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 early last year. In December, the nine-time gold glover announced the cancer had recurred and that he would again begin more “intensive treatment.” 

And sadly, Dexter Scott King—the youngest son of the Rev. Martin Luther King Jr., PhD—died of prostate cancer last year. 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 one of the most common types of 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. Meanwhile, risk for prostate cancer is also higher among Black men. The decision to undergo prostate cancer screening is based on patient risk and age. 

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

In this installment, two physicians took time to discuss what patients need to know about prostate cancer. They are:

• William L. Dahut, MD, a hematologist-oncologist and chief scientific officer for the American Cancer Society. 
• Paul Kozlowski, MD, a urologist at Virginia Mason Franciscan Health in Seattle, Washington. 

Virginia Mason Franciscan Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“In 2024, almost 300,000 men were diagnosed with prostate cancer and there were about 35,000 deaths,” said Dr. Kozlowski. “The leading cause of cancer mortality in men is still lung, second is prostate, third is colorectal or colon cancer.”

“Prostate cancer is one of the most commonly diagnosed malignancies in men,” he said. “It’s a very prevalent disease.” 

“Prostate cancer clearly increases the older you are. That’s the greatest risk factor,” said Dr. Dahut. “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,” said Dr. Dahut. “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.”

“We are increasingly seeing that men 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 find 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 U.S. Preventive Services Task Force (USPSTF) is currently updating their prostate-cancer screening guidelines, which were last updated in 2018. 

Prostate cancer currently “has a C rating for men between 55 and 69, which means talk to your doctor about” the potential benefits and harms of screening before doing it, said Dr. Kozlowski. 

The USPSTF notes that prostate cancer screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, potential harms of screening include false-positive results that require additional testing and possible prostate biopsy, overdiagnosis and overtreatment, and treatment complications, such as incontinence and erectile dysfunction. Prostate Specific Antigen (PSA)-based screenings for prostate cancer are currently not recommended for men 70 or older.

“But the American Urological Association recommends we do screening,” said Dr. Kozlowski, noting that it is recommended that physicians “start screening between 40 and 50 years old with a prostate cancer blood test called PSA” for men at increased risk of developing prostate cancer based on Black ancestry, germline mutations and strong family history. 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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The PSA test “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,” Dr. Dahut 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,” he said, noting that in 2023 “only about 25% of men between 50 and 64 … 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.”

“Prostate cancer—in the majority of patients—is a silent disease,” said Dr. Kozlowski. “People do not have outward signs or symptoms of prostate cancer. And that's why screening is important. And if people do have signs or symptoms, it usually means they have a later stage of the disease.”

“If men do have symptoms of increased urinary frequency or even obstructive symptoms, they tend to be benign growth of prostate cancer cells,” Dr. Dahut said. “If people do have weight loss, bone pain, blood in your urine, fatigue—any of those symptoms could be related to a cancer. In men, prostate cancer would be one to be concerned about.”

“There are different levels of aggressiveness and in cancer it’s called grade of the disease. And prostate cancer is called the Gleason score,” Dr. Kozlowski said. 

“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.” 

“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.”

“We know that prostate cancer is probably a natural part of aging. Most men, if they live long enough, will probably develop prostate cancer,” Dr. Kozlowski said. “But most of those men will die of other causes—old age, complications with their heart, other comorbidities.

“So, we know that there is a group of men with the low-grade cancers who we can actually follow through active surveillance and there’s a schedule of what these patients go through in terms of evaluations,” he added. “We’re looking to see if the prostate cancer changes or indicates it is time to treat.”

“There are treatments out there, and we do see that men who are picked up at early stages with intervention are living longer,” said Dr. Kozlowski. 

“Prostate cancer itself does not affect sexual health. Obviously, men worry about erectile function. We know that changes with aging but just having prostate cancer does not affect a man’s ability to be sexually active,” Dr. Kozlowski said. “Now, we know that some of the treatments for prostate cancer can affect sexual function as a potential side effect.”

“There’s no question about it that treatment can have an impact, particularly on sexual function,” Dr. Dahut 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,” he 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.”

“People who adopt healthy lifestyles—eating right, exercising, trying to maintain a good level of fitness—not only is it good for our overall bodies, our cardiovascular systems, but it can reduce the risk of people developing several cancers,” Dr. Kozlowski said. “We hear about high cholesterol or high fatty diets being associated with certain cancers. And we know that alcohol use can be associated with cancer.”

“There is no downfall to adopting a healthy lifestyle—it helps your heart, your organs, everything,” he said. 

“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.”