Medical Chart

THE MEDICAL CHART

There is no need to be bashful about asking your doctor for a copy of the medical chart. You have every right to obtain a copy of your records. Some offices may charge a nominal fee. It may even be necessary to request the information from more than one office. Once you have a copy you can proceed with answering the quiz. The chart will be divided into sections labeled, laboratory, pathology, progress notes and radiology. In these sections you will find the specific information needed to determine your stage.

1. Laboratory (PSA)

After you obtain the chart, create a chronological history of all your PSA levels. For purposes of the quiz, the highest PSA is entered. The only exception would be an abnormally elevated PSA due to prostate trauma. For example, PSA levels will remain elevated for two months after a needle biopsy.  PSA can also be artificially elevated for 24 hours or so after a digital rectal exam or after sexual activity.

2. Pathology (Biopsy Report)

The biopsy report is kept in the pathology section of the chart. The Gleason grading system was designed many years ago and as a result it has its quirks. For example, the lowest score is 6 and the highest is 10. A Gleason score that is reported as six will be written as 3+3=6.  A Gleason nine will be written as 4 + 5 = 9 or as 5+4=9. If the biopsy contains several different scores, the highest score from the report is the one that is entered into the quiz.
Stage Description
T1 or  “A” T1c: Tumor that cannot be felt by digital rectal examination
T2 or “B” Tumor confined within the prostate
T2a: Tumor that can be felt by DRE but less than half of one lobe
T2b: Unilateral tumor felt by DRE involving more than half of one lobe
T2c: Bilateral tumor felt in both lobes
T3 or “C” Tumor felt by DRE that extends through the prostate capsule
T3a: Extracapsular extension
T3b: Tumor felt by DRE that invades seminal vesicle(s)
T4 Tumor felt by DRE that invades rectum or bladder

3. Progress Notes (Digital Rectal Exam)

The results from the finger exam of the prostate, called the digital rectal examination or “DRE”, is termed the clinical stage or the T stage. Somewhere in the progress note, usually in the area marked Physical Examination, the doctor will record whether he felt any nodule and the relative dimensions of the nodule. The system of notation that doctors use to record their finding in the chart is presented in the table. To answer the quiz, you will need to know your T stage (see table).

4. Radiology Reports (Imaging Studies or Scans)

Will be found in the Radiology section of the chart. The information in a radiology report is summarized in a section of the report titled: “Impression.” For the purpose of answering the quiz, the most important facts to be gleaned from a prostate MRI report is the presence of one or more of the following: extracapsular extension, seminal vesicle invasion or lymph node spread.
In men whose PSA levels are above ten or whose Gleason score is above six, a bone scan (to look for bone mets) and a CT scan of the abdomen and pelvis (to look for cancerous (enlarged) lymph nodes) is performed. For the purposes of the quiz, if metastatic cancer is present, it is important to determine the area of the body where the metastases are located. Are the metastases exclusively in the pelvic lymph nodes or are they in some other area of the body outside of the pelvic lymph nodes such as the bones. A new scan has just come out called Axumin that uses positron emission tomography (PET) to detect cancerous lymph nodes at an earlier stage than either MRI or CT scans. Axumin is more accurate. But as things stand presently, Axumin is only covered by insurance for the evaluation of men who are relapsing after surgery or radiation.

5. Previous Treatment

Men who have undergone previous therapy with surgery, radiation, cryotherapy or hormone blockade and are now dealing with a rising PSA are assigned to a different stage. However, it is not always crystal clear what exactly constitutes a cancer relapse.  PSA is generally accurate but patients need to familiar with some of its subtleties. After surgery, the PSA is expected to be zero. Most doctors use a threshold of a PSA above 0.2 to indicate a relapse is occurring.
After radiation, as a rough starting point, consider a PSA elevation above 1.0 to be “abnormal.” However, there are many potential exceptions. It is possible to have a PSA above 1.0 and still be free of cancer. Noncancerous PSA elevations actually occur rather frequently after radiation, particularly after seed radiation. The term for these elevations is “PSA bounce.”*
Assessing resistance to hormone blockade is relatively easy since the PSA should always be undetectable if testosterone is fully suppressed, assuming that adequate time has transpired for the PSA to fully decline. In general, the PSA should be less than 0.1 within 6 months of starting hormone blockade. If the PSA is above 0.1 and testosterone in the blood is fully suppressed, then resistance to hormone blockade is occurring.
 *With a bounce, the main priority is to distinguish it from a cancer relapse. The most reliable way to do this is to examine a continuous graph of multiple PSA levels that have been checked over time. PSA from recurrent cancer tends to manifest as a smooth, unbroken, upward progression. Since a bounce is caused by inflammation, PSA levels from a bounce tend to wax and wane, oscillating up and down on a graph in a zig-zag, spiking pattern.

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