Prostate Cancer Awareness Month: What Should Patients Know About Screening, Diagnosis, and Treatment?

Prostate cancer affects more than 280,000 patients annually in the United States alone. It continues to be the second leading cause of cancer-related death in males, second only to lung cancer.¹ Early diagnosis and monitoring or treatment are critical to reducing potential prostate cancer-related morbidity and mortality.²

September is Prostate Cancer Awareness Month, and the Prostate Cancer Foundation is hosting fundraising and other events to raise public awareness of cancer prevention, detection, and treatment options.³ To do my part to commemorate Prostate Cancer Awareness Month, I’m highlighting the facts related to screening, diagnosis, and management that all men should know.

The prostate gland is a critical component of the male reproductive tract that is primarily responsible for the liquefaction of seminal fluid during the ejaculatory process. Prostate cancer screening is a series of methods used to identify early signs of prostate cancer prior to the formation of symptoms that would prompt evaluation during a visit to a primary care physician or urologist. Early detection can be critical for the treatment of prostate cancer, as diagnosing the disease early ensures the widest array of treatment options for the patient. Although many prostate cancers are slow growing and may not impact lifetime morbidity and mortality, some men will harbor higher-risk prostate cancers that can. Identification of these prostate cancers is critical. Often, such disease goes completely undetected because by the time prostate cancer causes symptoms such as difficulty urinating or blood in the urine, the disease has progressed.

Despite prior controversies, the US Preventive Services Task Force currently recommends periodic prostate-specific antigen (PSA) blood test screening for males 55 to 69 years of age as long as the patient and doctor review the potential harms and benefits of screening.⁴ A PSA test measures the level of this protein in the blood stream. PSA levels are often, but not always, elevated in the setting of potential prostate cancer. Other causes of elevated PSA include prostatic inflammation or certain forms of prostatic manipulation.

Digital rectal examination is another tool that many physicians utilize to aid in the detection of prostate cancer. In this physical examination, the physician will insert their gloved finger per rectum to feel the prostate for lumps or abnormalities.

Once any abnormality in PSA and/or via digital rectal examination is detected, a referral to a urologist is warranted, often for a prostate biopsy and/or further workup. Urologists are physicians who specialize in the diagnosis and treatment of diseases of the urinary tract and male reproductive system. Many clinicians will order a confirmatory PSA test prior to pursuing any further testing. This approach is supported by the American Urological Association/Society of Urologic Oncology (AUA/SUO) 2023 Early Detection of Prostate Cancer guidelines, a series of recommendations made by urologists regarding the early identification of prostate cancer.⁵  The latest guidelines state that clinicians should repeat PSA prior to pursuing any additional biomarkers, imaging, or prostate biopsy.⁵

After initial consultation, although not necessary, many urologists now suggest that patients undergoing workup for potential prostate cancer should undergo magnetic resonance imaging (MRI) of the prostate prior to biopsy. In fact, the latest AUA/SUO guidelines suggest that obtaining an MRI prior to initial biopsy may increase the detection rate of clinically significant prostate cancer.⁵ MRI is a type of body imaging that uses magnetic energy to obtain highly detailed images of the prostate. Many MRI reports will contain a Prostate Imaging Reporting and Data System (PI-RADS) score. PI-RADS is a grading system utilized by radiologists to categorize suspicious prostate lesions.⁶

MRI images can be used by urologists to identify suspicious areas of the prostate that may be concerning for prostate cancer. The latest iteration of such technology includes MRI/ultrasound fusion prostate biopsies that combine the images obtained by MRI with the ultrasound images obtained by the urologist at the time of biopsy. This combination allows for greater precision, as well as the ability to target potential prostate lesions that were found to be concerning.

The final step in the diagnostic process is a prostate biopsy. In this procedure, the urologist will use a needle to take samples of tissue from the prostate, which are subsequently analyzed by pathologists under a microscope to determine the presence or absence of cancer. Currently, and  consistent with recommendations, most urologists will obtain at least 2 cores from a prostate lesion found to be suspicious on an MRI. They will also perform targeted biopsies in conjunction with a systematic biopsy.⁵

The results of the biopsy will be reviewed by the urologist with the patient, and options for treatment will be discussed if the biopsy result was positive. Treatment options (depending on severity of disease) include surgery, radiation, and even active surveillance, which involves actively monitoring the cancer with the urologist on a routine basis. All of these options have different side effect profiles, and the risks and benefits of each treatment can vary dramatically. If the biopsy was negative, guidelines support continued surveillance. It is inadequate to discontinue prostate cancer screening solely based on a negative prostate biopsy.⁵

The risks and benefits of checking for prostate cancer can differ significantly based on a plethora of patient-specific factors, including age, family history, ethnicity, and background, as well as a patient’s personal preferences for treatment. The AUA/SUO guidelines recommend that patients at risk for early development of prostate cancer, such as those with a family history of prostate cancer, should begin screening as early as 40 to 45 years of age.⁵ Furthermore, the guidelines recommend that patients at average risk can be screened every 2 to 4 years. For patients who had an initial negative workup, adjunctive tools such as more advanced blood and urine biomarkers can be used to help guide decision-making for the patient and urologist regarding a repeat biopsy.⁵

In honor of Prostate Cancer Awareness Month, I advise all patients who are thinking about prostate cancer screening to talk to their primary care physician or urologist about the benefits and potential risks of screening to identify prostate cancer early. Physicians can help guide their patients on what the best options are based on a patient’s values and preferences.

Akhil Abraham Saji, MD, Fellow at the University of Southern California, is a urologist specializing in minimally invasive surgery and urologic oncology with an interest in technology-driven innovation within health care.

References

1. September is Prostate Cancer Awareness Month. American Association for Cancer Research. Accessed September 23, 2023. https://www.aacr.org/patients-caregivers/awareness-months/prostate-cancer-awareness-month/
2. Cancer stat facts: prostate cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed May 14, 2023. https://seer.cancer.gov/statfacts/html/prost.html
3. Prostate Cancer Awareness Month. Prostate Cancer Foundation. Accessed September 23, 2023. https://www.pcf.org/prostate-cancer-awareness-month/
4. US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(18):1901-1913. doi:10.1001/jama.2018.3710
5. Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):46-53. doi:10.1097/JU.0000000000003491
6. Prostate Imaging Reporting & Data System (PI-RADS). American College of Radiology. Accessed September 23, 2023. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/PI-RADS