And other questions

Prostate cancer is the most commonly diagnosed cancer in men in the U.S, with over 170,000 men diagnosed with prostate cancer each year. In 2019 alone, it is estimated that there were over 31,000 prostate cancer-related deaths. This means that approximately one out of seven U.S. men will be diagnosed with prostate cancer during their lifetime, and nearly 2.8% of men will die from the disease. Most of us have either heard of someone or known someone who has been diagnosed with prostate cancer. While the numbers may seem daunting, there is also good news. Men can be checked (or screened) for prostate cancer, and diagnostic tests can be ordered. If a man is then diagnosed with prostate cancer, many treatment options may be available. Some common questions (and answers) about screening for prostate cancer follow.

Q: What is the prostate, and what does it do?

A: The prostate is a gland about the size of a chestnut and weighs about 30 grams (about one ounce). It is located inside the body and sits between the bladder and the penis. The urine channel (urethra) runs through the middle of the prostate and carries the urine out of the body. The prostate’s most important function is to produce fluid that makes up part of semen. The rectum is behind the prostate, which makes it possible for the physician to feel the gland from the rectum using his finger.

Q: What are the signs and symptoms of prostate cancer?

A: In its early stages, prostate cancer often produces no symptoms, and men may not notice any signs for many years. However, benign prostatic hyperplasia or enlargement (BPH/BPE) may produce several common symptoms. As men age, they may experience a decrease in their force of stream and taking longer to empty their bladders, both of which may indicate prostate enlargement that may be pinching their urine channel and partially obstructing their flow (similar to low water pressure). It is important to note that an enlarged prostate is not necessarily a cancerous prostate and vice versa. Other signs and symptoms, such as painful or bloody urination or ejaculation, can be associated with prostate cancer and other conditions and should be promptly evaluated by a physician.

Q: What are the typical tests to screen for prostate cancer?

A: The two most common tests are a digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood level. A physician may insert his finger into the patient’s rectum and feel the edge of the prostate where a cancer is most likely to start growing. A smooth, rubbery prostate is less worrisome than one with a hard area or lump. PSA is a substance produced in small amounts by the prostate, but it can increase in certain men with prostate enlargement, infection, inflammation and prostate cancer. While the PSA and DRE combination may identify men at risk for prostate cancer and can prompt additional testing like a prostate biopsy, neither test definitively diagnoses a man with prostate cancer.

Q: Should I be screened for prostate cancer?

A: This is an important question and definitely one to address with your physician. The goals of cancer screening are to detect a potentially lethal cancer at an early stage to offer potentially curative treatments and lower the burden of overall treatment. Screening for prostate cancer has been a controversial topic for the last decade. While it may seem like a good idea to start screening asymptomatic, younger men for prostate cancer, more men may be diagnosed with early-stage cancers. As such, they may undergo treatment earlier in their lives and may be subjected to prolonged side effects worsening their quality of life. On the other hand, delaying screening may have less impact on the immediate quality of life. Still, it may lead to the diagnosis of more advanced cancers later, which may impact lifespan.

Since a man’s decision to screen for prostate cancer is very personal, physicians may invoke a process called “shared decision making.” As opposed to the physician simply recommending certain tests, shared decision-making involves inviting the patient and their families to participate in the discussion and considering their values and preferences. The options are presented, and the risks and benefits are outlined. The physician then assists the patient in evaluating those options, facilitates the decision-making process, and ensures that they follow through on their screening decisions.

The American Urological Association recommends shared decision-making for men ages 55 to 69 years who consider PSA screening and proceeding based on the patients’ values and preferences. A routine screening interval of two years may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. While routine screening in those ages 40 to 54 years at average risk is not recommended, those at higher risk (e.g., African-Americans and men with a first-degree relative with prostate cancer and/or certain breast cancers) should consider beginning PSA screening 40 years of age. Routine PSA screening is not recommended in men over age 70 or any man with less than a 10- to 15-year life expectancy.

Alex Gomelsky, MD, FACS, professor and chairman, Department of Urology; director, female urology, neurourology, and reconstructive pelvic surgery; urology residency program director and holder of the Burdette E. Trichel MD Endowed Professorship in Urology at LSU Health Shreveport.