Q: Is prostate cancer an “old man’s” disease?
A: Yes and no. In general, growing older is considered the biggest risk factor for most types of cancer. This is because genetic instability increases with aging, and it might also be because some people are more susceptible to a lifetime accumulation of environmental toxins that damage a cell’s DNA. So yes, prostate cancer is more prevalent in aging men. However, the number of younger men diagnosed with prostate cancer has increased nearly six times in the last 20 years,[i] and it’s often more aggressive.
Q: What are the risk factors for prostate cancer?
A: Known risk factors include a family history of prostate cancer, especially a first degree relative; a family history of breast cancer, especially a first degree relative; certain ethnicities, especially African American; exposure to known toxins such as Agent Orange or other chemicals; lifestyle factors such as high fat diets, lack of exercise, and stress; and chronic prostate inflammation such as prostatitis.
Q: What are the symptoms?
A: In its early stages, prostate cancer rarely has any signs. That is why it is often called a “silent killer.” As it grows, it may cause symptoms that mimic other pelvic diseases or conditions: difficulty urinating, frequent urge to urinate, painful urination, blood in urine or semen, erectile dysfunction, discomfort in the pelvic area. It’s important to rule out other conditions. In more advanced cases, there can be pain in the back or bone pain in other areas, in addition to the other symptoms.
Q: How can I know if I have prostate cancer?
A: A simple blood test called the PSA (prostate specific antigen) can detect the blood level of circulating proteins (antigens) from the prostate gland. However, anything that irritates or stimulates the gland besides cancer (e.g. infection, inflammation, noncancerous enlargement due to aging, bicycle riding, orgasm, etc.) can also cause higher PSA levels. For this reason, the PSA blood test is not specific. However, blood from the same blood draw can be analyzed for variants called free PSA, PSA density, etc. When taken together with the basic PSA level, they give a better idea if cancer is present.
Q: Since PSA is not specific for cancer, are there any other tests that give a definite answer?
A: Today, there are additional blood, urine and tissue tests (from a biopsy) for “biomarkers” that are very specific for prostate cancer. Although they are not routinely done unless a man has known risk factors, and may cost extra, they are often worth ordering before deciding to have a needle biopsy. Talk to your doctor about genomic testing if you are concerned.
Q: What is a needle biopsy?
A: A needle biopsy is the only way to accurately diagnose cancer. It is based on taking tissue samples from the prostate gland. Obtaining each sample is done by inserting a hollow needle into the gland to capture “threads” of tissue. When seen under a microscope, the presence of any cancer cells can be seen, giving information as to the size, location and aggressiveness of prostate cancer, if present. In addition, some genomic tests are based on the tissue, not on a blood draw. Most prostate biopsies are done in a urologist’s office. The samples are taken through the rectal wall, guided by an ultrasound wand inserted in the rectum, with an average of 12-14 samples taken. Such a large number is needed because ultrasound cannot define tumors, therefore it’s “blind” and requires random sampling.
Q: Is the biopsy risky?
A: There is 30-40% risk of “false negative” results (missed cancer). There are slight risks of pain and the chance of infection. However, most urologists will numb the prostatic nerves, and start patients on a short course of antibiotics to prevent infection. After the biopsy, blood may show up in urine, semen or bowel movement, usually short-lived and not painful. The more needles used, however, the greater the risks. In a small minority of cases, complications can lead to hospitalization.
Q: Can I avoid having a biopsy and still know for sure if I have prostate cancer?
A: No. Only a biopsy can accurately diagnose the aggressiveness, size, location and stage of prostate cancer tumors. However, an important step between getting a worrisome PSA test and having a biopsy is a special prostate scan called a multiparametric MRI (mpMRI). When done on a powerful magnet by an experienced radiology team, the imaging has > 95% accuracy in revealing suspicious prostate tumors with an indication of their severity. If tumors are seen, a biopsy done inside the MRI with a minimum number of needles can take tissue samples precisely where the most dangerous cells are likely to be. This makes a real-time MRI-guided biopsy (with numbing) the most accurate biopsy with the least risk.
Q: What if I’m diagnosed with prostate cancer?
A: Today, more than ever, we can match the treatment to the cancer. The less aggressive the tumor, the less aggressive the treatment. For cancer that is still contained in the gland – which is the majority of prostate cancers – treatments range from Active Surveillance (monitor using periodic blood tests and mpMRI scans), focal therapy such as Focal Laser Ablation to treat just the tumor and spare healthy tissue, surgery to remove the gland (prostatectomy, either traditional or with robotic assistance), and various types of radiation or radioactive seed implants.
Q: If I have cancer, isn’t it best to just remove or radiate the whole gland to “get it all out”?
A: Many men today choose Active Surveillance or focal treatment because statistics show two things: 1) overtreating prostate cancer does not add to survival, and b) the risks of urinary and sexual side effects are much greater. Each patient should discuss all treatment options with his doctor, do research, talk to other patients (e.g. support group or online forum), and weigh lifestyle factors. The important point to recognize is that when diagnosed early, prostate cancer can be successfully watched or treated.