Prostate Cancer and Separating Fact From Fiction
After skin cancer, prostate cancer is the most commonly diagnosed cancer in men in the United States.
Prostate cancer has varied behavior – it can be slow growing and not affect health or longevity, or it can be aggressive and potentially lethal. This presents a challenge: how do we identify more aggressive types of prostate cancer in a window of curability, while sparing men with slow-growing prostate cancer unnecessary testing and diagnosis? Fortunately, sophisticated tools have emerged to help us better understand which men are at highest risk.
Here are some common questions and answers about prostate cancer to ensure men have the facts, rather than fiction, about this disease.
Should I have prostate cancer screening?
“Screening” is checking men for their risk of cancer before any symptoms arise. This is important for prostate cancer because symptoms typically only appear once a prostate cancer is more advanced. PSA, or “prostate specific antigen,” is the most common screening test for prostate cancer. It is a chemical made by the prostate that is measured through a blood sample. The main limitation of PSA is that it can be elevated for reasons unrelated to cancer, such as prostate enlargement or inflammation. Nonetheless, it is a quick, inexpensive, and useful starting point for discussion. PSA is generally drawn in a primary care provider's office after a discussion of risks and benefits of screening, in light of a man's age, other risk factors, and preferences.
Should you, a friend or a loved one have a screening PSA?
The answer is not simply "yes" or "no." Guidelines from professional societies, including the American Cancer Society, state that men should have discussions with their doctor regarding screening somewhere between ages 40 and 50, depending on their risk factors.
While age is the biggest factor for prostate cancer there are other important risk factors to consider, these include:
- African American descent
- a father or brother with prostate cancer diagnosed before age 65
- multiple relatives with other malignancies
- lifestyle and dietary habits
Men at higher risk should start the conversation sooner, as early as age 40 to 45. Men without risk factors should consider screening starting at age 50.
Men should not be screened into their later years. If a man has an acceptable PSA and lacks other risk factors by age 70 to 75, the evidence suggests that further screening is unlikely to find dangerous cancer, and is more likely to detect a slow growing, age-related cancer that isn't consequential to a man’s health.
What should I do if my PSA is elevated?
Unfortunately, there is no single "cutoff" for a normal PSA. The number will be influenced by age, prostate size, some medications, and other factors. Your doctor can help interpret your PSA in light of your overall risk and decide whether a discussion with a urologist is warranted.
A urologist will review your risk factors and give you options for further testing. The doctor may reassure you that your numbers are acceptable and you can be monitored. Other blood and urine tests may be sent ("biomarkers") that help assess risk more accurately than a PSA. You may be referred for a prostate MRI to look non-invasively at the prostate to determine if your risk is elevated. If there is sufficient concern, a urologist may recommend a prostate biopsy to determine whether cancer is present.
What is a prostate biopsy and does it hurt?
A prostate biopsy is typically an office-based procedure done with local anesthesia, in which a small needle is placed in the prostate to obtain samples of tissue. This is generally done using a combination of images from ultrasound and magnetic resonance imaging (MRI) to target the areas of greatest concern. The procedure can be done across the rectal wall (transrectally) or across the skin behind the scrotum (transperineally). Generally 12 biopsies are taken, with additional biopsies as needed. The procedure is relatively quick, lasting 10 to 15 minutes.
Comfort and safety are prioritized, with generous numbing medication and antibiotics to prevent infection. Most men are pleasantly surprised by its tolerability. It is not uncommon for there to be some blood in the urine, bowel movements, and/or semen afterward, which typically resolve quickly.
Critically, biopsy is reserved for men with the highest risk, for whom the relatively minor risks and discomforts of biopsy are warranted to ensure there is not a greater threat.
If I have prostate cancer, what are my options?
It depends. If a slow growing type of cancer is detected, men are encouraged to pursue "active surveillance," a monitoring approach to avoid unnecessary treatment in the short- and possibly the long-term. If there are signs of aggressiveness, it is recommended that men have a multidisciplinary team of experts from urology, radiation oncology, and possibly medical oncology.
Treatment options may include surgery (typically by a robotic-laparoscopic approach), radiation therapy (various types of external beam radiation therapy or brachytherapy), or others.
Fortunately, there has been tremendous progress in prostate cancer therapies to improve cure rates while preserving quality of life, including urinary and sexual function. Men vary in their preferences for treatment and risk factors for certain side effects, thus a "shared decision-making" approach to educate men on options and guide them to the best treatment is encouraged.
For more information on prostate cancer and treatment, visit our website.
About the Author:
Elias S. Hyams, MD
Dr. Elias Hyams is a board-certified urologist at the Minimally Invasive Urology Institute of The Miriam Hospital.
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