injection of the donor’s white blood cells. This procedure is called a “donor lymphocyte infusion.”
16. What is a “tandem transplant”?
A “tandem transplant” is a type of autologous transplant. This method is being studied in clinical trials for the treatment of several types of cancer, including multiple myeloma and germ cell cancer. During a tandem transplant, a patient receives two sequential courses of high-dose chemotherapy with stem cell transplant. Typically, the two courses are given several weeks to several months apart. Researchers hope that this method can prevent the cancer from recurring (coming back) at a later time.
17. How do patients cover the cost of BMT or PBSCT?
Advances in treatment methods, including the use of PBSCT, have reduced the amount of time many patients must spend in the hospital by speeding recovery. This shorter recovery time has brought about a reduction in cost. However, because BMT and PBSCT are complicated technical procedures, they are very expensive. Many health insurance companies cover some of the costs of transplantation for certain types of cancer. Insurers may also cover a portion of the costs if special care is required when the patient returns home.
There are options for relieving the financial burden associated with BMT and PBSCT. A hospital social worker is a valuable resource in planning for these financial needs. Federal Government programs and local service organizations may also be able to help.
The National Cancer Institute’s (NCI) Cancer Information Service (CIS) can provide patients and their families with additional information about sources of financial assistance (see below).
18. What are the costs of donating bone marrow, PBSCs, or umbilical cord blood?
Persons willing to donate bone marrow or PBSCs must have a sample of blood drawn to determine their HLA type. This blood test usually costs $65 to $96. The donor may be asked to pay for this blood test, or the donor center may cover part of the cost. Community groups and other organizations may also provide financial assistance. Once a donor is identified as a match for a patient, all of the costs pertaining to the retrieval of bone marrow or PBSCs is covered by the patient or the patient’s medical insurance.
A woman can donate her baby’s umbilical cord blood to public cord blood banks at no charge. However, commercial blood banks do charge varying fees to store umbilical cord blood for the private use of the patient or his or her family.
19. Where can people get more information about potential donors and transplant centers?
The National Marrow Donor Program® (NMDP), a federally funded nonprofit organization, was created to improve the effectiveness of the search for donors. The NMDP maintains an international registry of volunteers willing to be donors for all sources of blood stem cells used in transplantation: Bone marrow, peripheral blood, and umbilical cord blood.
The NMDP Web site contains a list of participating transplant centers at http://www.marrow.org/PATIENT/Plan_for_Tx/Choosing_a_TC/US_NMDP_Transplant_Centers/tc_list_by_state.pl on the Internet. The list includes descriptions of the centers, as well as their transplant experience, survival statistics, research interests, pretransplant costs, and contact information.
Organization:     National Marrow Donor Program
Address:     Suite 100
3001 Broadway Street, NE.
Minneapolis, MN 55413–1753
Telephone     612–627–5800
1–800–627–7692 (1–800–MARROW–2)
1–888–999–6743 (Office of Patient Advocacy)
E-mail:     patientinfo@nmdp.org
Internet Web site:     http://www.marrow.org
20. Where can people get more information about clinical trials of BMT and PBSCT?
Clinical trials that include BMT and PBSCT are a treatment option for some patients. Information about ongoing clinical trials is available from NCI’s Cancer Information Service (see below), or from the NCI’s Web site at http://www.cancer.gov/clinicaltrials on the Internet.
For more help, contact:
NCI’s Cancer Information Service
Telephone (toll-free): 1–800–4–CANCER (1–800–422–6237)
TTY (toll-free): 1–800–332–8615

The Prostate-Specific Antigen (PSA) Test: Key Points
* Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA in the blood (see Question 1).
* The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a digital rectal exam to help detect prostate cancer in men age 50 and older. The FDA has also approved the PSA test to monitor patients with a history of prostate cancer to see if the cancer has recurred (come back) (see Question 2).
* Doctors’ recommendations for PSA screening vary (see Question 3).
* The higher a man’s PSA level, the more likely it is that cancer is present, but there are other possible reasons for an elevated PSA level (see Questions 4 and 5).
* Doctors take several factors into account for men who have a rising PSA after treatment for prostate cancer (see Questions 2 and 6).
* The PSA test for screening has limitations and is still controversial (see Questions 7 and 8).

1. What is the prostate-specific antigen (PSA) test?
Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor takes a blood sample, and the amount of PSA is measured in a laboratory. Because PSA is produced by the body and can be used to detect disease, it is sometimes called a biological marker or tumor marker.
It is normal for men to have low levels of PSA in their blood; however, prostate cancer or benign (not cancerous) conditions can increase PSA levels. As men age, both benign prostate conditions and prostate cancer become more frequent. The most common benign prostate conditions are prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH) (enlargement of the prostate). There is no evidence that prostatitis or BPH causes cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.
PSA levels alone do not give doctors enough information to distinguish between benign prostate conditions and cancer. However, the doctor will take the result of the PSA test into account when deciding whether to check further for signs of prostate cancer.
2. Why is the PSA test performed?
The U.S. Food and Drug Administration (FDA) has approved the PSA test along with a digital rectal exam (DRE) to help detect prostate cancer in men age 50 and older. During a DRE, a doctor inserts a gloved finger into the rectum and feels the prostate gland through the rectal wall to check for bumps or abnormal areas. Doctors often use the PSA test and DRE as prostate cancer screening tests; together, these tests can help doctors detect prostate cancer in men who have no symptoms of the disease.
The FDA has also approved the PSA test to monitor patients with a history of prostate cancer to see if the cancer has recurred (come back). If the PSA level begins to rise, it may be the first sign of recurrence. Such a biochemical relapse typically precedes clinical relapse by months or years. However, a single elevated PSA level in a patient with a history of prostate cancer does not always mean the cancer has come back. A man who has been treated for prostate cancer should discuss an elevated PSA level with his doctor. The doctor may recommend repeating the PSA test or performing other tests to check for evidence of recurrence. The doctor may look for a trend of rising PSAs over time rather than a single elevated PSA.
It is important to note that a man who is receiving hormone therapy for prostate cancer may have a low PSA reading during, or immediately after, treatment. The low level may not be a true measure of PSA activity in the man’s body. Men receiving hormone therapy should talk with their doctor, who may advise them to wait a few months after hormone treatment before having a PSA test.
3. For whom might a PSA screening test be recommended?
Doctors’ recommendations for screening vary. Some encourage yearly screening for men over age 50, and some advise men who are at a higher risk for prostate cancer to begin screening at age 40 or 45. Others caution against routine screening, while still others counsel men about the risks and benefits on an individual basis and encourage men to make personal decisions about screening. Currently, Medicare provides coverage for an annual PSA test for all men age 50 and older.
Several risk factors increase a man’s chances of developing prostate cancer. These factors may be taken into consideration when a doctor recommends screening. Age is the most common risk factor, with nearly 65 percent of prostate cancer cases occurring in men age 65 and older (1). Other risk factors for prostate cancer include family history, race, and possibly diet. Men who have a father or brother with prostate cancer have a greater chance of developing prostate cancer. African American men have the highest rate of prostate cancer, while Asian and Native American men have the lowest rates. In addition, there is some evidence that a diet higher in fat, especially animal fat, may increase the risk of prostate cancer.
4. How are PSA test results reported?
PSA test results report the level of PSA detected in the blood. The test results are usually reported as nanograms of PSA per milliliter (ng/mL) of blood. In the past, most doctors considered PSA values below 4.0 ng/mL as normal. However, recent research found prostate cancer in men with PSA levels below 4.0 ng/mL (2). Many doctors are now using the following ranges with some variation:
* 0 to 2.5 ng/mL is low.
* 2.6 to 10 ng/mL is slightly to moderately elevated.
* 10 to 19.9 ng/mL is moderately elevated.
* 20 ng/mL or more is significantly elevated.
There is no specific normal or abnormal PSA level. The higher a man’s PSA level, the more likely it is that cancer is present. But because various factors (such as age) can cause PSA levels to fluctuate, one abnormal PSA test does not necessarily indicate a need for other diagnostic tests. When PSA levels continue to rise over time, other tests may be needed.
It should be noted that it is common for normal PSA ranges to vary somewhat from laboratory to laboratory.
5. What if the screening test results show an elevated PSA level?
A man should discuss elevated PSA test results with his doctor. There can be different reasons for an elevated PSA level, including prostate cancer, benign prostate enlargement, inflammation, infection, age, and race.
If no other symptoms suggest cancer, the doctor may recommend repeating DRE and PSA tests regularly to watch for any changes. If a man’s PSA levels have been increasing or if a suspicious lump is detected during the DRE, the doctor may recommend other tests to determine if there is cancer or another problem in the prostate. A urine test may be used to detect a urinary tract infection or blood in the urine. The doctor may recommend imaging tests, such as ultrasound (a test in which high-frequency sound waves are used to obtain images of the kidneys and bladder), x-rays, or cystoscopy (a procedure in which a doctor looks into the urethra and bladder through a thin, lighted tube). Medicine or surgery may be recommended if the problem is BPH or an infection.
If cancer is suspected, a biopsy is needed to determine if cancer is present in the prostate. During a biopsy, samples of prostate tissue are removed, usually with a needle, and viewed under a microscope. The doctor may use ultrasound to view the prostate during the biopsy, but ultrasound cannot be used alone to tell if cancer is present
6. What if the test results show a rising PSA level after treatment for prostate cancer?
A man should discuss rising PSA test levels with his doctor. Doctors consider a number of factors before recommending further treatment. Additional treatment based on a single PSA test result is often not recommended. Rather, a rising trend in PSA test results over a period of time combined with other findings, such as an abnormal DRE, positive prostate biopsy results, or abnormal CT (computed tomography) scan results, may lead to a recommendation for further treatment.
According to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Prostate Cancer (3), additional treatment may be indicated based on the following PSA test results:
* For men who have been in the watchful waiting phase—PSA levels have doubled in fewer than 3 years or PSA velocity (change in PSA levels over time) is greater than 0.75 ng/mL, in addition to a prostate biopsy showing evidence of worsening cancer (3).
* For men who have had a radical prostatectomy (removal of the prostate gland)—PSA does not fall to undetectable levels after surgery or a detectable PSA (> 0.3 ng/mL) that increases on two or more subsequent measurements after having undetectable levels (3).
* For men who have had other initial therapy, such as radiation therapy and/or hormonal therapy—PSA levels have risen three consecutive times at least 3 months apart after having reached an undetectable or very low level (3).
Please note that these are general guidelines. Prostate cancer is a complex disease and many variables need to be considered by each patient and his doctor.
7. What are some of the limitations of the PSA test?
* Detection does not always mean saving lives: When used in screening, the PSA test can detect small tumors. However, finding a small tumor does not necessarily reduce a man’s chance of dying from prostate cancer. PSA testing may identify very slow-growing tumors that are unlikely to threaten a man’s life. Also, PSA testing may not help a man with a fast-growing or aggressive cancer that has already spread to other parts of his body before being detected.
* False positive tests: False positive test results (also called false positives) occur when the PSA level is elevated but no cancer is actually present. False positives may lead to additional medical procedures that have potential risks and significant financial costs and can create anxiety for the patient and his family. Most men with an elevated PSA test turn out not to have cancer; only 25 to 30 percent of men who have a biopsy due to elevated PSA levels actually have prostate cancer (4).
* False negative tests: False negative test results (also called false negatives) occur when the PSA level is in the normal range even though prostate cancer is actually present. Most prostate cancers are slow-growing and may exist for decades before they are large enough to cause symptoms. Subsequent PSA tests may indicate a problem before the disease progresses significantly.
8. Why is the PSA test controversial in screening?
Using the PSA test to screen men for prostate cancer is controversial because it is not yet known if this test actually saves lives. Moreover, it is not clear if the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called overdiagnosis, puts men at risk for complications from unnecessary treatment such as surgery or radiation.
The procedure used to diagnose prostate cancer (prostate biopsy) may cause side effects, including bleeding and infection. Prostate cancer treatment may cause incontinence (inability to control urine flow) and erectile dysfunction (erections inadequate for intercourse). For these reasons, it is important that the benefits and risks of diagnostic procedures and treatment be taken into account when considering whether to undertake prostate cancer screening.
9. What research is being done to validate and improve the PSA test?
The benefits of screening for prostate cancer are still being studied. The National Cancer Institute (NCI), a component of the National Institutes of Health, is currently conducting the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, or PLCO trial, to determine if certain screening tests reduce the number of deaths from these cancers. The DRE and PSA are being studied to determine whether yearly screening to detect prostate cancer will decrease a man’s chance of dying from prostate cancer. Full results from this study are expected in several years.
Scientists also are researching ways to distinguish between cancerous and benign conditions, and between slow-growing cancers and fast-growing, potentially lethal cancers. Some of the methods being studied are:
* PSA velocity: PSA velocity is the change in PSA levels over time. A sharp rise in the PSA level raises the suspicion of cancer and may indicate a fast growing cancer. A 2006 study found that men who had a PSA velocity above 0.35 ng/mL per year had a higher relative risk of dying from prostate cancer than men who had a PSA velocity less than 0.35 ng/mL per year (5). More studies are needed to determine if high PSA velocity more accurately detects prostate cancer early.
* Age-adjusted PSA: Age is an important factor in increasing PSA levels. For this reason, some doctors use age-adjusted PSA levels to determine when diagnostic tests are needed. When age-adjusted PSA levels are used, a different PSA level is defined as normal for each 10-year age group. Doctors who use this method generally suggest that men younger than age 50 should have a PSA level below 2.4 ng/mL, while a PSA level up to 6.5 ng/mL would be considered normal for men in their 70s. Doctors do not agree about the accuracy and usefulness of age-adjusted PSA levels.
* PSA density: PSA density considers the relationship of the PSA level to the size of the prostate. In other words, an elevated PSA might not arouse suspicion if a man has a very enlarged prostate. The use of PSA density to interpret PSA results is controversial because cancer might be overlooked in a man with an enlarged prostate.
* Free versus attached PSA: PSA circulates in the blood in two forms: free or attached to a protein molecule. The free PSA test is more often used for men who have higher PSA values. Free PSA may help tell what kind of prostate problem a man has. With benign prostate conditions (such as BPH), there is more free PSA, while cancer produces more of the attached form. If a man’s attached PSA is high but his free PSA is not, the presence of cancer is more likely. In this case, more testing, such as prostate biopsy, may be done. Researchers are exploring different ways to measure PSA and to compare these measurements to determine if cancer is present.
* Alteration of PSA cutoff level: Some researchers have suggested lowering the cutoff levels that determine if a PSA measurement is normal or elevated. For example, a number of studies have used cutoff levels of 2.5 or 3.0 ng/mL (rather than 4.0 ng/mL). In such studies, PSA measurements above 2.5 or 3.0 ng/mL are considered elevated. Researchers hope that using these lower cutoff levels will increase the chance of detecting prostate cancer; however, this method may also increase overdiagnosis and false positive test results and lead to unnecessary medical procedures.
* Protein patterns: Scientists are also studying a test that can rapidly analyze the patterns of various proteins in the blood. Researchers hope that this technique can determine if a biopsy is necessary when a person has a slightly elevated PSA level or an abnormal DRE.
For additional information about prostate cancer, contact the NCI’s Cancer Information Service (see below).

Selected References
1. Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2004. Bethesda, MD: National Cancer Institute, 2007.
2. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter. New England Journal of Medicine 2004; 350(22):2239–2246.
3. National Comprehensive Cancer Network, Inc. (2007). NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer v.1.2007. Retrieved March 23, 2007, from http://www.nccn.org/professionals/physician_gls/PDF/prostate.pdf.
4. Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values. The Journal of Urology 1994; 151(6):1571–1574.
5. Carter HB, Ferrucci L, Kettermann A, et al. Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of curability. Journal of the National Cancer Institute 2006; 98(21):1521–1527.

For more help, contact:
NCI’s Cancer Information Service
Telephone (toll-free): 1–800–4–CANCER (1–800–422–6237)
TTY (toll-free): 1–800–332–8615