Last Updated on December 15, 2023 by Max
Welcome to the journey towards clarity and understanding, where facts meet compassion and information empowers action. Prostate cancer, a term often cloaked in uncertainty and fear, becomes less intimidating when we unravel its intricate layers. Understanding how it’s diagnosed, what steps are involved, and why they’re essential can transform confusion into comprehension and apprehension into action.
Each year, hundreds of thousands of men worldwide hear the words “You have prostate cancer.” These words can send shockwaves through anyone’s life, yet knowing the process that led to that diagnosis can provide a roadmap for what comes next. From initial screenings to advanced diagnostic procedures, this comprehensive guide will illuminate every step of the prostate cancer diagnosis journey. It aims to empower you, whether you’re a man who’s reached the recommended age for screening, someone recently diagnosed, or a loved one seeking to provide support. So, shall we step into the light of understanding together?
Remember, knowledge is power. Now, let’s harness that power as we delve into the intricacies of prostate cancer diagnosis.
- Pre-diagnostic Screening: The First Step to Awareness
- Initial Diagnostic Tests: Probing Deeper into the Unknown
- Interpreting the Results: Unveiling the Story Behind the Numbers
- Biopsy: A Closer Look
- Staging Prostate Cancer
- Biopsy Results and Gleason Score
- Gleason Score’s Role in Treatment Decisions
- Weighing the Risks: Understanding the Downsides of Biopsy
- Innovations in Diagnosis: Exploring the Pros and Cons of Liquid Biopsies
- Advanced Diagnostic Procedures: The Next Steps in Prostate Cancer Diagnosis
- Importance of Second Opinions and Top Clinics for Prostate Cancer Diagnosis
- What to Expect After a Prostate Cancer Diagnosis
- Conclusion: A Proactive Journey Towards Health
Pre-diagnostic Screening: The First Step to Awareness
Prostate cancer often begins its journey in silence, showing few symptoms until its later stages. That’s why we must balance the importance of regular screening. It is akin to having a vigilant sentry, ever-watchful, alerting us to the possibility of danger ahead.
Regular screening is the first line of defense in detecting prostate cancer early when treatment is most likely successful. It is typically recommended for men aged 50 and above. However, for those with a family history of prostate cancer or other risk factors, screening might start earlier, at around age 40 or 45 (American Cancer Society, 2021). But how do these screenings work, and what do they involve? Let’s dive in.
PSA Blood Test
Cells in the prostate gland produce a protein known as PSA or Prostate-Specific Antigen. The PSA test measures the level of this protein in a man’s blood, acting as an essential biomarker in detecting potential prostate issues.
Elevated PSA levels may suggest prostate cancer, but it’s essential to note they could also indicate other conditions such as prostatitis or an enlarged prostate. A high PSA level doesn’t confirm a cancer diagnosis but instead signals the need for further investigation (National Cancer Institute, 2019).
Digital Rectal Examination (DRE)
Another vital component of pre-diagnostic screening is the Digital Rectal Examination. During a DRE, a healthcare provider gently inserts a lubricated, gloved finger into the rectum to examine the prostate. They’re feeling for any abnormalities in size, shape, and texture that might suggest cancer (Centers for Disease Control and Prevention, 2021).
The PSA blood test and DRE can provide valuable early warning signs of prostate cancer, yet they are not definitive diagnostic tools. They’re the preliminary scouts on our pathway to understanding, giving us crucial information on whether we need to explore further. And now, the question arises, what happens when these tests suggest something may be amiss? What are the next steps on the journey?
We’d love to hear from you if you’ve ever experienced a PSA test or DRE. How did it go? Were you nervous? Please share your experience below, and let’s continue the conversation.
Initial Diagnostic Tests: Probing Deeper into the Unknown
Your healthcare provider will likely recommend further tests if your PSA levels rise or a DRE suggests an abnormality. These tests, or initial diagnostic tests, take a deeper dive into the unknown, seeking to confirm or rule out the presence of prostate cancer. Let’s walk through these initial diagnostic procedures, their importance, and what they entail.
Confirmatory PSA Test
An elevated PSA doesn’t always mean cancer. It could be due to other factors such as a urinary tract infection, recent physical activity, or even natural variations in PSA levels. So, the first step is usually a repeat PSA test to confirm the initial results (Prostate Cancer Foundation, 2021).
Biopsy: A Deeper Examination
If PSA levels remain high, the next step is a biopsy, which allows doctors to look closely at your prostate cells. Typically, doctors perform this procedure transrectally, using an ultrasound probe to guide the needle’s placement and ensure accuracy. It might sound intimidating, but they administer local anesthesia to minimize discomfort (American Cancer Society, 2020).
The biopsy results will either confirm the presence of cancer or give you the all-clear. But, when they find cancer, the biopsy also gives crucial information about the potential aggressiveness of the cancer. Doctors determine this by examining the appearance of the cancer cells, a measure known as the Gleason score.
Interpreting the Results: Unveiling the Story Behind the Numbers
The results from PSA tests, DRE, and biopsies are critical indicators that medical professionals use to navigate the complex map of prostate health. Understanding these results equips you to participate in your healthcare journey actively. Let’s dive deeper into the interpretation of these results.
Decoding PSA Test Results
A PSA test reports the level of PSA in nanograms per milliliter (ng/mL) of blood. While we don’t designate a specific normal or abnormal PSA level, traditionally, doctors have considered a PSA level of 4.0 ng/mL or lower as average (American Cancer Society, 2020). However, many men with PSA levels below 4.0 ng/mL may have prostate cancer, while others with higher levels do not. Therefore, rising or fluctuating PSA levels, even if within the normal range, may indicate a need for further testing.
It’s also important to note the PSA velocity (the rate at which the PSA levels change over time) and the PSA density (the PSA level in relation to the size of the prostate). Both these parameters provide additional insights into prostate health.
PSA Velocity refers to the rate of change in PSA levels over time. If your PSA levels steadily increase over consecutive tests, your doctor might consider this a high PSA velocity.
While a single elevated PSA result could be due to various reasons like infection, inflammation, or recent physical activity, consistently rising levels may indicate the presence of prostate cancer. Some studies, such as the one by Carter, H.B. (2006), suggest that if the PSA velocity increases by more than 0.75 ng/mL per year, it may associate with a higher risk of prostate cancer.
However, remember it’s crucial to consider PSA velocity alongside other factors and test results for a comprehensive understanding of prostate health.
PSA Density takes into account the size of the prostate. It’s calculated by dividing the PSA level by the prostate volume, determined through transrectal ultrasound. A larger prostate naturally produces more PSA so a high PSA level could mean a larger prostate, not necessarily cancer.
Typically, a PSA Density greater than 0.15 is considered suspicious and may warrant further investigation, such as a biopsy (Urology Care Foundation, 2021). However, PSA Density should be interpreted alongside other tests and factors to avoid false alarms or missed diagnoses.
Understanding DRE Results
The doctor palpates the prostate in a DRE to assess its size, shape, and texture. A healthy prostate feels smooth and firm, like the palm of a hand. If the prostate feels hard, lumpy, or asymmetrical, this could indicate the presence of cancer. However, DRE findings alone cannot confirm a cancer diagnosis but may signal the need for further tests like a biopsy (Centers for Disease Control and Prevention, 2021).
Biopsy: A Closer Look
A biopsy is the most definitive way to diagnose prostate cancer, helping distinguish benign conditions from malignant ones, and defining the grade of the tumor, if present. In this section, let’s delve deeper into the specifics of the biopsy procedure and how results are interpreted.
The Need for a Biopsy in Prostate Cancer Diagnosis
While blood tests like PSA and imaging studies can raise suspicions of prostate cancer, only a biopsy can confirm the diagnosis. During a biopsy, a doctor takes small samples of your prostate tissue to examine under a microscope. If cancer is present, the cells in these samples will appear abnormal.
Types of Biopsy Procedures
There are several types of prostate biopsy procedures:
- Transrectal Ultrasound (TRUS) Guided Biopsy: This is the most common type of prostate biopsy. Guided by ultrasound imaging, the doctor inserts a thin, needle-like probe into the rectum to take tissue samples from the prostate.
- Transperineal Biopsy: In this procedure, tissue samples are taken through the perineum (the skin between the anus and the scrotum) instead of the rectum. This approach can reduce the risk of bacterial infection.
- MRI-Guided Biopsy: If initial TRUS-guided biopsy results are inconclusive or if there’s a specific area of concern on MRI, an MRI-guided biopsy might be performed. This involves either fusing previous MRI images with real-time ultrasound (fusion biopsy) or directly sampling areas under real-time MRI guidance.
Staging Prostate Cancer
Staging describes how far cancer has spread, guiding treatment decisions. Prostate cancer stages range from I (cancer is small and confined to the prostate) to IV (cancer has spread beyond the prostate to other body parts) (American Cancer Society, 2021).
Gleason scores, along with PSA levels and findings from physical examination and imaging, inform the stage:
- Stage I: Cancer is small and entirely within the prostate (T1, N0, M0), with a Gleason score of 6 or less and a PSA level under 10.
- Stage II: Cancer is more extensive but still confined to the prostate, with varying PSA levels and Gleason scores.
- Stage III: Cancer has spread beyond the prostate to nearby tissues (T3 or T4) but not to lymph nodes or distant sites (N0, M0).
- Stage IV: Cancer has spread to nearby lymph nodes or distant body parts, such as bones.
Biopsy Results and Gleason Score
Biopsy results are reported in a pathology report, which includes information about whether cancer cells were found and, if so, how abnormal they look (a measure known as the Gleason score).
The Gleason score ranges from 2 to 10 and is determined by adding the two most common patterns of cells seen under the microscope. A score of 2-6 is considered low-grade cancer, seven is intermediate, and 8-10 indicates high-grade cancer. High-grade cancers are more likely to grow and spread quickly (National Cancer Institute, 2019).
Biopsy Probes and Calculating Gleason Scores: A Closer Look
The diagnosis of prostate cancer pivots around two central processes: the biopsy procedure and the interpretation of biopsy results, notably the Gleason score. Let’s explore these in greater detail.
Prostate Biopsy Probes
A doctor typically collects 10 to 12 tissue samples from different prostate parts using a thin, needle-like probe. This approach ensures a comprehensive assessment of the prostate and increases the likelihood of detecting cancer if it is present.
In some cases, when initial biopsy results are inconclusive or doctors choose active surveillance as a management strategy, they might opt for a saturation biopsy. This involves collecting more extensive tissue samples (20-40 or more) for a more detailed examination (Prostate Cancer Foundation, 2021).
Calculating the Gleason Score
The Gleason score, determined by a pathologist examining the biopsy samples, is critical in understanding the nature and potential aggressiveness of the detected prostate cancer.
Here’s a step-by-step explanation of how Gleason scores are calculated:
- Identify the Grades: The pathologist identifies the two most prevalent patterns of cancer cells in the tissue samples. Each pattern is assigned a grade ranging from 1 (most similar to normal cells) to 5 (most abnormal).
- Add the Grades: The Gleason score is the sum of the two grades. The first represents the most common grade, and the second represents the next most common grade. So, if the most common grade is three and the second most common grade is 4, the Gleason score is 7.
It’s important to note that a Gleason score of 7 with primary grade 3 (3+4=7) tends to be less aggressive than a Gleason score of 7 with primary grade 4 (4+3=7). This distinction is essential when considering treatment options (American Cancer Society, 2020).
- Gleason 6 or below: These cancers are likely to grow slowly. They’re considered “well-differentiated,” meaning they look more like normal tissue.
- Gleason 7: These cancers have a mix of grade 3 and 4 cells and are likely to grow moderately. They’re considered “moderately differentiated.”
- Gleason 8-10: These cancers will likely grow and spread more quickly. They’re considered “poorly differentiated” or “undifferentiated,” meaning they look less like normal tissue (Prostate Cancer Foundation, 2021).
A higher Gleason score often suggests a more aggressive cancer, influencing treatment decisions. However, one should consider the Gleason score alongside other factors like PSA levels, the number of biopsy samples containing cancer, and the cancer stage.
In essence, each test and score is a piece of the larger puzzle of prostate health. Only when considered together can they paint an accurate picture.
Decoding biopsy results and Gleason scores can seem challenging, but remember; you’re not alone on this journey. Your healthcare provider is there to guide you, and understanding these processes can help empower your dialogue with them.
Gleason Score’s Role in Treatment Decisions
The Gleason score plays a pivotal role in informing treatment decisions. Low-grade cancers (Gleason 6) may be managed with active surveillance, especially in older men or those with other significant health issues.
Higher-grade cancers (Gleason 7-10) might require more aggressive treatment, such as surgery, radiation, hormone therapy, chemotherapy, or a combination.
Have you had to make decisions based on your Gleason score and cancer stage? Understanding your Gleason score and cancer stage can give you control over your treatment journey, aiding in decision-making and preparing you for what lies ahead. Your insights might offer guidance to someone else on a similar journey. Share your experiences in the comments below.
Weighing the Risks: Understanding the Downsides of Biopsy
While biopsy is a critical tool in diagnosing prostate cancer, it is an invasive procedure and, as with any medical procedure, comes with certain risks and downsides. The decision to proceed with a biopsy should always be a discussion between you and your healthcare provider, carefully weighing the potential benefits and risks.
Complications from Biopsy
The potential complications of a prostate biopsy can include the following:
- Infection: Despite preventive measures like antibiotics, infections can occur after a prostate biopsy. Studies show that serious infections requiring hospitalization occur in about 1% to 4% of men undergoing a prostate biopsy (Loeb S. et al., 2013).
- Bleeding: Visible blood in the urine or semen is common after a biopsy, affecting up to 84% of men, but severe bleeding is rare. Less than 1% of men may experience significant bleeding requiring further intervention (National Institute for Health and Care Excellence, 2019).
- Pain or Discomfort: Most men report some pain or discomfort during the biopsy, and up to 20% report pain afterward. However, the pain is typically mild and can be managed effectively with over-the-counter pain medications (Bruyère F. et al., 2016).
- Difficulty Urinating: A small proportion of men, around 1-2%, may experience acute urinary retention (a sudden inability to urinate) after a biopsy, which might require the temporary placement of a urinary catheter (Rosario, D.J. et al., 2012).
Risk of Spreading Prostate Cancer
A common concern is whether the biopsy procedure could potentially spread cancer cells, if present, into the surrounding tissue or bloodstream. While this could occur, the risk is shallow. A large-scale study found no evidence that prostate biopsies increase the risk of cancer spread (Hu, J.C. et al., 2014).
As always, the decision to have a prostate biopsy should be made in consultation with your healthcare provider, considering the potential benefits and risks. Understanding these numbers can help you make an informed decision.
Navigating these waters of medical decisions can feel challenging. How did you weigh the potential risks and benefits if you’ve faced similar choices? Share your experiences below. Your story could provide invaluable insights to someone else facing a similar situation.
Risk versus Benefit
The decision to undergo a prostate biopsy is a balance of risks and benefits. On the one hand, a biopsy is the only definitive way to diagnose prostate cancer, and early detection can significantly improve treatment outcomes. On the other hand, the procedure carries potential risks and discomforts.
Therefore, it is essential to have an open discussion with your healthcare provider about your risk of prostate cancer, the potential benefits and risks of a biopsy, and alternative strategies for monitoring prostate health.
Have you or a loved one faced the decision to have a biopsy? What were your considerations and concerns? Share your experiences in the comments below. Together, we can empower each other on this health journey.
Innovations in Diagnosis: Exploring the Pros and Cons of Liquid Biopsies
As technology and research advance, new methods for diagnosing prostate cancer are emerging. One such promising technique is the liquid biopsy. Unlike traditional biopsies, which require tissue sampling, liquid biopsies detect cancer by examining DNA and other materials shed by tumor cells in the blood.
Pros of Liquid Biopsies
1. Non-invasive: Liquid biopsies are essentially blood tests, avoiding the discomfort and potential complications associated with tissue biopsies.
2. Real-time monitoring: Liquid biopsies allow continuous monitoring of the tumor’s genetic makeup, which can evolve during treatment, thus enabling personalized treatment adjustments.
3. Early detection of recurrence: By monitoring specific genetic changes, liquid biopsies could detect cancer recurrence before it becomes evident in imaging studies (Jenkins, R.W. et al., 2021).
Cons of Liquid Biopsies
1. Limited Sensitivity: Liquid biopsies may not detect all cancers, particularly those at an early stage or low volume. A patient can have cancer that is not detected by a liquid biopsy.
2. Unclear Significance: While liquid biopsies can detect genetic changes, not all of these changes necessarily indicate cancer. This can make interpreting the results challenging and lead to further unnecessary testing.
3. Cost and availability: As of my knowledge cutoff in September 2021, liquid biopsies were more expensive than traditional biopsies and not universally available or covered by all insurance companies.
While liquid biopsies hold much promise, they currently serve as a complement to, rather than a replacement for, traditional biopsies in the diagnosis of prostate cancer. Continued research is needed to refine this tool further and define its role in the diagnostic process.
Have you encountered liquid biopsies in your health journey, or do you know someone who has? What were your experiences and perceptions of this new technology? Share your thoughts in the comments below. Your insights could inform others on their health journeys.
Advanced Diagnostic Procedures: The Next Steps in Prostate Cancer Diagnosis
Once a biopsy confirms the presence of prostate cancer and you understand your Gleason score, the journey isn’t over. In many cases, especially for higher Gleason scores, advanced diagnostic procedures become necessary to stage cancer and accurately determine the best treatment strategy.
When and Why Advanced Diagnostic Procedures Are Necessary
Advanced diagnostic procedures, such as imaging tests, become necessary when the biopsy indicates a higher risk of cancer (higher Gleason score, higher PSA level, or a larger volume of cancer in the biopsy samples) or if symptoms suggest cancer might have spread. These procedures can help determine whether and how far the cancer has spread beyond the prostate, which is crucial for treatment planning.
Imaging Tests for Staging: A Closer Look
Several imaging tests can be used in the staging process:
- Bone Scans: A bone scan can detect whether the cancer has spread to the bones, a common site of prostate cancer metastasis. A small amount of radioactive material is injected into a vein, which travels through the bloodstream and is absorbed by the bones. Areas of rapid bone change, such as those caused by cancer, will absorb more of the material and appear ‘hotter’ on the scan.
- PET Scans: Positron emission tomography (PET) scans can help determine if prostate cancer has spread and where. Recently, a PET scan with a tracer called gallium-68 PSMA-11 has been approved for detecting prostate cancer spread in certain situations (Fendler W.P. et al., 2021).
- MRI: An MRI can provide detailed images of the prostate and surrounding tissues, helping determine whether the cancer is still confined to the prostate or has spread to nearby tissues. MRI might also be used to guide a biopsy if earlier biopsy results were inconclusive or if cancer appears to be of a higher grade.
How Advanced Procedures Aid in Determining Cancer Spread
These advanced diagnostic procedures, each with its strengths and limitations, work together to give a clearer picture of the cancer’s extent. They provide critical information about whether the cancer is still localized to the prostate, has spread to nearby tissues or lymph nodes (locally advanced), or has reached other body parts (metastasized). This information, in turn, directly influences the recommended treatment strategy.
Navigating these advanced diagnostic procedures can be a challenging part of the prostate cancer journey. If you’ve undergone any of these tests, consider sharing your experiences in the comments below. Your insights could help others prepare for their own diagnostic journeys.
Importance of Second Opinions and Top Clinics for Prostate Cancer Diagnosis
In the complex world of prostate cancer diagnosis, obtaining a second opinion is often a wise choice. It can help ensure your diagnosis is accurate and you have all the information you need to make informed treatment decisions.
The Importance of a Second Opinion
- Confirmation of Diagnosis: Prostate cancer diagnosis involves several elements, including PSA levels, DRE findings, imaging results, and biopsy pathology. A second opinion can confirm these results or reveal additional factors.
- Exploring Treatment Options: Prostate cancer treatment is not one-size-fits-all. Doctors may have varying opinions on the best course of action based on their experience and understanding of recent research.
- Peace of Mind: A second opinion can provide additional confidence in your diagnosis and treatment plan, reducing anxiety and facilitating informed decision-making.
Approaching Another Doctor for a Second Opinion
When seeking a second opinion, be open and honest about your intentions with both your current and prospective doctors. Bring all relevant medical records, including lab and imaging results. Be prepared with questions, and don’t hesitate to ask them.
Notable Clinics for Prostate Cancer Diagnosis and Second Opinions
Several clinics in the United States are renowned for their expertise in diagnosing and treating prostate cancer. These include:
- Mayo Clinic: Mayo Clinic is known for its comprehensive, personalized approach to patient care and has a dedicated Prostate Cancer Clinic (Mayo Clinic, 2021).
- Johns Hopkins Hospital: Johns Hopkins is a leader in prostate cancer research and treatment, offering a multidisciplinary Prostate Cancer Program (Johns Hopkins Medicine, 2021).
- Cleveland Clinic: Cleveland Clinic’s Glickman Urological & Kidney Institute is top-ranked in the U.S. for urology and has a specialized team for prostate cancer (Cleveland Clinic, 2021).
- MD Anderson Cancer Center: As one of the world’s most respected centers for cancer care, MD Anderson has a specialized Genitourinary Cancer Center with an expert team dedicated to prostate cancer (MD Anderson Cancer Center, 2021).
- Memorial Sloan Kettering Cancer Center: This New York-based institution is one of the world’s leading cancer centers, featuring a distinguished team of prostate cancer experts in their Urology Service (Memorial Sloan Kettering, 2021).
- Dana-Farber Cancer Institute: In collaboration with Brigham and Women’s Hospital, Dana-Farber offers an advanced prostate cancer clinic that provides comprehensive care, from diagnosis to treatment (Dana-Farber Cancer Institute, 2021).
Remember, when seeking a second opinion, it’s essential to consider the team’s expertise, their prostate cancer experience, and the location’s convenience for you. Would you like to share your experience or the factors you considered when seeking a second opinion? Share your thoughts in the comments below.
What to Expect After a Prostate Cancer Diagnosis
A prostate cancer diagnosis begins a journey of treatment decisions. You’ll discuss your Gleason score, PSA level, cancer stage, and overall health and personal preferences with your healthcare team. These factors will guide your treatment plan, including active surveillance, surgery, radiation therapy, hormone therapy, chemotherapy, or a combination.
Also, anticipate follow-up tests, regular doctor visits, and lifestyle changes to manage side effects and maintain your overall health. Remember that seeking mental health support is okay to cope with any emotional stress associated with your diagnosis.
The Importance of a Support System and Coping Strategies
A robust support system is invaluable during this journey. This can include friends, family, healthcare providers, or support groups. Many men find that speaking with others through a similar experience provides comfort and practical advice.
Coping strategies such as maintaining a healthy diet, regular exercise, relaxation techniques, and staying socially active can also be beneficial. Don’t hesitate to seek help from mental health professionals if you’re struggling with anxiety, depression, or other emotional challenges.
Remember, it’s crucial to understand your options, ask questions, and make informed decisions after diagnosis. It’s your journey and at your pace. Have you navigated this path and have insights to share? Please leave your thoughts in the comments below.
Conclusion: A Proactive Journey Towards Health
Navigating the path of a prostate cancer diagnosis might seem daunting, but understanding the steps can make it more manageable. This journey starts with initial screening tests—PSA blood test and DRE—then, depending on results and risk factors, may progress to a prostate biopsy. The biopsy results, specifically the Gleason score, help assess the aggressiveness of the cancer.
Further diagnostic procedures, such as imaging tests, may be necessary to understand the extent of cancer spread. Seeking a second opinion can be invaluable at all stages, as it ensures the accuracy of your diagnosis and keeps you well-informed about treatment options.
Ultimately, the journey underscores the importance of early detection and accurate diagnosis in successfully managing prostate cancer. It’s a reminder for all men to be proactive in their healthcare: to regularly schedule screenings, follow up on any unusual symptoms, and engage in open, informative discussions with their healthcare providers.
The path to diagnosis may have its challenges, but remember, you’re not alone. Whether it’s the shared knowledge of the medical community, the support of loved ones, or the experiences of those who have walked this path before, resources abound to help navigate your journey.
Your experience can, in turn, illuminate the path for others. Do you have insights, thoughts, or questions about your diagnostic journey? Please share them in the comments below.
- Cleveland Clinic. (2021). Prostate Cancer: Diagnosis and Tests.
- Dana-Farber Cancer Institute. (2021). Prostate Cancer Treatment Center.
- Fendler, W.P., et al. (2021). “68Ga-PSMA-11 PET/CT in Prostate Cancer Patients.” The New England Journal of Medicine.
- Johns Hopkins Medicine. (2021). Prostate Cancer Program.
- Mayo Clinic. (2021). Prostate Cancer Clinic.
- MD Anderson Cancer Center. (2021). Prostate Cancer.
- Memorial Sloan Kettering. (2021). Prostate Cancer: Diagnosis & Treatment.
- The American Cancer Society. (2021). How Prostate Cancer is Diagnosed.