Prostate cancer is the most common non-skin cancer and the second most common cause of cancer-related death in men, surpassed only by lung cancer. It is estimated that 241,740 new prostate cancer cases will be diagnosed in 2012, with 28,170 men dying of the disease during the year.
Prostate cancer is best cured when detected early. The American Urological Association recommends an annual screening with digital rectal exam and prostate specific antigen test for all men with a 10- to 15-year life expectancy, starting at the age of 40. This is especially important in African-American men and in men with a family history of prostate cancer, as they are at higher risk than other individuals.
PSA, a protein produced by the prostate, can be tested with a simple blood test. It is specific to the prostate but not to prostate cancer, as other factors like infection, inflammation of the prostate, or having a catheter in the bladder can cause an elevated PSA. Therefore, not all men need a prostate biopsy, and the urologist considers all these factors before recommending a prostate biopsy.
There has been a 40 percent decrease in deaths from prostate cancer since the PSA was introduced in the early 1990s, as patients are being diagnosed earlier, at a more curable stage.
There has been controversy regarding the usefulness of the PSA test since the United States Preventive Services Task Force issued a recommendation discouraging its use for prostate cancer screening in October 2011. It raised the concern that having this test “has no net benefit or the harms outweigh the benefits.”
Urologists, represented by the AUA, strongly disagree with this recommendation. While everyone realizes the PSA test has its limitations, the fact that doctors are diagnosing cancer at an earlier stage due to this test represents a strong argument to continue it as part of the annual prostate cancer screening. Urologists agree that PSA has to be used and interpreted appropriately, and not every patient may need to have the test — or a prostate biopsy — done. Prostate cancer that is felt by rectal exam represents a higher stage than one diagnosed by a biopsy done due to elevated PSA.
Many patients who present with prostate cancer that can be felt on rectal exam may have an advanced stage where cure is not an option and palliation (such as easing symptoms without curing) is the only treatment we offer. Going back to diagnosing patients only by rectal exam would do a disservice for men who wish to have their cancers detected early. The screening PSA test is particularly important because prostate cancer does not cause any symptoms in its early stages.
There have been significant advances in treating prostate cancer in the past 10 to 15 years with the availability of treatment options with fewer side effects. Radiation (X-ray therapy) and surgery are the mainstay curative treatments for localized prostate cancer. Radiation is aimed at the prostate gland from numerous directions and, with improved technology, the X-ray machine can deliver the radiation to the prostate very precisely, minimizing any damage to surrounding tissues. Advances in robotic surgery of the prostate have helped surgeons perform the surgery through small incisions with less blood loss and quicker patient recovery.
Not all men with prostate cancer will die from the disease. In some patients, the cancer can be slow-growing and is not lethal. The decision to treat will depend on the patient’s health and life expectancy and usually is made after extensive counseling by the urologist. While significant research is underway to find a better test than PSA for predicting a lethal disease, we will continue to recommend screening with digital rectal exam and PSA.