[4 MIN READ]
In this article:
Prostate cancer is highly treatable when detected at an early stage.
Prostate-specific antigen (PSA) tests are imperfect, but doctors strongly recommend them as part of an overall approach to prostate cancer screening.
Urologist James Kuan, MD, offers expert advice on how men can work with their doctors to find prostate cancer early and understand their treatment options.
Prostate cancer is the most common cancer in men, just behind skin cancer. One in eight men will get prostate cancer in their lifetime. The American Cancer Society estimates that in 2022 about 268,000 new cases of prostate cancer will be diagnosed and about 34,000 men will die from it.
The good news is that early detection and treatment saves lives. We listened to a recent conversation between Rick Malambri, host of His health podcast, and Dr. James Kuan, Swedish Board Certified Urologist, who shed some light on this important topic. Here are some important points.
The His Health Podcast is produced by Providence Health System and sponsored by Boston Scientific.
Q. Thank you for joining us today, Dr. Kuan. Can you remind our listeners of your background?
A. Sure. I’m a urologist at Swedish in Seattle, specializing in men’s health – specifically male sexual dysfunction. Prostate prevention, detection and treatment are an integral part of my practice.
Q. Let’s start with the basics. What is the prostate?
A. The prostate is a gland that only men have, and its main function is sexual reproduction. The prostate produces semen, the fluid we release during orgasm that contains semen.
The prostate sits below the bladder and is about the size of a walnut in a healthy male.
Q. What causes prostate cancer?
A. It is usually a combination of factors – these can be environmental or hormonal or related to lifestyle or family history. There may also be genetic factors at play.
Q. Is prostate cancer considered an aggressive form of cancer?
A. In general, no. Most men diagnosed with prostate cancer will die of something else, even if their cancer has spread beyond the prostate. That said, there are aggressive forms of prostate cancer. When this is the case, we can often manage the disease for many years before it leads to the complications we expect to see with advanced cancers.
Q. How treatable is prostate cancer?
A. When prostate cancer is diagnosed early, the cancer is contained in the prostate – it hasn’t spread to the bones or lymph nodes. This is the scenario for most men and their chances of survival are very good.
Q. Are screenings important for early detection of prostate cancer?
A. Yes. The screening assessment generally includes two important elements: a finger examination (called a “digital examination”) of the prostate and a PSA blood test. PSA stands for prostate specific antigen, a protein that only the prostate makes. A rising or elevated PSA is an indicator of potential prostate cancer.
The PSA test isn’t perfect, but urologists look at the results and put them in context with other risk indicators, such as family history, the presence or absence of symptoms, the size or sensation of the prostate on examination, and whether the PSA level has changed over time. This “big picture” helps us decide if a man can benefit from a biopsy, which is the only way to definitively diagnose prostate cancer. A biopsy simply involves obtaining a sample of tissue.
The screening process usually takes place in the primary care office, and if there is a problem, the doctor will refer the patient to a urologist.
Q. When should men start getting tested?
A. The current recommendation is that men talk to their GP or urologist about getting tested at age 55. If a man is of African American heritage or has a sibling or father with a history of prostate cancer, his screenings should begin in his 40s.
Q. What are the treatment options for men with prostate cancer?
A.The mainstays of treatment for most men with prostate cancer are radiation therapy and prostatectomy (surgery to remove the prostate). Some men may have both radiation and surgery – this is often the case when the cancer is more advanced.
Active surveillance – what we used to call watchful waiting – is something we can discuss with men whose cancer is at very low risk. Low risk means the man has a very low PSA level and his cancer is growing slowly and a biopsy shows only a small amount of tumor.
Active surveillance may involve PSA tests every three or six months, repeat biopsies at different stages, and possibly magnetic resonance imaging (MRI) scans. This may be the best approach when we believe that a particular patient’s prostate cancer is of such low risk that it may never become a problem in their lifetime. About 30% of men with prostate cancer can be actively monitored.
Thus, not everyone receives the same treatment approach. But a discussion of all options is necessary to help a man make informed treatment decisions.
Q. How does not having a prostate affect sexual function?
A. After a prostatectomy, a man can still have an orgasm but not ejaculate. This is because the gland that produces sperm has disappeared. This side effect can also occur after radiation therapy.
The other side effect that men worry about is whether they will be able to get an erection after the surgery. It depends on what happens during the surgery. The two nerves that stimulate an erection sit on the surface of the prostate. If the surgeon can spare these nerves during the operation, chances are the patient will be able to get an erection. However, sometimes the surgeon must remove one or both of these nerves to get rid of the cancer cells. This will impact the possibility of an erection after surgery.
Q. What about urination?
A. The prostate is like a speed bump that holds back urine. When a man no longer has a prostate, we strongly recommend doing Kegel exercises to strengthen his pelvic floor. With Kegels, about 90% of men are continent a year after surgery, which means they don’t have to wear a towel or anything like that to stay dry.
Q. How should men choose a surgeon if they need one?
A. There is very good data that indicates that the results of prostate surgery are better when the surgery is performed by someone who has had a lot of prostatectomies. Most prostatectomies are done by robot, which is less invasive than open surgery. Compared to open surgery, minimally invasive surgery results in a shorter hospital stay and a faster return to your usual activities
At Swedish, we have a well-established robotics program. In fact, we are one of the busiest hospitals on the West Coast for robotic surgery. Our surgeons have performed thousands of prostatectomies herewith excellent results.
Q. What does long-term follow-up look like for men who have been treated for prostate cancer?
A. Longer term, these men will need follow-up PSA tests for the rest of their lives. An increase in the PSA level would indicate that the cancer may have returned.
Fortunately, the five-year survival rate for men with localized prostate cancer is almost 100%. However, up to 40% of men will experience a recurrence, so it is essential to understand your risk and get tested periodically. And be sure to talk to your doctor about any changes, treatment side effects, or any other concerns you may have.
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This information is not intended to replace professional medical care. Always follow the instructions of your healthcare professional.