Prostate cancer is among the most common cancers in men, along with skin, lung, and colorectal cancer.
Dr. Alexander Berry, a urologist at Holyoke Medical Center, was asked about the role of the prostate gland and what men should know about detecting prostate cancer.
What is the role of the prostate gland in the male reproductive system and how important is this role in terms of fertility and general health?
The prostate plays an important role in men’s health. The main function is to produce 95% of the fluid that occurs with ejaculation. This fluid transports sperm to the cervix and provides energy in the form of sugar that allows the sperm to complete its “fantastic journey.”
Prostate activity is controlled by circulating testosterone.
As a man ages, the prostate becomes more sensitive to testosterone and will continue to grow. This is often called BPH, benign prostatic hypertrophy, and can lead to common symptoms such as weak flow, getting up at night to empty, and feelings of incomplete emptying.
When would a patient start a digital rectal exam as part of a wellness exam? What can such an examination detect?
Prostate exams are generally recommended for all men age 50 and older. There are situations when a prostate exam would be recommended in younger men. Typically, these would be men whose father or uncle had prostate cancer at an earlier age, and those men who have prostate symptoms.
A digital rectal exam is a type of screening exam. Doctors seek to determine if there are significant changes, such as an increase in size or a change in consistency.
It is important to understand that many men who have prostate cancer will have a normal prostate on examination.
What is the Prostate Specific Antigen (PSA) blood test designed to verify and what would be considered a normal reading for the presence of this protein in the blood?
Prostate Specific Antigen (PSA) is a protein that is released by the prostate and is found in the blood.
The protein is continuously released at a low level by normal prostate tissue. If the prostate tissue is infected, inflamed, or otherwise altered, the level of PSA found in the blood increases.
Cancer cells cause damage to the prostate and are strongly associated with an increase in PSA.
For men 55 and younger, a normal PSA is considered to be 2.5 ng / ml, for those 55 and older, a normal PSA is around 4.0 ng / ml. There may be concern about lower PSA levels if this represents a jump from a stable benchmark trend.
Two years ago, the United States Preventive Services Task Force changed its recommendations on which of the men between 55 and 69 should have a PSA blood test, saying this is a decision between a man and his doctor based on part in risk factors and family preference.
Could you explain the pros and cons around PSA detection?
All prostate men produce PSA. PSA can increase in response to infection, changes in prostate size, and cancer. As men age, PSA will generally increase slowly as a result of the slow increase in prostate size due to BPH. Because PSA can increase due to reasons other than cancer, this means that it can be difficult to determine what causes an increase in PSA without doing a prostate biopsy.
Testing the PSA at an appropriate interval can help your doctor decide if you have a normal pattern of PSA increase or if the increase may represent cancer.
What we do know is that 95% of prostate cancers in men 55 and older have a PSA of 4.0 ng / ml or more. The difficulty is that many men with normal enlargement also have a PSA greater than 4.0 ng / ml.
What do you advise your patients about detecting prostate cancer?
My advice to men is that they want to start receiving their first PSA checkup around age 45, and then again at age 50. Based on your family history and the pattern over time of your PSA levels, you should monitor your PSA at regular intervals between the ages of 50 and 75.
In addition to a regular PSA checkup, your prostate must be examined annually with a digital rectal exam.
Is a biopsy always necessary to confirm cancer when there is an elevated PSA level?
There have been a number of new different urine markers that are available to help determine the risk of prostate cancer in a man with an elevated PSA. In general, if a PSA is significantly elevated, I would recommend a prostate biopsy to screen for prostate cancer.
For men with mild PSA elevation, a urine DNA test will help guide the decision to have a biopsy.
Unfortunately, at this time there is no way to confirm if a man has prostate cancer without doing a prostate biopsy.
It is important to remember that an enlarged prostate is a benign reason for an elevated PSA. This is more common among older men, and therefore most prostate biopsies performed will show BPH instead of cancer.
Would you explain the active surveillance approach for men with a cancer considered to be slow growing and recommend it?
Active surveillance is a commonly used form of prostate cancer management.
Depending on the PSA level, the type of prostate cancer and the volume of prostate cancer that an individual is actively monitoring may be a suitable management option.
Men who have low-volume, low-risk prostate cancer can be closely monitored with a combination of imaging, PSA testing, and genetic evaluation instead of undergoing prostate cancer therapy.
Active therapy for prostate cancer carries a risk of erectile dysfunction and changes in urinary continence. For this reason, many men with favorable prostate cancer findings prefer active surveillance.
When would surgery or other options for prostate cancer be recommended and what are the risks?
Therapy options for prostate cancer include surgical removal and a variety of different forms of radiation therapy.
Surgery is generally offered as an option for younger men in the context of increased volume or increased risk of prostate cancer. Genetic evaluation of the prostate cancer biopsy and magnetic resonance imaging findings can help determine if prostate cancer is confined to the prostate itself.
In those situations, surgery can result in long-term, long-term control of prostate cancer.
In the context of older patients, those with prostate cancer that has just escaped the prostate or those with very high-risk disease, radiation treatment offers a better balance of control against complications such as erectile dysfunction and changes in urinary output.
Overall, are most prostate cancers found early today through screening, and what are the long-term survival rates?
Long-term survival with prostate cancers detected through a screening program is generally very good. For most prostate cancers that are at a relatively early stage, treatment means there will be no significant impact on life expectancy.
Do you see other tests that will be introduced soon in terms of prostate cancer screening?
PSA tests and regular digital rectal exams are still the standard way to detect prostate cancer.
Doctors are always trying to develop new ways to help detect prostate cancer.
There are urine DNA tests that can help assess the risk of prostate cancer, and we know that magnetic resonance imaging can help increase the accuracy of a prostate biopsy.
I incorporate both in my evaluation of a male for prostate biopsy, however, neither technique is likely to be used in the primary care setting in the near future.
What are the most common conditions and their recommended treatments that affect a man’s prostate health in addition to cancer?
The two most common prostate problems seen are prostatitis and benign prostatic hypertrophy (BPH).
There is not much a man can do to prevent BPH.
This is determined by a combination of age and genetics. Prostatitis is an inflammation of the prostate that can occasionally occur.
We are not sure how it happens, but regular fluid intake and emptying of the bladder seem to reduce its frequency.
Overall prostate health is maximized when prostate irritants, such as coffee, are taken in moderation.
There are pros and cons around prostate massage. Have you had many inquiries about patients? What do you recommend?
Prostate massage exists in two main therapeutic and stimulating forms.
Therapeutic prostate massage is occasionally used for men with recurrent prostatitis and pain in the pelvic floor. There are specially trained physical therapists in the region who will perform pelvic floor physiotherapy and specific prostate massages as part of a therapeutic program to treat chronic pelvic floor pain.
Occasionally, patients ask about stimulating prostate massage.
There is a percentage of men for whom prostate massage can be stimulating. The exact percentage is uncertain, but it appears to be around 10-15%. There appears to be minimal risk as long as this is done smoothly.
