Besides skin cancer, prostate cancer is the most common cancer in American males. About one in eight men will receive a prostate cancer diagnosis during his lifetime. The National Cancer Institute estimates doctors will diagnose more than 280,000 new cases of prostate cancer in 2023.
Despite those statistics, doctors can treat—and often cure—prostate cancer in the early stages. Knowing the signs and symptoms and keeping up with recommended screenings can help catch prostate cancer early.
Urologist Justin Cox, MD, radiation oncologist Christopher Freese, MD, and medical oncologist Brian Mannion, MD, discuss what men and their loved ones should know about prostate cancer, including the risks and treatment options.
What is prostate cancer?
A cancer is named after where it begins. Prostate cancer affects a man's prostate, a small gland located between the base of the penis and the rectum. The prostate plays an important role in reproduction. It produces a fluid that mixes with sperm to make semen.
What are the risk factors for prostate cancer?
All men have a risk of prostate cancer, but some have a higher risk than others. Risk factors for prostate cancer include:
- Age—The risk of prostate cancer increases as men get older.
- Diet—Foods high in fat, such as meat and dairy, may increase the risk of prostate cancer. However, experts have not proven this link.
- Family history—Men with a close relative, such as a father or brother, diagnosed with prostate cancer have an increased risk.
- Genetics—Inherited genetic abnormalities in the BRCA1 and BRCA2 genes can increase the risk of prostate cancer.
- Race—Black males have a higher risk of prostate cancer than white males.
- Lifestyle—Smoking cigarettes and not exercising may increase risk, but experts have not proven this link.
What are the symptoms of prostate cancer?
Dr. Cox says prostate cancer itself usually doesn't cause symptoms, which is why screening is so important. Most of the symptoms men experience come from an enlarged prostate which narrows the urethra, the tube that carries urine and semen from the body.
This can cause dysuria, or painful urination, more frequent urination, or a weakened stream. However, men whose cancer has spread to the bone may have pain or weight loss. They may also have blood in their semen or urine and trouble getting or maintaining an erection.
Who needs prostate cancer screening?
Dr. Cox says men should decide when to get screened for prostate cancer with their doctor, but know that when prostate cancer is caught early, the results are very favorable. The American Urological Association (AUA) recommends that patients with an average risk of prostate cancer start screening between the ages of 45 and 50.
Men with an increased risk for prostate cancer, such as black males, those with genetic mutations, or a strong family history of prostate cancer, should be offered screening at age 40 to 45, adds Dr. Cox. Doctors should offer regular screenings every two to four years for males 50 to 69.
“Age alone should not determine prostate cancer screening," Dr. Cox says. “It has more to do with the general health of the patient and their life expectancy. Timing and frequency should be personalized for each patient."
How do doctors diagnose prostate cancer?
Most men receive a prostate-specific antigen (PSA) blood test as their first screening test. While high levels of PSA may indicate prostate cancer, other conditions like an enlarged or inflamed prostate can also increase PSA levels. Vigorous exercise, such as cycling, or ejaculating within 24 to 48 hours of the test can also increase PSA levels. PSA also naturally increases with age, however most men without prostate cancer have PSA levels under 4 ng/mL.
Doctors may also offer a digital rectal exam (DRE) alongside the PSA. During a DRE, a doctor will check the prostate for enlargement, tenderness, or lumps.
An abnormal DRE and PSA test typically warrants further testing, such as a prostate MRI. The radiologist assigns a Prostate Imaging Reporting & Data System (PI-RADS) score that helps determine the risk of prostate cancer:
- PI-RADS 3—50% risk of prostate cancer
- PI-RADS 4—80% risk of prostate cancer
- PI-RADS 5—90-100% risk of prostate cancer
From there, the doctor will perform a biopsy of the prostate. A biopsy removes tissue samples for lab testing.
“A biopsy can be done trans-rectal or trans-perineal," says Dr. Cox, “but the trans-perineal option has significantly less risk of infection." Currently, The Christ Hospital Urology is the only group in the region offering the trans-perineal option.
How do doctors treat prostate cancer?
Once you are diagnosed with prostate cancer, treatment options based on your risk group may include active surveillance, surgical removal of the prostate, radiation, and the addition of medications for high risk / advanced stage cancer.
Active surveillance is actually a form of treatment for prostate cancer, says Dr. Freese, and not the same thing as having no treatment.
“We monitor low risk patients and if you evolve to a more aggressive disease, we move to active treatment such as radiation or surgery. This minimizes toxicity, minimizes side effects from treatment and hopefully avoids treatment overall," says Dr. Freese.
Patients who choose active surveillance should have regular follow up, including a PSA test, a DRE, and a biopsy on a schedule recommended by their urologist, continues Dr. Freese.
Surgery for prostate cancer treatment
If cancer has not spread beyond the prostate, a surgeon will remove the entire prostate gland and surrounding tissues. Patients with a 10-year or more life expectancy with no other health conditions can have surgery, although this is not the only determinant for who is appropriate for surgery.
The most common surgery is a minimally invasive, robot-assisted surgery that uses multiple small incisions on the abdomen rather than one large incision. The advantages of robot-assisted surgery include significant reductions in pain and narcotic use, shorter hospital stay, less bleeding, and a quicker return to normal activities.
“Robotic-assisted surgery has greatly advanced our ability to improve urinary control and return of sexual function," says Dr. Cox.
All men will have side effects initially, says Dr. Cox. Side effects of surgery include stress incontinence—leakage of urine with activity such as coughing, laughing, sneezing—and erectile dysfunction.
“It can take six months to a year for men to regain full urine control and about two to two and a half years for full erectile recovery," says Dr. Cox, “but we expect both of these to get better and usually see improvement within a few months. Kegel exercises before surgery and once your catheter is removed can greatly help outcomes. The Christ Hospital also has a team of Pelvic Floor physical and occupational therapists to help men pre and post op. We have a protocol to help men regain their sexual function, but it will take time. Patience is key."
Radiation for prostate cancer treatment
Radiation is another option for prostate cancer treatment. Two of the most common types of radiation are external beam therapy and stereotactic body radiotherapy. Both treatments use machines that aim high doses of radiation at cancer cells. Patients usually complete external beam therapy in 20 sessions. Stereotactic body radiotherapy only takes five sessions because it uses larger doses of radiation per therapy session.
Dr. Freese says studies have not yet concluded which radiation therapy is best for patients.
“If you talk to 20 different doctors, all of them will give you their pitch for why they use what they use," he says, “but there are no trials that prove one is better than another; they are all pretty equal. The National Comprehensive Cancer Network does have recommendations that all radiation oncologists use to help determine the best radiation modality based on the patient's risk group. It also comes down to patient choice based on side effect profiles."
Side effects of radiation therapy can include fatigue, pain, burning during urination and diarrhea. Patients may have blood in their stool on rare occasions, but that usually goes away with time.
Medication for prostate cancer
Doctors combine medication with radiation or surgery to treat prostate cancer. Dr. Mannion says medication also controls the disease once it spreads beyond the prostate.
“Even though it may not cure patients, this control can be successful for many, many years. The impact it has on prostate cancer is not trivial," he says.
Prostate cancer cells need testosterone to grow and spread. Doctors use medications that block testosterone production first because of their effectiveness. Men who take testosterone blockers may experience hot flashes, low libido and erectile dysfunction. Some men may also have low energy levels or depression. Side effects can be managed with additional medications or other therapies, such as physical therapy.
When to get a second opinion
Dr. Mannion recommends patients ask for a second opinion to understand their treatment options better.
“If you see just one person, sometimes you can get a very biased perspective," he says. “For example, if you see a radiation oncologist, they may only talk to you about radiation. The best way to get answers is to see an entire treatment care team."
The Christ Hospital Prostate Second Opinion Clinic allows you to meet with an entire care team including medical oncology, radiation oncology and urology to get a full consensus for treatment, Dr. Mannion says. Getting a second opinion can also help ensure the appropriateness of your initial treatment, as well as identify clinical trials that may be available.