If your doctor thinks you might have prostate cancer, certain exams and tests will be needed. Your doctor will start by asking questions about your health history, your symptoms, any risk factors, and your family history of disease.

Your doctor will do a physical exam. The doctor may also do a digital rectal exam (DRE) by putting a gloved, lubricated finger into your rectum to feel for hard bumps on your prostate.

You will also have blood tests. These are used to check your overall health and your PSA level. PSA is prostate-specific antigen. It's a protein made by prostate cells. High PSA levels may be a sign of prostate cancer.

If the DRE and your PSA level suggest that you have prostate cancer, the next step is often a prostate biopsy.

A biopsy is the removal of tiny pieces of tissue for testing. The removed tissue is called a sample. A biopsy is the best way to know for sure that a person has prostate cancer. A core needle biopsy is the type that's done most often.

A core needle biopsy to check for prostate cancer is most often done by a urologist. This is a doctor who specializes in diagnosing and treating problems of the urinary and genital tracts. The procedure takes about 10 minutes. It's often done in a doctor's office.

During a prostate biopsy:

• A thin needle is used to inject medicines that numb the area near your prostate.
• An ultrasound probe is put into your rectum. It uses sound waves and a computer to make images of your prostate and help guide the biopsy tool to the right place.
• The biopsy tool has a thin, hollow needle that's used to take the samples from the prostate. The needle may be put through the wall of the rectum (called a transrectal biopsy). Or it may go in through the skin between your scrotum and anus (called a transperineal biopsy). The needle moves in and out very fast. Because of this, you may not feel much discomfort.
• About 12 samples are taken from different parts of the prostate.
• To help prevent infection, you may be given antibiotics before and after the biopsy.

After the biopsy, you might have:

• Soreness in the area.
• Blood in your urine or semen.
• Bleeding from your rectum.

Once the biopsy is done, the tissue pieces are sent to a pathologist. This is a doctor who specializes in testing and looking at tissue samples using a microscope. It often takes a few days to get the results of a biopsy. They may come back as:

• Positive for cancer.
• Negative for cancer.
• Suspicious (changes are seen, but it's not clear that it's cancer).

When cancer cells are found, the cancer is assigned a grade by the pathologist. The grading system for prostate cancer is called the Gleason score.

This scale uses numbers 1 to 5 to show how much the tissue looks like normal prostate tissue. A grade is given to each of 2 samples of the prostate that have the most cancer cells.

• Grade 1. The tissue looks a lot like normal prostate tissue. The cells are abnormal but still appear to be organized in rings. This may mean a slow-growing cancer.
• Grades 2 to 4. The tissue looks in between normal and very abnormal. The cells vary more in size and shape. Fewer rings are visible. These cancer cells may grow more quickly or may still be slow-growing.
• Grade 5. The tissue looks very abnormal. The cells form irregular, closely packed rings or don't form rings at all. They vary even more in size and shape than lower-grade cells. This grade means it's likely a fast-growing cancer.

The grades from the 2 areas are added together. The main area of cancer gets the first grade score. The second main area of cancer gets the second grade score. That total number is then the Gleason score.

Gleason scores are between 2 and 10. But scores below 6 are seldom used. The results may be reported as:

• Gleason score of 6 or less. This is low-grade cancer.
• Gleason score of 7. This is medium-grade cancer.
• Gleason score of 8 to 10. This is high-grade cancer.

The higher the Gleason score, the more likely the cancer will grow and spread.

Most medical experts use Grade Groups to describe prostate cancer. This is more accurate than the Gleason scores. For example, not all cancers with a Gleason score of 7 are the same. Cancers with more Grade 3 areas (3 + 4 = 7 Gleason score) are less likely to grow and spread than cancers with more Grade 4 areas (4 + 3 = 7 Gleason score). And Gleason score 8 cancers are less likely to grow and spread than cancers with a Gleason score of 9 or 10.

The Grade Group system breaks up prostate cancers into 5 Grade Groups:

• Grade Group 1 = Gleason 6 (or less)
• Grade Group 2 = Gleason 3 + 4 = 7
• Grade Group 3 = Gleason 4 + 3 = 7
• Grade Group 4 = Gleason 8
• Grade Group 5 = Gleason 9 or 10

If your biopsy report shows that you have prostate cancer, it might show both the Gleason score and the Grade Group.

A negative biopsy result means no cancer cells were found in samples taken from your prostate.

Sometimes a biopsy doesn't find any cancer when cancer is there. This is called a false negative. This might happen if the biopsy needle misses parts of your prostate with cancer. If your doctor thinks you have prostate cancer (for example, if your PSA level is very high) even though your results are negative, you may have more testing. This might include another biopsy.

A pathologist may report cells that aren't normal but aren't cancer. They may call these cells suspicious. Suspicious cells may be:

• Prostatic intraepithelial neoplasia (PIN). This is abnormal growth, but it's not cancer. PINs may be low-grade or high-grade. Low-grade PIN is not linked to cancer. But people with high-grade PIN have a higher chance of getting prostate cancer.
• Atypical small acinar proliferation (ASAP). ASAP is also called atypia. The cells look like cancer, but there are very few of them. ASAP means there's likely cancer in the prostate.
• Proliferative inflammatory atrophy. This means there are prostate cells that are smaller than normal, and there's inflammation in the area. This may lead to high-grade PIN or prostate cancer.

If you have any of these, your doctor may watch your prostate health more closely. The doctor may recommend more testing, including another biopsy in a few months.

When your doctor has your biopsy results, you and your doctor will talk about next steps. This may include talking about treatment choices if cancer is found, getting another biopsy later, or having regular checkups.

Talk with your urologist or other doctor if you have questions or concerns after your biopsy. Make sure you understand your results and know what follow-up is needed.