Checking for prostate cancer and available treatment options

Prostate cancer is often a slow-growing disease that doesn’t exhibit symptoms for up to a decade. Early detection is key to identifying prostate cancer early and determining whether treatment or observation should be the next step. While your family history is key for determining how likely it is you may develop the disease, all men should eventually be screened for prostate cancer.

The prostate is a small gland below the bladder that produces fluid for semen. Other than skin cancer, prostate cancer is the most common form of cancer among men, with significant prostate affecting about 5% of men. Modern screening options help men to identify prostate cancer in its early stage, before symptoms appear. Warning signs of prostate cancer may include blood in the urine or semen, changes in urine urgency or frequency or bone pain in the hips, back or ribs.

Risk for this disease is tied closely to family history. A man with a father or brother with prostate cancer is more likely to develop the disease. The same is true for men with a mother or sister with breast cancer.

“It’s important to know your family history for a couple reasons,” said Dr. Clint Bahler, urologist at I Health. “Men with a family history of prostate cancer should start screening sooner. These men will start getting the prostate-specific antigen (PSA) blood test at age 40. But there are more aggressive prostate cancers that don’t create an elevated PSA, so a digital rectal exam will be important to catch that cancer early.”

The most accurate tests for prostate cancer

The two most common prostate cancer screenings are the PSA blood test and digital rectal exam. Most cases of prostate cancer are detected using a PSA blood test, which is offered to most men by the age of 50. Cells in the prostate gland create a protein called a prostate-specific antigen, and small amounts of this protein show up in the bloodstream. Through a blood test, physicians can check a man’s PSA levels to determine his risk for prostate cancer.

While a PSA test result of 4 or 5 nanograms per milliliter (ng/mL) is cause for a physician to do further testing to check for prostate cancer, it doesn’t necessarily mean someone has the disease. As men age, their prostate enlarges, and their PSA level can rise. Other factors that can lead to abnormal PSA include:

• An unusually large prostate
• Certain medications
• Illness or infection

Since PSA levels can change, it’s important for men to continue these screenings annually between the ages of 50 and 70 to monitor for trends in the number. While one person may start out with a higher PSA than someone else, ongoing monitoring helps the physician notice any unique trends or significant changes that could indicate cancer.

While there are at-home PSA tests, this prostate screening should be completed by a physician, as it requires specialized knowledge to interpret results and determine what tests are necessary.

Sometimes prostate cancer does not secrete PSA. Your doctor may also perform a digital rectal exam (DRE) to physically check the prostate gland for tumors. During a DRE, the doctor inserts a lubricated, gloved finger through the rectum to check the prostate for cancerous growths. While a DRE may be uncomfortable, it is typically brief and painless.

If a PSA or DRE suggests cancer, the physician may repeat the PSA to see if the level has changed. They may also perform an MRI (magnetic resonance imaging) to view the prostate. If any of these tests suggests cancer, the doctor will perform a prostate biopsy to obtain tissue that can be viewed under a microscope to confirm a cancer diagnosis.

Grading and treating prostate cancer

By grading prostate cancer, doctors can categorize fast- and slow-growing tumors. Grading prostate cancer helps categorize fast- and slow-growing tumors to help plan treatment. Grading has improved over time, with physicians now using a 1-5 scale based on the Gleason Grading system.

Low-risk prostate cancer describes most prostate cancers, or pre-cancers. This is Grade 1, which may also be described using a Gleason score of 6. These cancers grow very slowly and may never cause any symptoms or health concerns. Patients with low-grade prostate cancer may not need to be treated for their cancer. Since it is slow growing, the physician may simply want to monitor Grade 1 prostate cancer over time with a combination of PSA tests, MRIs and biopsies. Genomic testing can also be done to further assess cancer risk.

Intermediate-risk prostate cancers are more able to spread beyond the prostate, and they’re graded higher. Intermediate-risk prostate cancer (Grade 2-3; Gleason 7) is often treated with a single therapy, such as surgery, radiation or a focal therapy, such as High-Frequency Ultrasound (HIFU). HIFU was developed by IU School of Medicine physicists and engineers with help from IU Health surgeons. IU Health is one of the highest-volume HIFU centers in the country, and Dr. Bahler trains physicians across the country on this ultrasound wave therapy.

High-risk prostate cancer (Grade 4-5; Gleason 8-10) is likely to metastasize or spread throughout the body. This type of prostate cancer often requires multiple forms of treatment, including surgery, radiation and hormone therapy. Surgery may include a prostatectomy to remove the prostate and seminal vesicles.

Since it can take more than 10 years for prostate cancer to spread and case pain or death, treatment depends on the patient’s health and life expectancy. It can be a complex and challenging decision that should be made with the support of a trusted physician.

“It comes down to reputation. You want to find a physician who’s a champion for prostate cancer. It’s important to go to a cancer center where there are specialists who are dedicated specifically to treating prostate cancer,” Dr. Bahler said. “Finding someone you can trust is key to having peace of mind and focusing on healing.”