Okay men, admit it. You’re not excited to schedule a prostate cancer screening. First off, you’re half as likely as women to even go to the doctor within a two-year period, according to the CDC. Add in anxiety over what a test will feel like, and what it might find out, and the number of men seeking screening decreases.
Here’s the important takeaway, though: prostate cancer screenings are easy. And they can potentially save your life.
What is the prostate, anyway?
Before discussing screening, it helps to get a baseline on what the prostate is and does. The prostate is a gland about the size of a large walnut (when not cancerous), says the National Cancer Institute. It is located inside a man’s body at the very base of the urethra – the thin tube through which urine passes out of the penis. Its role? To create fluid that mixes with sperm cells from the testicles to make semen. The prostate muscles also are responsible for ejaculation – forcefully releasing semen through the urethra, required for fertilization/reproduction.
Is prostate cancer a big risk for men?
Prostate cancer is the second most common cancer diagnosed in men, according to the American Cancer Society. About 174,650 new cases of prostate cancer will be diagnosed in 2019. That’s the equivalent of one in nine men. Approximately 31,620 men will die this year from prostate cancer.
Prostate cancer develops mainly in older men and in African-American men. About 6 cases in 10 are diagnosed in men aged 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 66.
The disease is largely survivable – if it’s caught early through screening.
What is a PSA test?
PSA is an acronym for prostate-specific antigen, a protein created by the prostate gland. PSA plays a role in creating semen. Most PSA is discharged during ejaculation, and a tiny amount is always circulating in a healthy bloodstream, according to the National Cancer Institute.
The PSA screening test is a simple blood test to measure whether the amount of PSA in a man’s blood is average for his age and health, high or low. PSA levels are typically less than four nanograms per milliliter (ng/mL) of blood in healthy men.
The presence of cancer in the prostate is one possible reason for a high PSA level. Cancer of the prostate causes the body’s natural PSA removal systems to be less efficient, and for PSA levels to rise. However, other causes can also increase PSA in the blood, such as an enlarged prostate.
That’s why the PSA test must be combined with other tests to determine if a man has prostate cancer or not.
The dreaded DRE (Digital Rectal Exam)
No exam is perhaps less loved by men as the Digital Rectal Exam (DRE). But in reality, the hype is way worse than the actuality. According to the American Society of Clinical Oncology (ASCO) your primary can physician can perform the DRE during a routine physical. A DRE might be briefly uncomfortable but is rarely painful. If your doctor finds an abnormality, he or she will run further diagnostic tests.
“The DRE takes less than a few minutes. It allows a doctor to feel for any abnormal growths around the prostate,” says Dr. Bruno Nahar, a urologist with Sylvester Comprehensive Cancer Center. “It is part of the available tests for prostate cancer. A DRE is important as one of the first steps in the prostate cancer screening process.”
Additional tests if cancer is suspected
Over the past 15 years, much debate has occurred in the medical profession about the value of the PSA test, due to its inexact nature. Most physicians agree it remains a valuable part of the prostate cancer screening and diagnosis “kit” for doctors. If a PSA test shows consistently above normal levels, the next steps might include taking a urine sample and a blood sample to screen for molecular biomarkers of prostate cancer.
MRI is becoming a popular tool to evaluate for any suspicious lesion in the prostate. More importantly, urologists can use the MRI to guide a prostate biopsy, if a suspicious lesion is detected.
The best way to determine if cancer is present is to undergo a biopsy. A biopsy is a procedure to remove a tiny sample of the prostate. Cells from the tissue sample then are studied under advanced microscopes. Cancer cells can be detected, as well as the type of prostate cancer cell (aggressive, slow-growing, etc.).
To biopsy or not biopsy: decreasing unnecessary surgeries
While a biopsy is the gold standard for detecting cancer, it’s also a surgical procedure. So it is invasive and also can cause side effects.
“Biopsies might find cancer. But most prostate cancers found are slow-growing, and might not cause any negative symptoms for a man before his natural death,” says Dr. Nahar.
Far too many men are then rushed into surgery to remove the prostate (called a prostatectomy), which could cause more problems than it solves for low-risk prostate cancers, he says. The side effects of even the most accurate prostate cancer removals (whether open surgeries or robotic-assisted surgeries) can include temporary or long-term incontinence (inability to control urine flow); temporary or longer-term inability to have or maintain an erection; and/or complications of surgery.
Improved options for screening
Prostate cancer risk “calculators,” or risk prediction models, are used to help reduce unnecessary surgeries and procedures. A doctor enters data, such as family history, test results, age, race, prior biopsy findings, tumor markers, ultrasound and imaging test results.
“The strategy is to reserve biopsies, and treatment, for the men who are at the highest risk for aggressive prostate cancers,” says Dr. Nahar. “Aggressive cancer cells more easily grow and spread to other parts of the body.”
He says that slow-growing prostate cancers can often be watched through routine check-ups (called active surveillance) and monitored with non-invasive tests. If one eventually begins to show signs of growing or spreading, the decision can then be made to operate and remove the prostate gland.
“If you have a very low-risk prostate cancer, and go to your routine follow-up screenings, your risk of dying of the disease in 10 to 15 years is extremely low. Surgery in such a case would be an unwise choice,” says Dr. Nahar. “We have many biomarker tests such as 4Kscore, phi, pca3, and also MRI that can help urologist to decide whether a biopsy is needed.”
When to start screening
Not all men whose prostate cancer is detected through screening require immediate treatment. But your doctor may run periodic blood tests and prostate biopsies to determine the need for future treatment.
The American Urological Association strongly recommends shared decision-making with a physician for men 55 to 69 years of age. However, PSA screening is not recommended for men 70 years old and older, or for any man with a life expectancy remaining of under 10 to 15 years. That’s because prostate cancer cells are extremely slow-growing. Older men with prostate cancer largely outlive the disease and die of other causes.
Younger men considered higher risk for prostate cancer should discuss screening with their doctors at an earlier age--typically starting at age 45. This includes men with a first-degree relative who had advanced prostate cancer at diagnosis, developed metastatic prostate cancer, or died of prostate cancer. This also applies to African American men even without a prostate cancer family history.
Regardless of race, if your first-degree relative had prostate cancer at an early age, begin talking to your doctor about the pros and cons of screening at age 40.
John Senall is a contributing writer for UMiami Health News. He is a former hospital and comprehensive cancer center communications director.