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This is the third step in a series aimed at helping newly diagnosed people understand some of the basics of a complex disease. Our recommendation is that the steps are followed in sequence - the next two steps after this one are SURVIVING : TREATMENT CHOICES. Each of these steps is linked to the next. If you missed the first two steps go here DON'T PANIC : GOOD NEWS!


Before looking at the various aspects of diagnosis, some men may be in the same position I was when I was diagnosed. Up until then I didn't know I had a prostate gland and I certainly didn't know where it was or what it did. Anyone else with this problem should go to PREPARING FOR YOUR JOURNEY before returning here to continue.

It is of utmost importance that you understand your diagnosis and what it means so you can assess status before determining strategy. Many terms used may be foreign to you and the medical people often will not have time to explain them all. Many words have acquired specific meanings that differ from those you may have attached to them in the past. The best example, perhaps, is the use of the words "positive" and "negative." In your usual "pre-cancer" existence, broadly speaking positive = good and negative = bad. These positions are somewhat reversed in the medical world. A positive result to a test is not what you want. A positive result means that there are definite signs of the disease. On the other hand a negative result does not mean you are disease free. There are merely no positive signs. So positive = bad and negative = not positive, not good.

We list below some of the common terms you will come across in the sequence in which you might come across them, as you go through the diagnostic process. As you scroll down the page you will see there is a lot of information. Please take the time to read it all because the more you understand, the better decision you will make when choosing a course of action.


This is the standard test which is used to indicate the possibility of cancer in the prostate. Very severe cases will have a PSA count in the hundreds or even the thousands, but the threshold of concern is generally a reading of 4.0 ng/ml. Some specialists believe a lower figure to be appropriate. You should be aware of the fact that it is NOT cancer specific and that your PSA count can be raised by many things, apart from cancer. About 35% of men over the age of 50 with an elevated PSA will be found to have prostate cancer; about 25% of men who do not have an elevated PSA will also be found to have prostate cancer if biopsied. The most common causes of an elevated PSA reading are DRE (Digital Rectal Examination) which may cause excess PSA to be excreted for a period, BPH (Benign Prostatic Hyperplasia), bladder or prostate infections and sexual activities.

There has been a great deal of discussion about this test and you may well have seen something of these in the media. In May 2012, the US Preventive Service Task Force (USPSTF) made a recommendation that the PSA test should be discussed with men prior to its being given so that there is a clear understanding about the potential value and problems associated with the test. The American Urological Association (AUA) made a similar recommendation. Dr Gerald Chodak has drawn up a draft CONSENT DOCUMENT which he feels helps this process.

I have expanded on this subject in the piece PSA 101 and it may be useful to read that. Men who have had surgery will often use ULTRA-SENSITIVE PSA TESTS, which are also subject to a fair degree of inaccuracy.


Much feared by most men, for no good reason other than embarrassment. Many refuse to even consider it. Most women cannot understand what the fuss is about. It is a simple procedure and there is no discomfort when it is done well - and if the man is relaxed. The examination does not take very long - usually less than 30 seconds.

Because the prostate gland is so well hidden, the only way it can be physically examined by your doctor is via the rectum. If you have an understanding of where the prostate is located, it is pretty obvious that this is the only way it can be reached. The doctor inserts a finger to feel the prostate - trying to establish whether there is anything unusual about the gland: a firmness or softness perhaps, or nodules, or roughness on the surface. A biopsy may well be ordered if the DRE reveals any abnormal features even if there is no elevated PSA.

Before the widespread use of PSA tests, the DRE was virtually the only way in which prostate cancer was diagnosed, unless there were symptoms. This method of diagnosis is not very accurate because of the limits imposed by the examination. For one thing the doctor can only feel one side of the gland; for another, the examining finger is clad in a surgical glove. Despite these limitations an annual examination after the age of 40 or 50 should include a DRE because there is a rare form of prostate cancer that generates very low amounts of PSA but which may be detected by DRE.


This is a non-cancerous condition of the prostate gland. It results in the growth of both glandular and connective tissue. This enlarges the prostate and causes obstruction to the urine stream. The symptoms are slowing of the stream, needing to urinate frequently, especially during the night and an urgency to urinate. It is a benign growth that is present to some degree in most men over 50 years of age. BPH and urinary tract infections are the most common cause of an elevated PSA result. BPH is commonly treated by medication, although this may be less successful than a TURP (Transurethral Resection Of The Prostate) or a similar procedure.

There is a technique which may be helpful for men with BPH in helping to drain the bladder. As the illustration above shows, the urethral tract which drains the bladder sweeps down to the perineum (the area between the anus and the scrotum) and runs along it until it exits through the penis. This tract is usually close to the surface of the perineum. Massaging this area can help in draining the bladder and relieving some of the annoying symptoms.


If BHP (see above description) is serious enough, it can cause the prostate to restrict the flow of the urine. TURP is usually a minor surgical procedure whereby an instrument called a resectoscope is inserted into the penis to relieve the pressure of the prostate on the urethra. There are, however, variations on this procedure, using heat, termed TUNA (TRANSURETHRAL NEEDLE ABLATION) OR TUMT (TRANSURETHRAL MICROWAVE THERMOTHERAPY) and lasers PVP (Photoselective Vaporisation of the Prostate) or LASER GREENLIGHT™ to achieve the same result.

Although late stage prostate cancer can produce similar symptoms to BPH, the TURP procedure cannot be used to remove the prostate cancer.


A biopsy involves taking very small specimens of prostate tissue with very fine needles for microscopic examination in a laboratory. The prostate is well hidden so it is difficult to take specimens. In the early days of the post-PSA era the standard needle biopsy saw the use of six spring-loaded needles, but twelve is a more common number now - some doctors use more. In some cases a 'saturation' biopsy is used which involves 50 or more needles. You should ensure that a saturation biopsy is essential and will serve a valuable purpose before agreeing to this.

The needles are usually shot into the prostate via the rectum. More rarely, and for saturation biopsy procedures, they are aimed though the perineum - the area between testicles and anus. For most men the normal procedure sounds worse than it is. For them it is rather like getting a hard kick in the backside each time a needle goes in. For some reason pain relief is rarely offered, yet a significant number of men suffer considerable pain. It is wise to ask for pain relief rather than to wait to find out into which category you fit.

The most common side effects of the procedure are that urine and semen are usually blood stained for some time afterwards. Just how long is variable. It usually clears up within a few days but may continue longer - up to six weeks in some cases. There can be other more serious side effects but they are rarely reported.

Many men are concerned that biopsy procedures may cause the cancer, if there is any within the gland, to spread beyond the gland. There is no good evidence that this will occur, although there are some small studies that suggest it may be so. Since there are literally hundreds of thousands of biopsy procedures carried out each year, if the disease were spread by the procedures, there would be the expectation that the number of cases of advanced cancer would soar. This has not happened.

You should ask the doctor, before the procedure if the specimens will be well labeled - showing where they come from in the prostate. This is not done in all cases and can reduce the knowledge required for a good decision on the best treatment.





The biopsy samples are examined in a pathology laboratory. The pathologist or technician will be looking for groups of abnormal cells - cells that have lost their natural shape and have created unusual glandular patterns. The first (prime) focus is on the abnormal patterns making up more than 50% of the sample. The second (secondary) and third (tertiary) foci are on abnormal glandular patterns that make up less than 50% of the sample. Not all abnormalities are identified as cancer - there are at least four conditions that can be confused with adenocarcinoma, the most common form of prostate cancer. Reference is also sometimes made to 'atypical' cells. This merely means that they are not normal, but does not necessarily mean they are cancerous.

HGPIN - High Grade Prostatic Intraepithelial Neoplasia: is described as a pre-cancerous change to the cells of the prostate, which resemble adenocarcinoma in a number of structural changes. It is called 'pre-cancerous' or 'pre-malignant' because there are studies that show a correlation between HGPIN in an initial diagnosis and prostate cancer in a subsequent diagnosis. Although most pathologists recognize the association between HGPIN and prostate cancer, they do not all agree that every HGPIN lesion is necessarily pre-malignant. A study published in May 2013 concluded HG-PIN ALONE SHOULD NOT BE AN INDICATION FOR FURTHER BIOPSIES IN THE PSA ERA in the PSA era. There is another condition, discussed less often than HGPIN which is termed ASAP - Atypical Small Acinar Proliferation. Neither HGPIN nor ASAP can metastasize. It is important for pathologists to distinguish between these conditions and prostate cancer in their reports. Inexperienced pathologists may not identify them properly. To read more go to PRECANCEROUS LESIONS OF THE PROSTATE

Adenocarcinoma: is used to describe epithelial tissue in a gland that has become malignant. It is identified in a pathology laboratory and given the name of the tissue affected. e.g. the prostate gland tumor gets the name 'prostate adenocarcinoma', because its cells resemble the cells of the prostate.

Prostate Cancer. Frequently referred to as PCa, PC or CaP. As those who have been following the steps recommended in this part of the site - going from DON'T PANIC through SOME GOOD NEWS! to here - will be aware, there are many varieties of prostate cancer. Most are a slow growing cancer and there is usually an ample amount of time to research available options. No one diagnosed with PCa should have to undertake treatment until they understand what the treatment involves and what the outcomes and side effects of the treatment will be. One of the RECOGNIZED EXPERT PATHOLOGISTS is Dr. Jonathan Oppenheimer who has this to say:

For the vast majority of men with a recent diagnosis of prostate cancer the most important question is not what treatment is needed, but whether any treatment at all is required. Active surveillance is the logical choice for most men (and the families that love them) to make.


If prostate cancer cells are discovered in the biopsy material, they are evaluated using a scale known as the Gleason Grade (GG) which was established in the 1960s and which had five grades. As explained above, the pathologist or technician would look for the patterns in first (prime) focus making up more than 50% of the sample of the cancerous material. Patterns that were well differentiated, but abnormal, were graded as 1; at the other end of the scale, poorly differentiated patterns were graded as 5. Healthy glandular tissue is well differentiated, so a Gleason Grade of 5 is "bad" news: a Grade of 1 is "good" news. A similar approach is applied to the second (secondary) focus with abnormal glandular patterns making up less than 50% of the sample. No attention was paid to a third (tertiary) focus initially

After each focus was graded, the primary and secondary Gleason Grades are added together to establish a Gleason Score (GS). The Gleason Score therefore was a scale that ran from 2 (1+1=2= "good") to 10 (5+5=10=("bad"). Typical examples of Gleason Scores would be shown as GS 3+2=5 or GS 3+3=6. These were the most common scores until the end of the last century. A Score of 6 was the midpoint in the overall scale. It is important to note the difference between a Gleason Grade and a Gleason Score (which is the sum of the Grades.)

Since the advent of PSA testing in 1987 there has been a gradual change in the interpretation of Gleason Grades starting in 2005. The changes were formally recognized in January 2010.

Grades 1 and 2 are no longer labeled as adenocarcinoma or cancer in material obtained through a needle biopsy.

It is recommended that some material that was previously graded as Grade 2 should now be graded as Grade 3 and some material previously graded as Grade 3 should now be graded as Grade 4. This means that from the time the changes were made a Gleason Score of 6 (3+3) is the entry level for a positive diagnosis. Previously it was the midpoint on the overall scale.

Some tunors with a Gleason Score of 5(3+2) previously will now have a Gleason Score of 6 (3+3): some which had a Gleason Score of 6 previously will now have a Gleason Score of 7.

Since some of the new Gleason Score 7 tumors will have an outcome more similar to Gleason Score 6 tumors, a some distinction is made between a Gleason Score of 7a (3+4) and 7b (4+3).

These changes make some comparisons between current studies and old studies more difficult.

The Gleason Score is a critical item that drives much of the decision making process. Grading biopsy samples is a subjective process. Numerous studies show that agreement on Gleason Scores will only occur in about 35% of cases, with roughly equal Scores higher and lower than the original Score. It is very important to get a second opinion on the material from any biopsy procedure from a RECOGNIZED EXPERT before making any final decision on treatment.

For more detailed information go to GLEASON GRADES. BOB PARSONS wrote an excellent piece analysing his biopsy slides and including some good images of them. Although I labeled it BOB PARSONS' PATHOLOGY 101 it may be a little advanced for a newly diagnosed man.


The final part of an initial diagnosis is to stage the disease. This describes the estimated extent of the cancer or the degree to which it has progressed. The old system had four stages - ABCD to describe the progress of the disease but the currently recommended system is known as the TNM system. The details can be read at this link STAGING SYSTEM. The main features are:

T refers to the estimate of the amount of tumor within the prostate. There are four main T stages each with three subsets. The most common staging is T1c which means there is a tumor present, found in a needle biopsy performed due to an elevated serum PSA but not detectable clinically or with imaging. A T2 staging is the next most common and would refer to a tumor associated with a positive DRE. T2 tumors are thought to be contained within the prostate gland.

N refers to the status of the lymph nodes near to the prostate - whether the prostate cancer has spread there or not. It is unusual to see any N status other than NX - cannot evaluate the regional lymph nodes.

M indicates if the disease has metastasized. As the tumor grows within the prostate it may start to spread beyond the prostate gland and capsule to more distant parts of the body. The cancer sites away from the prostate are called metastasized sites - sometimes referred to as secondaries or more commonly 'mets'. The most common M stage is MX - cannot evaluate distant metastasis.

The result of the staging is a formula such as cT2aN0MX. This would indicate a tumor in half or less than half of one of the prostate gland's two lobes with no sign of spread to the lymph nodes and an inability to ascertain the presence or absence of any metastasis.

The initial staging is known as the clinical stage and is signified by the letter c in front of the formula mentioned above - the most common staging being cT1cNXMX or cT1cN0M0. This means that on initial examination the tumor is not detectable clinically or with imaging and there is no evidence of spread beyond the gland.

If the gland is removed in surgery, another pathology report is prepared. The pathological staging is usually different to the clinical staging and is prefixed by the letter p. There may be significant changes in the staging which is one of the main reasons for having surgery. A clearer picture is obtained. The pathological staging for example might go to pT2cN1M0 - the tumor is in both lobes; there has been spread to the regional lymph nodes; there is no distant metastasis.

It is important to understand the difference between clinical and pathological staging if any of the various tools - such as the Partin Tables mentioned below - are used to try to estimate outcomes. The data in those tables is usually based on clinical staging. After an initial diagnosis is made, a number of further tests and scans may be ordered. The data from the diagnosis may also be used in the various calculators or nomograms that have been developed to try and predict the outcome of the diagnosis or treatment options.


After an initial diagnosis is made, a number of further tests and scans may be ordered. The data from the diagnosis may also be used in the various calculators or nomograms that have been developed to try and predict the outcome of the diagnosis or treatment options.


Scans are done in order to try to establish what, if any, spread there is into or beyond the prostate capsule. The benefit of some of these scans is doubtful in many cases. Some leading practitioners consider the automatic ordering of CAT and bone scans, which occurs frequently, as a waste of money. Their necessity should be established before the scans are undertaken.

The Partin Tables (described further on) can help in making this decision. The chances of there being metastases to the bone are remote with a small volume, low-grade (Gleason Grade 6) tumor However, there is a high correlation between high Gleason Grades (8 and above), a large tumor and the extent the disease has moved beyond the gland. According to one leading authority there is virtually no possibility of metastasis occurring until the tumor reaches a critical volume of about 12 cc. The average prostate gland has a volume of about 25 gm, so in this view about half the gland would be occupied by cancer cells before metastasis occurred. In such a case there would usually be a positive DRE (Digital Rectal Examination) and a palpable mass. A leading expert has also expressed the view that metastasis will not occur if the PSA is less than 50 ng/ml, unless the Gleason Score is very high - greater than 8.


It was standard practice to order X-rays as a matter of course on diagnosis. However, the chances of any signs of spread being shown, using X-rays alone, are slim. Since it is more usual to run other scans, there is little point in having an X-ray. Many people strongly believe in avoiding any unnecessary exposure to X-ray to minimize the chance of cell damage.


Although these two scans CT/CAT (Computer Axial Tomography) and MRI (Magnetic Resonance Imaging) use differing technology, they are similar in the the sort of output they produce. Both create a series of images, in effect showing views of the organ being examined in "slices". The CAT scan uses X-rays to create the images. The MRI scan uses a very strong magnetic field for this purpose. The MRI images can be enhanced by the use of an endorectal coil. This is a small device inserted into the rectum, which generates secondary fields.

Both examinations can be a little intimidating for those having them for the first time. The person being scanned lies on a small trolley, which enables them to be moved into a large cylindrical structure containing the scanning machinery. There is very little room in the older cylinders, especially for larger men, and a feeling of claustrophobia can result. Newer machinery has more room. The MRI process is noisy and operators should provide earplugs or headphones. Most men do not have signficant pain from either procedure - just a degree of discomfort from remaining immobilized during the scan, and the noise - but this is not always the case.

Some experts feel that CAT scans are only of value in the diagnostic process of advanced prostate cancer, which is usually associated with PSA readings of 50 ng/ml or higher and Gleason Scores greater than 8. CAT scans are highly insensitive in detecting disease in the lymph nodes, and valueless in most patients in detecting penetration of the capsule, which is usually the first stage of progression of the disease. MRI scans with the endorectal coil can be much more useful but even then will only be associated with an accuracy rate of between 75% and 90%. Both types of scan have high false positive and false negative results. In other words they will identify tumors which don't exist or miss ones which do exist.

There are several other scans in use. Two for which claims are made of greater accuracy are the COLOR-DOPPLER and the Ferraheme. The former is not available in many institutions. It combines two forms of scan - Ultra Sound and MRI to produce an image that, it is claimed, show a more precise picture of any areas likely to contain cancer cells. The two best known practitioners being Duke Bahn at Community Memorial Hospital, Ventura, California and Fred Lee at Crittenton Hospital Medical Center, Rochester, Michigan who can be seen talking in THIS VIDEO. Ferraheme has yet to be approved by the FDA and is based on the COMBIDEX scan. The manufacturers of Combidex could not get FDA approval in the United States and production of the scan has ceased. The Ferraheme scan is used, still in an experimental mode, at SAND LAKE IMAGING in Florida.


Bone scans fall under the general term of nuclear medicine. The way in which these scans work is the reverse of a CAT scan or an X-ray. In those examinations, the radiation is sent out of a machine through the patient's body. Nuclear medicine examinations, however, use the opposite approach. A radioactive material is introduced into the patient's body (usually by injection), and is then detected by a machine called a gamma camera in the case of the bone scan.

The procedure for a bone scan involves nuclear material injected into a vein (usually in the arm). There is a wait of two to three hours for the material to circulate in the system. The person being examined then lies on a special table and the gamma cameras (one above and one below) slowly track down the length of the body. The entire procedure takes between 30 and 60 minutes. Bone metastases are usually associated with advanced prostate cancer, so bone scans are not considered essential for early stage disease. For men with a PSA of less than 10 and a Gleason Grade of 6 or less, the chances of the disease having metastasized to the bone has been estimated at less than 1% - which is equivalent to zero in medical terms.

Some people are concerned about the introduction of nuclear material into the body, but it is said that the radiation from this procedure is similar to that from a normal X-ray. The material is quickly cleared from the body. There is nothing painful about the procedure - apart from the injection, but having to remain motionless for the time of the scan can be a little uncomfortable.


A PET (Positron Emission Tomography) scan is also a nuclear medicine imaging test in which a small amount of liquid radioactive material is injected into your body. It is claimed that they can identify soft tissue metastases more accurately than other scans. PET scanners are now commonly combined with computed tomography (CT) scanners, called PET-CT scanners.

As is the case with the bone scan you will have to wait for about 90 minutes after the liquid radioactive material is injected. It may be necessary to drink some contrast material that moves through the stomach and bowel and helps to improve the interpretation of the scan. Occasionally, depending on the medical indication a catheter may be placed into your bladder to help improve image quality. Positioned on the PET scanning bed, it is important to remain as still as possible during the scan as movement can result in reduced image quality and the images may be blurry.

If you are having a PET-CT, the CT scan is performed first and takes less than 2 minutes. The PET scan takes approximately 30 minutes but the time will vary depending on the regions of your body being scanned.


There are two other tests that have been used in the past but which are often ignored now and one new test. Whilst none of these tests is definitive, all can give a little added information to help in the process of assessing status before determining strategy. The older tests are the DNA ploidy and PAP (Prostatic Acid Phosphatase) tests; the newer one is the PCA3 test.


The PROGENSA PCA3 assay is a urine based test that identifies the level of a genetic component that is often present in prostate cancer. It was approved by the FDA (Food and Drug Administration) in the United States in February 2012 and has been in use in Europe for some time. The primary use of the assay is to assist in the identification of cases where a biopsy procedure is justified because of an elevated PSA or where an elevated PSA has resulted in a negative biopsy. Because the PCA3 assay result is said to be unaffected by BPH (Benign Prostate Hyperplasia) cells, it is claimed that when used in conjunction with PSA tests, it may give a better indication as to whether prostate cancer is present despite negative biopsy results. The assay should not be used for men with atypical small acinar proliferation (ASAP) on their most recent biopsy.

One of the drawbacks to the use of the assay is that there is a requirement that the prostate gland be "massaged vigorously" in order to get a viable result. There may be physical problems in achieving this and it may be difficult to have a consistent understanding of the term 'vigorous'.The clinical study of the PCA3 assay upon which FDA approval was given only included men who were recommended for repeat biopsy. Therefore, the performance of the assay has not been established in men for whom a repeat biopsy was not already recommended.


DNA ploidy is another test that may indicate the potential aggressiveness of a tumor and its likely responsiveness to androgen deprivation therapies. Ploidy is a term used to describe the chromosome content of the cell population of a tumor. Diploid cells have normal chromosome pairs and normal DNA. They tend to grow slowly and respond well to hormone therapy. Aneuploid cells have abnormal numbers of sets of chromosomes. They tend to be more aggressive and not to respond as well to hormone therapy. Aneuploid tumors are more often associated with high Gleason score prostate cancer (8-10) and non-organ confined prostate cancer. The ploidy test may not be done by all laboratories, but is done by Bostwick, one of the laboratories recognized as being a RECOGNIZED EXPERT PATHOLOGIST.


The PAP (Prostatic Acid Phosphatase) test is a blood test that may be an indicator of early metastasis (spread of the cancer) although only 75% of patients with metastases have an elevated PAP. Few doctors seem to be aware of the potential value of the test and may dismiss PAP as having been replaced by PSA as a prostate cancer indicator. Like many other tests, it may be worth tracking PAP results over time. Persistently elevated levels - 3.0 or higher - are cause for further investigation and may indicate that surgery is not the best option.


There are tables and nomograms that are used to try to calculate the likelihood of the spread of PC out of the capsule of the prostate using your PSA, Gleason Ratings and Staging. Although they look complicated at first, they are understandable with a bit of patience. As part of your to gain a better understanding of your condition you should do your best to do this. The PARTIN TABLES prepared by the Brady Urological Institute was one of the first calculators and gives a very good explanation. It allows you to make your own calculation of the probabilities. To do this you will need your clinical staging, your PSA and your Gleason Score. Other calculators are listed on the PALPABLE PROSTATE site. Some of these are more complex than the Partin Tables and need more information concerning your diagnosis.


We have only listed some of the most common terms. There are many comprehensive Glossaries on the Internet giving many more of the terms used. Here are two good ones:


The process of diagnosis can be a frightening and stressful experience for most. Tests are ordered, often without any apparent reason or explanation; results are given in language that is difficult to interpret or understand; and all the time the fear grows. Hopefully, this section will take some of that fear away. There is also often a feeling that time is limited, that a decision regarding treatment must be made very soon after diagnosis. For the vast majority of men the window of opportunity for successful treatment is a wide one and decision-making may safely take many months.


There are three basic but important facts about all medical tests:


The first important fact - No test is 100% accurate. Diagnosis is not an exact science.

The degree of error can vary considerably, depending on the complexity of the test - and some tests are very complex indeed. Sophisticated machinery is used for some - the maintenance of the machinery can alter the result. Chemicals are used in other tests - the use-by date or source of these chemical agents can alter results. Technicians run the tests - their training can alter results. The outcome of all tests needs to be interpreted by a specialist - their expertise can vary. All this adds up to a degree of uncertainty and explains why it is very important to have all results checked by the most knowledgeable person available - and why second opinions should be sought automatically.


The second important fact - The value of many of the medical tests lies in measuring the change in the results, not in the results themselves.

The most obvious example is the PSA test. It is important to measure the size and speed of any change, since this gives an indication of the aggressiveness of the disease. To get this measurement it is necessary to have a series of tests at regular intervals. This may mean delaying the start of treatment but the information is invaluable. This same concept applies to other tests.


The third important fact - mistakes can be made.

The medical world does not differ from any other place. Human beings run it and they can make mistakes. Get copies of all test results - ensure they are yours. If an unusual result does not relate to other results, have a re-test in case a mistake has been made, before taking immediate action.

When you go to the next step you will see what we believe are actions you need to take to enhance your chances of survival.