What doctors wish patients knew about prostate cancer

We’ve seen prostate cancer gain more attention with the diagnosis of Chicago Cubs Hall of Famer Ryne Sanberg with the condition. And sadly, Dexter Scott King—the youngest son of Martin Luther King Jr.—died of prostate cancer. Despite this increase in awareness of prostate cancer, it is the tendency of many men to remain silent about their prostate issues. But overlooking this widespread health concern won’t lead to its resolution.

Prostate cancer is the most common cancer among men and the second-leading cause of cancer death among men in the U.S., with about one in eight being diagnosed during their lifetime. But prostate cancer is more likely to develop in older men. About 60% of prostate cancers are diagnosed in men 65 or older while it is rare in those under 40, according to the American Cancer Society. The decision to undergo prostate cancer screening is based on patient risk and age.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, William L. Dahut, MD, chief scientific officer for the American Cancer Society, took time to discuss what patients need to know about prostate cancer.

“Prostate cancer clearly increases the older you are. That’s the greatest risk factor,” said Dr. Dahut, a hematologist-oncologist who treats patients in the prostate-cancer clinic at Walter Reed National Military Medical Center. “Other things to worry about is family history. If your first-degree relative—such as your brother or your father—has prostate cancer, your risk goes up.

“If you have two first-degree relatives, that goes up significantly,” he added. “If you have certain inherited genetic mutations—the most common is the BRCA2 gene, which is called the breast cancer gene—then your risk is about five times greater than it would have been without that inherited gene.”

Black men, meanwhile, are 70% likelier than other men to be diagnosed with prostate cancer and between two and four times more likely to die of the disease.

“In some randomized clinical trials where everyone receives the same treatment, sometimes Black men actually do better than white men.

“So, there are situations, biases in the system, where Black men are less likely to be offered the same treatment even though they have the same grade and stage of cancer,” Dr. Dahut added, noting “there are definitely issues beyond simply the increased risk factors.”

“We are increasingly seeing that mean at higher genetic risk for prostate cancer with inherited mutations can develop a more aggressive prostate cancer,” Dr. Dahut said. “So, for a male patient, if you have a BRCA2 gene, you could potentially pass that on to your daughter or sons.”

“If you have an aggressive prostate cancer or a strong family history of prostate cancer, it is important to understand if you’ve inherited a genetic mutation that either puts you at higher risk or puts your family members at higher risk,” he said, noting there are “targeted therapies for men with those genetic mutations.”

“Prostate cancer, when we found it early, is an incredibly curable disease,” Dr. Dahut said, noting that when “found early, over 99% of men would be alive and cancer free at five years.”

But when “prostate cancer is advanced, once it has spread to the bones, it's not a curable cancer,” he said. “And then the life expectancy of men with metastatic prostate cancer is somewhere between three to five years.”

“In general, screening for prostate cancer depends a little bit on your individual risk. So, for men with average risk, we think a conversation should begin no later than 50,” Dr. Dahut said. “If you’re somebody at higher risk—if you have an inherited mutation or if you’re a Black man or if you have strong family history—you probably will need to talk about screening at 40 or 45.”

The American Urological Association recommends that when screening for prostate cancer, physicians should use a prostate-specific antigen (PSA) as the first screening test. It is also recommended that physicians offer prostate cancer screening beginning at 40 to 45 years old for men at increased risk of developing prostate cancer based on Black ancestry, germline mutations and strong family history of prostate cancer. Physicians may use a digital rectal exam alongside a PSA-based screening to establish risk of clinically significant prostate cancer, says the American Urological Association. 

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Meanwhile, the US Preventive Services Task Force is updating their prostate cancer screening recommendations. But currently, for men 55 to 69 years old, the task force indicates that the decision to undergo screening for prostate cancer should be an individual one. Men should discuss the potential benefits and harms of screening with their physician. PSA-based screenings for prostate cancer are not recommended for men 70 or older.

Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, there are potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. 

“Now, screening is multifocal. The first step is simply a blood test—a prostate-specific antigen test. It doesn’t tell you whether you have prostate cancer or not, but the higher the value, the more likely you are to have prostate cancer,” he said. “Then based on that, most men would be referred for a possible biopsy, which is done by ultrasound, or many times have an MRI [magnetic resonance imaging] done where prostate lesions can actually be visualized much easier. And those lesions can be targeted and biopsied, as well as biopsies of the other parts of the prostate.”

“Screening rates have gone down significantly since their peak about 20 years ago and we’ve seen increased incidences of men presenting with more advanced disease over the last decade or so,” Dr. Dahut said. “Only about 25% of men between 50 and 64 last year actually had a PSA test. Men, because of this fear of the treatment for cancer or fear of cancer, are not being screened at all.

“And thus, when they have a diagnosis of prostate cancer, once it has spread out to the bone, that’s not a curable cancer,” he added.

At the time of diagnosis, “most men do not have symptoms of prostate cancer,” said Dr. Dahut. “And if men do have symptoms of increased urinary frequency or even obstructive symptoms, they tend to be benign growth of prostate cancer cells.

“If people do have weight loss, bone pain, blood in your urine, fatigue—any of those symptoms could be related to a cancer,” he said, noting that “in men, prostate cancer would be one to be concerned about.”

“Prostate cancer has been initially graded by something called the Gleason score. The Gleason score looks at patterns of cells, kind of like wallpaper, as opposed to individual cells,” Dr. Dahut explained. “Those patterns are able to predict how aggressive your cancer is. And generally, the two most predominant areas are added together to give you a Gleason score.

“We start at three because one and two are no longer used. If you have a three plus three—a six— you probably could have your cancer safely watched, and maybe even a three plus four,” he said, noting “the highest is a five and under the microscope a prostate cancer with a score of five actually looks more like a cancer elsewhere in the body than a normal prostate cell.

“Those cancers have a very high likelihood of spreading,” Dr. Dahut added. “And then the stage basically looks at: Is it still in the prostate, is it outside the prostate, is it in the lymph nodes, or has it spread to more distant organs?”

“We’re trying to understand the role of lifestyle changes. There’s something called the polygenic risk score … which is a combination of what we call signal nucleotide polymorphisms,” Dr. Dahut said, noting that is “a combination of genes—some of which can just be normal variants, but when put together it puts you at higher or lower risk for prostate cancer.

“And there’s at least some data that men at the highest risk, the highest quintile of this, who had a heart healthy diet and exercised, retrospectively, did not decrease their prostate cancer risk, but their risk of aggressive prostate cancer did decrease,” he added. “So, it certainly seems like it’s possible that having a heathier diet, a low-fat diet, and exercising may have an impact on prostate cancer outcomes.”

“Prostate cancer, unlike many cancers, is not a cancer that always needs to be treated,” Dr. Dahut said, noting “we found over time that many men will actually die with prostate cancer as opposed to dying from it.

However, given that prostate cancer deaths often exceed 35,000 a year in the U.S., “it’s not something to be ignored,” he added. “Some cells actually become malignant, but then actually don’t progress or leave outside the prostate.”

“We have found over time that patients can often be what we call ‘undergo active surveillance’ where the prostate is monitored by a blood test, which is called the prostate-specific antigen and is measuring a circulating protein or by imaging with an MRI or a biopsy and needle into the prostate,” Dr. Dahut said. “Then an intervention—whether it’s radiation or surgery—can be done at a point where it’s still safe and still can have an outcome that’s of benefit for the patient.”

“We actually have data that, in general, prostate cancer has a greater impact on Black men’s quality of life than white men’s,” Dr. Dahut said. “Whether or not that’s because they have more disease at the time or presentation, or the impact of the therapies, is a little hard to know.”

“There’s no question about it that treatment can have an impact, particularly on sexual function,” he said, referring to erectile dysfunction, while noting that effective medications such as sildefanil (marketed as Viagra) and other medications can help.

“Not every person who has prostate cancer treatment has an impact on their ability to have erectile function,” Dr. Dahut said. “A lot depends on age and function going in. Younger, healthier men often do much better after surgery than older men that have poor performance to start out.”

“That’s why it’s all really important to find prostate cancer earlier on when these treatments are not necessarily needed,” he emphasized.

“We do think, in general, the things that one can do to keep oneself healthy are certainly important, because some of the drugs given for prostate cancer can lead to thinning of normal bones, particularly one to block the male hormone testosterone,” Dr. Dahut said. “So, keeping active physically and eating a low-fat diet as much as possible are things that we think potentially can be helpful.

That having been said, he noted that “we don’t have definitive data to say that whether you do that or don’t do that will help an individual patient.”

“What the diagnosis means to the patient is totally dependent on the aggressiveness and spread of the cancer,” Dr. Dahut said. “If the cancer has a very high Gleason score, then the patient will need treatment. Whether it’s a surgery or radiation or combination, if the cancer has spread to other parts of the body, then the patient will probably need hormonal treatment. In some cases, even chemotherapy.

“But if the prostate cancer is at a more indolent stage, the patient can safely undergo active surveillance and will need to have annual follow up visits with their physician,” he added. “If the cancer tends to progress, then patients will undergo a discussion of next steps.”