When to Screen for Prostate Cancer

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    The prostate is about the size of a walnut, but can grow larger as men age. Sometimes this causes the prostate to press on the bladder or urethera, causing benign prostatic hyperplasia, the symptoms of which are similar to those associated with prostate cancer. Urinary symptoms, inflammation and infection caused by BPH can typically be treated.

  • In the early stages of prostate cancer men may have no symptoms. Later, symptoms can include frequent urination, especially at night; difficulty starting or stopping urination; weak or interrupted urinary stream; painful or burning sensation during urination or ejaculation; and blood in urine or semen. Advanced cancer can cause deep pain in the lower back, hips, or upper thighs.

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    For most men, discussions about whether to screen for prostate cancer should begin at age 50 years. Certain individuals at higher risk for prostate cancer, such as black men and those with a father or brother diagnosed with prostate cancer before age 65 years, should consider screening earlier, at age 45 years.

  • Men with multiple family members who were diagnosed with prostate cancer before age 65 years are at appreciably higher risk and should starting screening at age 40 years, whereas those whose age and health status give them a life expectancy of less than 10 years should not be screened.

  • If a patient chooses to undergo prostate cancer screening, a blood test should be performed to measure prostate specific antigen (PSA), a protein produced by prostate cancer cells. This light micrograph shows cells from the prostate gland with PSA dyed red.

  • Digital rectal exams are now optional, and should be considered on an individual basis when PSA blood levels fall between 2.5 ng/mL and 4.0 ng/mL. Even in these patients, studies have shown that the benefit of DRE in detecting cancer is relatively small. Patients should be informed that PSA and DRE tests may produce false-positive or false-negative results, which can result in unnecessary anxiety and additional testing or missed cancer.

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    When blood levels exceed 4.0 ng/mL, further evaluation, perhaps including biopsy, is a reasonable approach, according to the ACS. Patients should be advised that prostate biopsy can be painful, may lead to complications and can sometimes miss significant cancer. A pathologist will analyze biopsy specimens for cell abnormalities and assign a Gleason grade ranging from 1 to 5. The sum of 2 Gleason grades is the Gleason score. These scores help determine the chances of the cancer spreading.

  • Some men may need additional tests to see if the cancer has spread beyond the prostate. These can include ultrasound, a CT scan, or an MRI scan. This colored axial MRI shows adenocarcinoma of the prostate gland. The bladder (grey), partially seen above the enlarged prostate gland, is being compressed by the cancer, which is affecting urination.

  • Staging used to describe how far prostate cancer has metastasized and to help determine the best treatment. In stage I cancer is small and still within the prostate; in stage II cancer is more advanced, but still confined to the prostate; in stage III cancer has spread to the outer part of the prostate and nearby seminal vesicles; and in stage IV cancer has spread to lymph nodes, nearby organs or tissues such as bladder or rectum, or distant organs such as bones or lungs.

  • Prostate cancer treatments include cryotherapy, radiation therapy, hormone therapy, chemotherapy and surgery. Many of these treatments can lead to urinary, bowel, sexual and other health problems, which in some cases are severe and permanent. Not all men whose prostate cancer is detected require immediate treatment. For some, active surveillance with periodic blood tests, biopsy or other testing may safely determine when, if ever, treatment is necessary.

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Screening for prostate cancer has long been part of the yearly checkup for many men. Although this procedure may reduce a patient’s risk for dying from the disease, evidence is conflicting about how helpful it actually is in reducing mortality. Because many prostate cancers are slow growing, treatment often does more psychological and physical harm than good.

Instead of hard and fast screening guidelines, the American Cancer Society currently recommends engaging patients in a shared, informed decision-making process to determine whether or not screening takes place.

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