The prostate, a gland found only in men, secretes fluids that help in the fertilization process. It serves no other purpose that we know of. In young men, the prostate is about the size of a walnut, and it sits at the base of the bladder, surrounding the channel through which men urinate.
As men age, two common medical conditions can occur — enlargement and cancer.
Enlargement of the prostate, known as benign prostatic hyperplasia or BPH, is very common in older men and can cause urinary symptoms such as frequency, urgency, weak stream, and getting up at night. While this is an annoyance, BPH is not life threatening. If symptoms become severe, BPH can be treated successfully with either medication or surgery.
The more concerning condition we see with the prostate in older men is prostate cancer. Although we have made great progress in detecting and treating prostate cancer, it still remains a great puzzle.
About 200,000 new cases of prostate cancer are diagnosed each year in the United States, and about 30,000 deaths are attributed to the disease annually. After skin cancer, it’s the most common cancer among older men. Most cases are diagnosed past age 65, and the vast majority of these are found before the cancer spreads.
Most men with prostate cancer have no symptoms. If they do have urinary symptoms, it is most commonly due to BPH and not cancer. The two conditions can coexist.
The point of prostate cancer screening is to catch the disease early enough to hopefully treat and cure the cancer. Unfortunately, screening can be a stressful and anxiety-provoking process. A number of prostate cancer screening tools are available, but the cornerstones of screening are a blood test called the PSA, or prostate-specific antigen, and the digital rectal exam.
Neither test is perfect. The PSA value we generally look for is less than 4, but many patients who have an elevated PSA do not have cancer. Also, the digital rectal exam is an imperfect, subjective test. We feel for lumps or bumps that can be consistent with prostate cancer, but many times turn out to be benign disease such as BPH.
Men should discuss prostate cancer screening with their physicians. In general, we recommend prostate cancer screening to begin around age 50. If you have a family history of prostate cancer or are of African-American descent, your physician may recommend to start screening earlier. Because prostate cancer is generally a slow-growing cancer, often taking years if not decades to progress, we generally stop screening at the age of 75.
If screening suggests cancer may be present, the next step normally is a prostate biopsy, but this too is a puzzle. Most of the time we are taking random biopsy samplings of the prostate, so even if you have prostate cancer, it can be missed during the biopsy. However, if there is a significant amount of cancer in the prostate, most of the time it will be detected.
The last puzzling question is what to do when you are diagnosed with prostate cancer. All prostate cancers are not created equal. Many, as previously stated, are very slow growing and take years or decades to cause problems. Others can cause a quick decline and death. Biopsy and other imaging studies can reveal the type of cancer it is.
Unlike many types of cancer, prostate cancer has a menu of treatment options, each with its own risks and benefits. These options include surgery, radiation, hormonal therapy, cryotherapy, proton therapy, hormone therapy, and high-intensity focused ultrasound. Chemotherapy and immunotherapy are used too, but not until the late stages of the disease. Side effects from treatment can be life altering. These can include impotence, incontinence, frequent urination, bowel issues and increased risk for other cancers. Only after a full discussion of options between the doctor and patient can a treatment be decided upon.
Prostate cancer has been and remains a puzzle for both the doctor and patient. As men age, it’s important for them to discuss prostate cancer with their physicians and decide whether screening is right for them. While screening does cause anxiety and stress, it is something that can literally save your life.