Prostate Cancer - Screening Saves Lives

The American Cancer Society estimates that prostate cancer is going to affect approximately 165,000 men in the US in 2018. About 30,000 men will die from prostate cancer. It is estimated that about 1 in 9 men will be diagnosed with prostate cancer during their lifetime.

What is the prostate and how does it work?

The prostate is a walnut-sized organ that is located deep in the pelvis and adjacent to the bladder and rectum. The urethra, the tube that carries urine from the bladder, passes through the prostate gland. The seminal vesicles are a set of organs that, along with the prostate, contribute to the male reproductive system. The role of the prostate and seminal vesicles is to contribute fluid to the semen. Sperm moves from the testicles through the vas deferens and gets deposited in the urethra along with fluid from the prostate and seminal vesicles. This combination of fluids comprises the ejaculate.

How is prostate cancer detected?

Prostate cancer screening consists of a blood test called the prostate specific antigen, or PSA, and a digital rectal exam, or DRE. The American Urological Association recommends PSA screening in men ages 55 to 69 years after a thorough discussion with their physician regarding risks and benefits of screening. Men at increased risk of prostate cancer, such as those with a family history or of African American race may be screened between age 40 to 54. Also, men older than 69 with a greater than 10-year life expectancy may benefit from screening.

What are the signs and symptoms of prostate cancer? 

Prostate cancer is often asymptomatic, especially in its early stages. It is therefore known as the “silent killer”. Occasionally, patients may experience urinary symptoms such as urinary urgency and frequency if the prostate is enlarged but this is not specific to prostate cancer.

How is screening performed?

Screening is encouraged in men of the following demographic:

• Ages 55-69
• African American
• Family history of prostate cancer

Screening may be performed earlier if there are risk factors and you should discuss this with your urologist. Screening consists of a blood test known as prostate-specific antigen (PSA) and a digital rectal exam (DRE). The PSA test may be elevated due to several reasons including infection or inflammation and prostate cancer. This number should be interpreted by your urologist, who may recommend further investigation into the reason of the elevation. The DRE is performed to palpate the shape, thickness, and contour of the prostate. Abnormal shape, symmetry, or nodules may prompt further investigation.

What can be done about an abnormal screening exam?

Your urologist will discuss any abnormal results with you to determine a jointly formed plan. This may consist of repeat lab work, a prostate biopsy, close surveillance, or a combination of approaches. For instance, your demographic information and exam results may be compared to population data to determine the percentage risk that prostate cancer may be detected on a biopsy. Other tests such as the 4K Score may help guide the decision for a biopsy as well. Once the risks and benefits of a biopsy are discussed, a jointly formed plan can be developed between you and your urologist.

What does a prostate biopsy entail?

Generally speaking, a biopsy is a procedure where tissue is taken from your body and looked at under the microscope to determine if any abnormalities such as cancer exist. A prostate biopsy is generally a 10-15-minute procedure. You may be given an antibiotic by your doctor prior to the procedure to help prevent any infections. An ultrasound device is used to locate the prostate similar to a Digital Rectal Exam (DRE). Your physician will then inject local anesthetic solution around your prostate to make the procedure more comfortable for you. Depending on whether this is your first or repeat biopsy, different number of samples are obtained. Your surgeon will usually have results of the biopsy back within 1-2 weeks post biopsy.

What are the complications of a prostate biopsy?

Complications are rare but you should expect to see some blood in your urine and stool for a few days and your ejaculate for up to several weeks after the biopsy. This is self-limiting and will resolve with time. Infection requiring antibiotics is also rare but may require additional antibiotics by your physician. In one large patient registry, the rate of infection-related hospitalization following transrectal prostate biopsy was 0.6%.

How is prostate cancer classified?

If prostate cancer is discovered on your biopsy, your physician will discuss the Gleason Score with you. In other words, the pathologist assigns “grades” to the biopsy samples. The grade or Gleason Score is a measure of how quickly the cells are likely to grow and spread outside the prostate. Each sample is given a grade between three (3) and five (5). Any grade below 3 is considered close to normal and is not reported. A grade 3 is considered a slow-growing tumor and a grade 5 is considered a fast-growing and aggressive tumor. Depending on these results, your urologist may recommend further testing such as imaging studies to further define your overall disease burden.

What treatment options are available?

There are different ways to approach prostate cancer depending on the amount and aggressiveness of tumor that was discovered. 

• Watchful Waiting: This approach is the least involved and refers to monitoring the cancer without getting regular tests or biopsies. It essentially allows the cancer to take its natural course.
• Active Surveillance: This approach is aimed at less aggressive cancers and at patients who do not wish to actively treat the disease. It involves routine laboratory testing and repeat biopsies to track the progression of the disease.
• Radical Prostatectomy: This is a surgical approach to the cancer that is aimed at removing the prostate, nearby vesicles, tissues, and lymph nodes. It is best suited for low and intermediate grade localized cancer that has not yet spread outside of the organ. There are different approaches to this surgery including the open approach or minimally invasive laparoscopic or robotic approach. Robotic prostatectomy is currently one of the most popular and effective surgical approaches in capable hands and has been shown to have the best overall short term and long term outcomes. Risks of surgery are bleeding, infection, and potential injury to surrounding structures. Depending on the expertise of your surgeon, you may experience erectile dysfunction and/or some degree of urinary incontinence after surgery.
• Radiation Therapy: Radiation can be done in two ways depending on your biopsy results. External beam radiation may involve multiple rounds of radiation that is aimed at killing cancer cells from outside-in. Brachytherapy or “seeds” is a form of radiation where small radioactive pellets are placed inside your prostate with the hope of killing the cells from inside-out. If radiation therapy fails to control the cancer, then surgical approaches may become much more challenging and the healing process may be impaired. Radiation therapy may also adversely affect surrounding tissues and have chronic consequences such as radiation cystitis and proctitis which are irreversible.
• Cryotherapy: This approach is aimed at freezing the prostate tissue to kill cancer cells. This approach is considered experimental by some and are only effective for a subset of patients.
• High-Intensity Focused Ultrasound (HIFU): This is an investigation treatment aimed at killing cancer cells by using sound waves. Like cryotherapy, this is in its early stages and not considered appropriate for most patients.
• Systemic Therapy: Systemic therapy may consist of hormonal therapy, chemotherapy, or immunotherapy. This is reserved for advanced or non-localized prostate cancers. Your surgeon will review these options with you if necessary.

The information above is meant to be informative and does not replace your physician's recommendations or judgement. Each individual case has to be evaluated carefully to determine the best course of action.