What you need to know about prostate cancer screenings

I’ve been a doctor for over 25 years. Some of the most important health advice I give my patients is to screen for cancer. But prostate cancer screening is not always clear.

Did you know that aggressive prostate cancer is the second leading cause of cancer death in men in the United States, behind lung cancer? But did you also know that most cases of prostate cancer will not cause a problem? These non-aggressive prostate cancers are called low-risk prostate cancer.

Treating aggressive prostate cancer can save lives. But treating low-risk prostate cancer the same way we treat aggressive prostate cancer has bad side effects. It can cause permanent problems, such as erectile dysfunction (not being able to get an erection) or issues with using the toilet.

Here I share 12 common questions I get asked by my patients about prostate cancer, when it’s recommended to get screened, what’s involved with the test and information about active surveillance for low-risk prostate cancer. I share some insights on how to have a special type of talk with your doctor. It is called shared decision-making.

I ask my patients to watch these videos for more information to help prepare for a doctor’s visit.

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1. What is prostate cancer?

Prostate cancer is when cancerous cells start growing within the prostate gland.

The prostate is a gland in the male reproductive system. It sits near the bladder and makes important hormones and fluid that makes up semen. Hormones are natural chemicals in the body that help it work.

2. Are there types of prostate cancer?

Yes, there are two main types of prostate cancer:

• Aggressive prostate cancer
• Non-aggressive prostate cancer

Aggressive prostate cancer is the second leading cause of cancer deaths in the U.S. Aggressive prostate cancer is when the cancer cells leave the prostate and invade other parts of the body.

Aggressive prostate cancer is also called “unfavorable intermediate” or “high-risk” because there’s a higher risk of it spreading and causing late-stage cancer.

Non-aggressive cancer is also called “low-risk” cancer. Low-risk prostate cancer makes up most prostate cancer cases. Low-risk prostate cancer stays in the prostate.

In fact, most of the 3.1 million men who live with prostate cancer will not die from prostate cancer because they have a low-risk disease.

3. What are the symptoms of prostate cancer?

Symptoms of prostate cancer can include:

• Frequent or painful urination
• Blood in urine
• Difficulty getting an erection
• Unusual bone or hip pain
• Unexplained weight loss
• Fatigue (weak feeling of the whole body)

If you have any of these symptoms, talk to your doctor right away. Many of the symptoms can be caused by things other than cancer, but it’s important to make sure it’s not cancer. Catching cancer early helps save lives.

4. At what age should I start prostate cancer screening?

If you’re age 45 to 50, ask your doctor if you need prostate cancer screening. If you’re at higher risk, talk to your doctor about starting screening at age 40 to 45. People at higher risk include:

• Black Americans
• Strong family history of cancer

Screening is when someone gets a test even though there are no symptoms. The purpose of screening is to find cancer early and treat it.

5. How is a prostate cancer screening done?

A prostate screening can be performed in two ways:

• Blood test, known as a prostate-specific antigen (PSA) test
• Physical exam

Most doctors recommend a blood test for prostate cancer screening. The PSA test takes some blood and looks for how high your prostate-specific antigen (PSA) is in your blood.

A higher PSA might be a sign of prostate cancer. Sometimes a higher PSA can be a sign of an infection (an illness caused by germs) or recent ejaculation. As men age, the prostate increases in size, so older men tend to have higher PSAs.

6. Why do some guidelines say men over age 70 may not need to screen?

Given that the prostate becomes bigger with age, many older men have higher PSA readings which result in false positives. A false positive is when the test results say there’s a problem but there really isn’t.

These men often get a biopsy and may be told they have low-risk prostate cancer. A biopsy is when a sample of tissue is taken from a part of the body for more tests.

Since most men found to have prostate cancer will likely have low-risk cancer, this means it will likely stay in the prostate gland.

Many men in their 70s are overtreated for low-risk prostate cancer and have a reduced quality of life due to harsh side effects. If you’re over 70, ask your doctor if you need to get screened.

7. What if my prostate screening test results come back abnormal?

Try to stay calm. A screening test cannot tell you for sure if you have cancer. If your test shows a higher PSA for the first time, usually your doctor will tell you to get a second PSA test.

If your second PSA test comes back high, then your doctor might refer you to a urologist for a biopsy. A urologist is a doctor who specializes in the genitourinary system (the male reproductive and urinary system).

8. What happens if I’m sent to a urologist?

The urologist will do a physical exam and may talk to you about getting a biopsy. If you need a biopsy, your urologist will put a biopsy device in your prostate. The doctor will remove small amounts of prostate tissue.

A pathologist then looks at the tissue in a lab to find out if you have cancer and your risk level.

Getting a biopsy is important because it’s the only way to know if you have prostate cancer and if it’s high- or low-risk.

9. What are my treatment options if I have high-risk prostate cancer?

If doctors find you have a high-risk prostate cancer, it’s important to get treated. High-risk prostate cancer means it’s an aggressive cancer. Treatment options include:

• Surgery
• Radiation therapy
• Hormone therapy
• Medicines

If you have high-risk cancer, but it’s found early, you’re more likely to have a much better outcome. An outcome measures how well a kind of treatment works.

10. What are my treatment options if I have a low-risk prostate cancer?

If you have low-risk prostate cancer, the path is not as straightforward. You should have a shared decision-making conversation with your doctor about active surveillance.

A shared decision-making conversation is when your doctor gives you evidence-based advice based on your personal health history and preferences. Then, you can make care choices with your doctor that work best for you based on your doctor’s advice.

What is active surveillance?

National guidelines and medical associations recommend active surveillance as the care path for most low-risk prostate cancer cases. Active surveillance means to monitor the cancer rather than treat it with surgery, radiation, drugs or hormones.

Patients on active surveillance have regular tests to watch for changes in their body. The tests include:

• Blood tests
• Imaging
• Additional biopsies

Some people check in with their care team about every 6 months to get a blood test or imaging test. Many people get another biopsy every 18 months to 2 years. If there are changes, your doctor may say you should go on active treatment.

It’s important to point out the word “active” in active surveillance. This doesn’t mean doing nothing. It’s actively keeping an eye on your condition through regular (on a planned schedule) tests and visits with your doctor.

Choosing active surveillance allows patients to avoid the side effects of radiation, surgery and hormone therapy. These side-effects may include:

• Urinary incontinence (not being able to start and stop urine)
• Trouble getting an erection
• Infertility (not being able to have children)

Choosing active surveillance requires a commitment on your part to keep your regular check-ups. The schedule will be different for each person.

It’s important to keep in mind, active surveillance isn’t a new idea. It’s been around for more than 20 years.

Can I change my mind about active surveillance?

Yes. Many people decide to go off active surveillance due to anxiety and not because their cancer has changed. They or their loved ones cannot tolerate the idea of having a cancer, even a low-risk cancer.

In contrast, some patients with low-risk prostate cancer that get treatment still have anxiety. Many patients find that after being on active surveillance for a while their anxiety lessens.

Each person is different, which is why it’s important to have shared decision-making conversations.

Is active surveillance the same as “watchful waiting”?

No, active surveillance and watchful waiting are different ways of handling an illness. But many people often think of them as the same thing.

Watchful waiting is only for very sick patients that have other conditions. For them, the active monitoring of prostate cancer, which includes biopsies, may cause health problems.

11. Why should I talk to my doctor about cancer screening?

The choice to get checked for prostate cancer isn’t straightforward. Most prostate cancers aren’t aggressive. This means most people will not die from prostate cancer. As a result, this can result in overtreating low-risk prostate cancer.

Cancer treatments such as surgery, radiation and some medicines can cause bad side effects. These bad side effects include:

• Urinary dysfunction (problems with urinating)
• Rectal dysfunction (not being able to start and stop bowel movements)
• Erectile dysfunction

Treating low-risk prostate cancer may result in a much lower quality of life. But the only way to know if you might have a high-risk prostate cancer is to get screened.

12. How should I talk to my doctor?

It is important to talk to your doctor. Sometimes it can be hard to know what to talk about. Having a shared decision-making talk with your doctor can be helpful.

A shared decision-making talk has three parts:

• Step 1: You actively share information with your doctor, including any concerns you have.
• Step 2: Your doctor talks to you about the care options that are best for you.
• Step 3: You both decide together any next steps.

Learn more about how to have a shared decision-making conversation with your doctor about prostate screening at Prostate Watch.

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About Dr. Kenneth Cohen

Dr. Kenneth Cohen is an experienced physician leader, practicing internist and researcher who has attained national recognition for health care quality improvement. He has successfully developed and reported numerous clinical quality studies in primary care, including tobacco cessation, osteoporosis, asthma, diabetes, hypertension and ischemic vascular disease. He is a founding physician of New West Physicians, one of the largest medical practices in Colorado, where he served as chief medical officer for 24 years. He currently serves as the Executive Director of Translational Research for Optum Health and leads the Optum Center for Research and Innovation.

Dr. Cohen has received awards of recognition and distinction for teaching, including the Lutheran Medical Center Physician of the Year award in 2011. Under his stewardship, New West Physicians won the AMGA Acclaim award in 2015 and the Million Hearts Hypertension Champion Award in 2017.

He is a Clinical Associate Professor of Medicine and Pharmacy at the University of Colorado School of Medicine.

Dr. Cohen holds degrees from Dickinson College and Hahnemann University. He is a Fellow of the American College of Physicians and a member of the Phi Beta Kappa and Alpha Omega Alpha honor societies.