By Ryan Smith, MD
If you’re a man, you may have asked yourself this question at some point. We hear a lot of talk about our prostates, whether it’s from Joe Theismann promoting vitamins for it or the NFL encouraging you to “Know Your Stats” as they relate to prostate cancer risks.
Prostate cancer is the second most common cancer among men in the United States and justifiably receives a lot of attention. In fact, what do Robert DeNiro, Arnold Palmer, Joe Torre, Rudolph Giuliani and Nelson Mandela have in common? All of these men, from all walks of life, were treated for prostate cancer. Like it or not, our prostate health can have a big impact on our quality of life as we age, and having a basic understanding of the controversies around it can help you take charge of your health. Despite all the media attention, many men still don’t realize where the prostate is or why we have one in the first place.
To start, the prostate is a gland found in the male reproductive system. Anatomically, it sits below the bladder and in front of the rectum. The tube that carries urine (the urethra) runs through the center of the prostate. In terms of function, the prostate helps make semen, which protects and nourishes sperm. In younger men, the prostate is typically described as being the shape and size of a walnut. As men age, the prostate can grow larger and that can result in difficulty passing urine. Enlargement of the prostate, when noncancerous, is termed benign prostatic hyperplasia or BPH. While benign enlargement is quite common, it is important to distinguish this from prostate cancer. The American Cancer Society estimates that 1 in 7 men will be diagnosed with prostate cancer in their lifetime.
Screening for prostate cancer has come under increased scrutiny recently, which has made the decision of whether to pursue testing all the more confusing for patients and physicians. Prostate cancer screening is generally conducted with a rectal exam and a “PSA” test. PSA is prostate-specific antigen, a protein produced by cells within the prostate. The blood level of PSA is often elevated in men with prostate cancer; however, PSA levels can also be high in men with an enlarged, infected or inflamed prostate. Determining what a high PSA level means is complex and must be judged in light of prior PSA values, age, size of the prostate, and any medications, which may affect PSA measurements. PSA is not a perfect screening test and carries its own limitations and potential harms.
The advantage of screening is that when cancer is identified early, treatments may be most effective and prevent cancer from becoming life-threatening or causing serious symptoms. Overall, however, there is a low risk of death due to prostate cancer, and many detected cancers are slow growing and may never spread beyond the prostate gland. While the PSA test is straightforward (a blood test is all that is required), the test may give “false-negative” or “false positive” results. Elevated values may cause unnecessary worry and lead to additional medical procedures in the setting of a “false-positive” test, meaning the PSA is elevated due to benign causes.
A PSA elevation may prompt a prostate biopsy, which is required to establish a diagnosis of prostate cancer. The majority of men who undergo prostate biopsy will not have prostate cancer and the biopsy itself carries some associated risks including bleeding, infection, and procedural discomfort. If cancer is detected, early treatment may more often result in cure, but not all prostate cancers need treatment. Interventions such as surgery or radiation for prostate cancer carry risks of urinary leakage and erectile dysfunction, which can negatively impact quality of life.
Adding confusion to the mix is that multiple professional organizations vary in their recommendations about who should and should not get a PSA screening test. The American Urological Association (AUA) recommends that beginning at age 55 men engage in shared decision-making with their doctor about whether to undergo a PSA test. Earlier testing may be called for in men at high risk (for instance a family history of prostate cancer in their father). The AUA recommends against routine screening in men over age 70 or those with less than a 10-to-15-year life expectancy. In contrast, the United States Preventive Services Task Force recommends against PSA-based screening regardless of age.
One commonality amongst most groups is that the PSA test should not be used without a discussion of the risks and benefits of screening between patients and their physician. In the right patient, a positive PSA test may save a life, identifying a prostate cancer that needs early and prompt treatment.