PSA (prostate-specific antigen) is a substance produced by the prostate. PSA mainly concentrates in sperm, and some amount is found also in blood. Majority of healthy men has low PSA level in blood — 4 ng/ml (nanograms per millilitre). An elevated PSA level in blood increases the likelihood of having prostate cancer. If the PSA level in blood stays between 4 ng/ml and 10 ng ml, a possibility to detect prostate cancer is 25%, if the PSA level exceeds 10 ng/ml, the likelihood of having the prostate cancer steps up to 50%. In some cases the prostate cancer can be detected also if the PSA level in blood is below 4 ng/ml.

Factors elevating PSA level in blood (except for the cancer).



• BPH (benign prostatic hyperplasia): prostate enlargement that is not related to cancer and that develops in many elderly men.
• Age: the PSA level slowly increases with the age even if no changes occur in the prostate.
• Prostatitis: prostate infection or inflammation.
• Ejaculation may increase the PSA level for a while, however it will reduce afterwards.

Finding out your PSA level is important not only for an early diagnostic of the prostate cancer. It can be useful also in other cases.

• For men already diagnosed with the prostate cancer, the PSA level together with other analyses can help to decide what additional examinations to take and what therapy method to choose.
• Very high PSA level may indicate that the tumour has spread outside the prostate. It also helps choosing the treatment method, because some of them cannot be applied if cancer cells have spread to lymph nodes or other organs.
• The PSA level helps finding out the efficiency of treatment and whether there is cancer recurrence after the treatment.
• If you have chosen 'surveillance tactics' instead of immediate treatment, you can follow-up cancer development with PSA level tests and start treatment, if necessary.

If the prostate cancer continues growing after the treatment (recurrence) or it has spread outside the prostate (metastases), the PSA level cannot capture these changes. The PSA level cannot be used to predict what symptoms are about to develop and to predict the survival. Many patients have very high PSA levels however, they feel good and have no complaints. Others, in turn, have low PSA levels and have typical complaints. Also, if a person has comorbidity, it is always useful to follow-up changes in the PSA level rather than evaluate its level from one blood count.

In this examination the doctor puts on medical gloves, spreads some lubricant on his finger and guides it into the rectum. The prostate is located next to the rectum and majority of cancers that originate in the prostate forms in the part that is adjacent to the rectum, therefore it can be palpated well. An increased prostate size that can be detected or uneven or hardened parts can be palpated indicating at probable cancer during the examination. Even though the examination is unpleasant, it is not painful and does not request much time.
Digital rectal examination is not as efficient as detecting of PSA level, nevertheless, sometimes cancer can be detected in men with normal PSA level in blood. Digital rectal examination must be performed also if the prostate cancer has been detected. This examination can reveal how wide the cancer has spread. It can also show whether the cancer has returned after the treatment.

Transrectal ultrasonography uses ultrasound waves to create prostate image in a computer. In order to perform this examination a small probe is inserted in the rectum. This probe sends sound waves that, when arriving at the prostate, generate an 'echo' also received by the probe. The computer translates the echo into a black and white image.

The examination takes several minutes. You will feel a slight pressure when the ultrasound probe is inserted into the rectum, however, usually it is not painful. Transrectal ultrasonography is applied also during the biopsy to make sure that biopsy needle is inserted correctly, and a sample is taken right from the area of the affected prostate

If some complaints or results of analyses raise a suspicion that you might have a prostate cancer, you should perform prostate biopsy to confirm the diagnosis completely.

The biopsy is the only way to find out precisely whether you have the prostate cancer.



Cells are sampled from the prostate during the biopsy and then sent to a laboratory where they are tested for cancer cells.
Most frequently the biopsy is performed with a hollow needle. The procedure goes like this: during the transrectal ultrasonography, following an image on the computer, the doctor inserts the needle in the prostate through the rectum wall. When the needle is removed, it has a small piece of tissue (approximately 1 cm in length and 2 mm in width) inside. Some doctors prick the needle through the skin between the anus and testicles.

Even though such description brings an association of a painful procedure, it causes only minor discomfort, because everything happens very fast. The doctor may apply local anaesthesia for the period of examination. The biopsy lasts for approximately 15 minutes. You can ask the doctor for local anaesthesia before the procedure. Sometimes tissue samples are taken from different parts of the prostate. Ask your doctor how many samples are to be taken.

In order to decrease a risk of infection, it is recommended to empty the rectum before the procedure, for example with Microlax. The doctor may also prescribe a short course of antibiotics before and after the biopsy. Several days after the procedure you might feel mild pain in the area of biopsy, some blood in the urine or mild bleeding from the rectum can also occur. Some men can have blood admixture in the sperm for one or even two months after the biopsy.

The cancer can be located only in a small part of the prostate rather than to overtake it completely Therefore, in some cases the biopsy sample might not show any cancer cells although the cancer is there. It is called a 'false negative response'. If your biopsy sample does not contain cancer cells, however, the doctor is sure that you have cancer, the biopsy must be repeated. In order to avoid another false negative response, a magnetic resonance imaging of the pelvis is advisable before the biopsy. Thus, it is possible to target the needle more precisely in the suspicious part of the prostate. This method is called 'targeted biopsy'.

Biopsy sample is sent to a lab. Doctor is checking the sample for cancer cells. If the cancer cells are found, the stage of the cancer must be detected. Grouping of cancer cells into stages allows to determine the growth and expansion rate of the tumour more precisely.

Biopsy conclusion shows the cancer stage (if applicable). Biopsy conclusion may contain also other information that helps evaluating the tumour. It may be:

• number of biopsy samples containing cancer cells (for example seven out of 12 samples contain cancer cells);
• number of cancer cells in each sample (in percentage);
• whether the cancer is located in one section of the prostate (right or left) or both (bilateral).

Sometimes the cells do not look like cancer cells, however they are not normal cells either. In such case a repeated biopsy is recommended.

Shortcomings of the method

According to different data sources, up to eighty percent of men, who had prostate biopsy performed, are not diagnosed with the prostate cancer or the tumour found is not aggressive. Therefore, many men are repeatedly subject to unnecessary medical manipulation, which does not lead to completely accurate and safe detecting of the prostate cancer and its aggressiveness level. Blood is often found in urine and sperm after the manipulation, the risk of infection and bacterial infection increases and some also report disturbed potency after repeated prostate cancer biopsies.
You can take 4Kscore® Test to find out if you need to have a prostate biopsy.

4Kscore® Test helps urologist to identify aggressiveness level of the prostate cancer before biopsy and allows finding out a likelihood of detecting an aggressive and high-risk prostate cancer.

What is 4Kscore® Test?

4Kscore® Test relies on the measurement of four prostate-specific kallikreins in the blood: total PSA (prostate-specific antigen), Free PSA, Intact PSA, and Human Kallikrein 2 (hK2).



The blood test results are combined with the clinical information (patient age, health condition, medical record, heritability risk – information about whether any close relative such as grandfather, father, brother or uncle had prostate cancer, as well as history of previous PSA measurements) in an algorithm helping to calculate the personal score of cancer aggressiveness risk for each patient

What are advantages of 4Kscore® Test?

4Kscore® Test can help decreasing the number of biopsies performed. If the risk of prostate cancer detected in the test is low, the patient and urologist can decide together not to do prostate biopsy and avoid unpleasant sensations and complications, such as bleeding and infection that might occur from the biopsy procedure.

If a low prostate cancer risk (Gleason score 6) is detected in the test, the patient may also avoid aggressive treatment of the prostate cancer. 4Kscore® Test can also provide information about risk of metastases in future in patients with low PSA levels.

Efficiency of the test is based on over a decade of research conducted in Europe, the United States of America by comparing several thousands of patients who had prostate cancer biopsy. Results of the biopsies performed are compared to results of 4Kscore® Test. The test is very accurate, and it has become very popular, because it is both comfortable for a patient and provides additional information for the treating doctor to make the best decisions.

More information about 4Kscore® Test is available at https://4kscore.com

Magnetic resonance imaging of pelvis is used to determine spread of the tumour in prostate and pelvic lymph nodes. The latest generation magnetic resonance imaging allows detecting tumour size and location in the prostate rather accurately, therefore, it is worth doing the magnetic resonance imaging before prostate biopsy.



Magnetic resonance imaging is not harmful to health, it is a high-resolution diagnostics with high preciseness for all parts of the body, used also in diagnostics of the prostate cancer.

The examination usually lasts for 15-30 minutes. A contrast agent might be administered, if needed, as it improves diagnostic accuracy. Medical radiologist decides whether a contrast agent needs to be used, basing on the clinical problem, renal function of the patient and, if needed, other parameters of the blood count. Contrast agent is administered intravenously.

During the examination a patient must be placed in a tunnel with a magnetic field, therefore, claustrophobic (being afraid from narrow spaces) patients must inform the doctor or magnetic resonance imaging technicians about his or her feelings. Medical radiologist assesses each case and decides on further examinations.

Before magnetic resonance imaging the patient needs to inform the referring doctor as well as magnetic resonance imaging technicians if he/she has:

• cardiostimulator;
• neurostimulator;
• hearing implants;
• artificial ventricles, aneurysm clips, other metallic implants;
• metal foreign bodies (bullets, chips, metal staples, as well as metal prosthetics in a hip joint and other body parts.

Computed tomography for pelvis minor and bones can detect spread of tumour metastases in the bones and pelvis minor. Computed tomography (CT) is a radiology examination method combining x-rays and computer technologies. Images of patient's body are generated from beams of x-rays shot from various directions. Information is digitally transformed giving 2D and also 3D images, that clearly present patient's tissues and organs.

The examination is painless. If needed, a contrast agent can be administered intravenously.

Computed tomography has its drawbacks when it comes to examining of the cancer. It cannot detect tumour foci smaller than 5-10 mm in diameter, and it can also give false positive findings.

Bone scan is used to detect whether the cancer has spread in the bones.

A radioactive substance with short half-life is administered into the vein and it is rapidly discharged from the body. Radiation dose that you receive during an examination is not larger than radiation during an x-ray scan.



Scintigraphy does not always show cancer metastases in bones. Today positron emission tomography is used to detect bone metastases.

PET-CT technology is one of the most advanced and most precise cancer diagnostic methods in the world, which performs two examinations in one equipment — positron emission tomography (PET) and computed tomography (CT). A PET-CT scan combines images from both examinations, generating very high-quality hybrid image, specifically showing prostate cancer cells and providing very accurate information about malignant changes in the body.



If a man is diagnosed with the prostate cancer, a PET-CT scan is the most efficient and accurate method for detecting the spread of cancer and discovering possible metastases. Most recent studies show that PET-CT has a number of other advantages in comparison to other conventional methods used so far to diagnose prostate cancer — ultrasonics, computed tomography, magnetic resonance imaging and bone scan.

Advantages of PET-CT scan
• If a recurrence of tumour is suspected after previous conventional surgery or radiotherapy, only PET-CT scan will identify the malignant cells while PSA level is less than 1.0 ng/ml;
• Studies show that PET-CT allows detecting metastases less than 5 mm in the lymph nodes;
• PET-CT method is suitable also for men who suspect a prostate cancer and their PSA level is elevated, however biopsy has not confirmed it.
• In case of individual metastases PET-CT scan is combined with robotic radiosurgery;
• In case of wide-spread metastases PET-CT method can be combined with radionuclides Y-90 or Lu-177-PSMA.
• PET-CT method not only helps to diagnose tumour accurately, but also to plan further therapy in all details — to determine whether a patient needs radiation or chemotherapy treatment course or a hormone therapy.

How does the examination proceed?
Equipment of PET-CT examination visually resembles a computed tomography device, the only difference being two gantries (rings) — the first performs computed tomography scan and the second performs positron emission tomography. Two gantry design of the equipment reduces discomfort and claustrophobic sensations in patients during the exam. During the examination the patient must lie down on the examination table while being slowly moved through the diagnostic device. Hands must be kept behind the head and patient should lie still during the examination. In addition to the PET-CT scan a doctor sometimes refer the patient to computed tomography with a contrast agent, which allows obtaining more information for diagnostics and in many cases it can be decisive for more clarity.

Is applied in cases of low risk prostate cancer, where a risk of spreading and progressing of the tumour is very low. The patient tests PSA level in blood on a regular basis and visits an urologist (once in 3-6 months). Steep PSA increase calls for a radical treatment.

Surgical treatment is intended for tumours in stage I, II and sometimes III. A surgery usually is an option for patients if the predictable survival exceeds 10 years. Entire prostate with the seminal vesicles are removed completely during the surgery. In case of high risk tumour the nearby lymph nodes are also removed together with the prostate. Post-operative complications may involve urinary incontinence and erectile dysfunction.


Oncologic results of surgical treatment are generally similar for all methods. The quality of a surgery depends on surgery experience and knowledge of the urologist.
If the prostate cancer grows outside its borders or has created metastases, i.e. if tumour foci have been detected in lymph nodes or other soft tissue and/or bones, it is called stage III-IV tumour. In this stage a surgery has no decisive impact, because the tumour cannot be removed completely, and any invasive manipulation exhausts the body even more.

When treating tumours in stage III and IV, most commonly used method is radiotherapy, robotic radiotherapy, hormonal therapy or a combination of such methods.

Staru terapija ir ārstēšana ar augstas enerģijas stariem (piemēram, rentgena stari), lai Radiotherapy is a treatment using intense energy beams (such as x-ray beams) to kill or devastate cancer cells. The beams come from a source located outside the body (external beam radiation) or from radioactive materials placed directly in the tumour (internal radiation or brachytherapy).
Radiotherapy is sometimes chosen as the first treatment method for a low risk prostate cancer that has not spread outside the prostate or has affected only nearby tissue.


Sometimes it is applied if a surgery cannot remove all cancerous tissue or there is a recurrence after a previous radical treatment of the prostate cancer in form of a surgery. In case of a primary tumour a chance to be treated with radiotherapy is equal to that of a surgical treatment. If the cancer is found in last stages, radiotherapy can help to reduce the volume of the cancer and alleviate pain.

External beam radiation therapy means treatment of the prostate from outside with radioactive beams. Conventional radiotherapy is an alternative to the surgery. This method can be recommended for elderly patients or patients who do not want to undergo a surgery.
Each radiation session lasts for few minutes. Usually the course of treatment is seven to nine weeks and it progresses on an out-patient basis, five sessions per week. Treatment as such is fast and painless. Each radiation session lasts for few minutes.

Today, the conventional radiotherapy is chosen much more seldom than before. The latest radiotherapy technologies allow a doctor to treat the very prostate itself with more success and without affecting the surrounding tissue. These methods are intended for more efficiency and less side effects.

Radiotherapy also has its complications, which can be brought to a minimum as the technologies develop. However, inflammation of the bladder manifesting as frequent and painful urination is possible after a treatment with older generation equipment. If the large intestine is affected, it can lead to painful diarrhea, even with an amount of blood. This inconvenience, however, is transitional and do not develop in all patients.

Robotic radiosurgery with CyberKnife or hypofractionated radiation therapy is a type of external beam radiation therapy that is currently recognised as the most efficient, safest low or medium risk prostate cancer treatment method with the least impact on the quality of life. It is applied to treat prostate cancers in stage I and II. Treatment as such is fast and painless. Each radiation session lasts for 45-60 minutes. Usually the treatment course consists of five sessions during one week on an out-patient basis.


This method is recommended to patients not eligible for a surgical treatment or in cases where the side effects of a surgical treatment can have a significant impact on the quality of life of a man. 10 years of studies of this method show a similar efficiency in controlling the tumour's recurrence to that of a surgical treatment and a better efficiency in comparison to the external beam radiation.
Hypofractionated radiation therapy also can lead to complications, however, in comparison to the surgery or conventional radiotherapy, they are reduced to a minimum. In some cases an urethra irritation is possible, manifesting as more frequent and less pleasant urination and, possibly, mild diarrhea. This inconvenience usually disappears within one month after the treatment.

Robotic radiosurgery with CyberKnife can be also applied for tumours in stage III and IV.
If the prostate cancer has been detected where it has already grown outside the prostate capsule, the robotic radiosurgery can be complemented both with conventional treatment methods and surgical treatment and external beam radiation therapy. In case of treatment of a previously treated cancer, and if a recurrence or separate metastases in bones, soft tissue or in other parts are established, robotic radiosurgery ensures high control of local recurrence and allows postponing the hormone replacement therapy and extend survival without symptoms.

Internal radiation of the prostate or brachytherapy means placing radioactive sources (metallic radioactive seeds) inside the prostate where they do their work for an extensive period of time. This method has less distinct side effects if compared to the external beam radiation therapy, because they have less influence on nearby organs. This method is newer and more efficient for tumours in stage I and II. This method requires anaesthesia. This method is not currently available in Latvia.

Goal of the hormonal therapy is to reduce the level of male sex hormones (androgens), including testosterone, in blood. Androgens that usually form in the testes stimulate an increased growth of prostate cancer cells. If the level of androgens is reduced, the prostate cancer either shrinks or it grows considerably slower. Hormonal therapy can control cancer, but it cannot treat it. If the hormonal therapy is continued for 3-4 years, so-called hormone-refractory state can occur, i.e. tumour cells become resistant against hormones.

Chemotherapy means administration of medications that kill cancer cells. These medications are most commonly administered through vein. Some medications can be in form of pills. When they reach the bloodstream, they spread around the body and kill cancer cells.
In case of a prostate cancer chemotherapy is chosen where the cancer cells have spread in entire body and hormonal therapy is inefficient. This is not a standard therapy in early stages of the prostate cancer. Studies are taking place to prove efficiency of a short-term chemotherapy course of treatment after surgical removal of the prostate.


Just like hormone therapy, the chemotherapy does not treat the cancer entirely. It cannot destroy all cancer cells, however it can slower the growth of the cancer and reduce symptoms, thus leading to a better quality of life.