Screening for prostate cancer
Whether to test healthy men with no symptoms for prostate cancer is controversial. Medical organizations don't agree on the issue of screening and whether it delivers benefits.
Some medical organizations recommend men consider prostate cancer screening in their 50s, or sooner for men who have risk factors for prostate cancer.
Discuss your particular situation and the benefits and risks of screening with your doctor. Together, you can decide whether prostate cancer screening is right for you.
Prostate screening tests might include:
- Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of the gland, you may need further tests.
- Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein in your arm and analyzed for PSA, a substance that's naturally produced by your prostate gland. It's normal for a small amount of PSA to be in your bloodstream. However, if a higher than normal level is found, it may indicate prostate infection, inflammation, enlargement or cancer.
PSA testing combined with DRE helps identify prostate cancers at their earliest stages. Hence, debate continues surrounding prostate cancer screening.
Diagnosing prostate cancer
If a DRE or PSA test detects an abnormality, your doctor may recommend further tests to determine whether you have prostate cancer, such as:
- Ultrasound. If other tests raise concerns, your doctor may use transrectal ultrasound to further evaluate your prostate. A small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to create a picture of your prostate gland.
- Collecting a sample of prostate tissue. If initial test results suggest prostate cancer, your doctor may recommend a procedure to collect a sample of cells from your prostate (prostate biopsy). Prostate biopsy is often done using a thin needle that's inserted into the prostate to collect tissue. The tissue sample is analyzed in a lab to determine whether cancer cells are present.
- MRI fusion. While still being developed worldwide, MRI fusion to assist in prostate biopsy and diagnosis is being used more and more.
At Mayo Clinic, urologists and radiologists collaborate to leverage MRI fusion biopsy technology, yielding the best fusion imaging available for prostate cancer care.
Mayo Clinic also leverages MRI-TRUS fusion technology, which blends (fuses) images from an MRI scan and transrectal ultrasound (TRUS) to create a more-precise 360-degree prostate map, which in turn can improve prostate biopsy accuracy.
Mayo Clinic is also the first medical center in the United States approved by the Food and Drug Administration to prepare and administer C-11 choline PET scanning to help detect recurrent prostate cancer at its earliest stages — before it can be detected by other imaging tests — and enable more-precise targeting for follow-up treatment.
Determining whether prostate cancer is aggressive
When a biopsy confirms the presence of cancer, the next step is to determine the level of aggressiveness (grade) of the cancer cells. A laboratory pathologist examines a sample of your cancer to determine how much cancer cells differ from the healthy cells. A higher grade indicates a more aggressive cancer that is more likely to spread quickly.
The most common scale used to evaluate the grade of prostate cancer cells is called a Gleason score. Gleason scoring combines two numbers and can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer), though the lower part of the range isn't used as often.
Most Gleason scores used to assess prostate biopsy samples range from 6 to 10. A score of 6 indicates a low-grade prostate cancer. A score of 7 indicates a medium-grade prostate cancer. Scores from 8 to 10 indicate high-grade cancers.
In addition, genomic testing is increasingly being used to more accurately assess risk and detect aggressive prostate cancer.
Mayo Clinic physicians and researchers are leaders in the development of biomarkers for prostate cancer. Doctors in Mayo Clinic's Center for Individualized Medicine are advancing research on the use of biomarkers in blood and in prostate tissue to better individualize and optimize treatment for men with prostate cancer. The technology helps caregivers distinguish between insignificant and significant prostate cancer, as well as identify particularly aggressive prostate cancer in men undergoing surgery.
Determining how far the cancer has spread
Once a prostate cancer diagnosis has been made, your doctor works to determine the extent (stage) of the cancer. If your doctor suspects your cancer may have spread beyond your prostate, one or more of the following imaging tests may be recommended:
- Bone scan
- Computerized tomography (CT) scan
- Magnetic resonance imaging (MRI)
- Positron emission tomography (PET) scan
At Mayo Clinic, caregivers can also turn to prostate-specific membrane antigen (PSMA) studies to help detect the extent of newly diagnosed prostate cancer and whether the disease has spread to nearby lymph nodes.
Mayo clinicians also use recent 7 Tesla (7T) magnet imaging technology advancements to differentiate between prostate cancer that does or doesn't require immediate intervention.
Not every person should have every test. Your doctor will help determine which tests are best for your individual case.
Your doctor uses the information from these tests to assign your cancer a stage. Prostate cancer stages are indicated by Roman numerals ranging from I to IV. The lowest stages indicate the cancer is confined to the prostate. By stage IV, the cancer has grown beyond the prostate and may have spread to other areas of the body.
The cancer staging system continues to evolve and is becoming more complex as doctors improve cancer diagnosis and treatment. Your doctor uses your cancer stage to select the treatments that are right for you.
Your prostate cancer treatment options depend on several factors, such as how fast your cancer is growing, how much it has spread and your overall health, as well as the potential benefits or side effects of the treatment.
Immediate treatment may not be necessary
For men diagnosed with low-risk prostate cancer, treatment may not be necessary right away. Some men may never need treatment. Instead, doctors sometimes recommend active surveillance.
In active surveillance, regular follow-up blood tests, rectal exams and possibly biopsies may be performed to monitor progression of your cancer. If tests show your cancer is progressing, you may opt for a prostate cancer treatment such as surgery or radiation.
Active surveillance may be an option for cancer that isn't causing symptoms, is expected to grow very slowly and is confined to a small area of the prostate. Active surveillance may also be considered for someone who has another serious health condition or who is of an advanced age that makes cancer treatment more difficult.
Active surveillance carries a risk that the cancer may grow and spread between checkups, making the cancer less likely to be cured.
Surgery to remove the prostate
Surgery for prostate cancer involves removing the prostate gland (radical prostatectomy), some surrounding tissue and a few lymph nodes. Radical prostatectomy can be performed in several ways:
- Using a robot to assist with surgery. During robot-assisted surgery, the instruments are attached to a mechanical device (robot) and inserted into your abdomen through several small incisions. The surgeon sits at a console and uses hand controls to guide the robot to move the instruments. Robotic prostatectomy may allow the surgeon to make more-precise movements with surgical tools than is possible with traditional minimally invasive surgery.
- Making an incision in your abdomen. During retropubic surgery, the prostate gland is taken out through an incision in your lower abdomen.
Discuss with your doctor which type of surgery is best for your specific situation.
Radical prostatectomy carries a risk of urinary incontinence and erectile dysfunction. Ask your doctor to explain the risks you may face based on your situation, the type of procedure you select, your age, your body type and your overall health.
Radiation therapy uses high-powered energy to kill cancer cells. Prostate cancer radiation therapy can be delivered in two ways:
- Radiation that comes from outside of your body (external beam radiation). During external beam radiation therapy, you lie on a table while a machine moves around your body, directing high-powered energy beams, such as X-rays or protons, to your prostate cancer. You typically undergo external beam radiation treatments five days a week for several weeks.
- Radiation placed inside your body (brachytherapy). Brachytherapy involves placing many rice-sized radioactive seeds in your prostate tissue. The radioactive seeds deliver a low dose of radiation over a long period of time. Your doctor implants the radioactive seeds in your prostate using a needle guided by ultrasound images. The implanted seeds eventually stop emitting radiation and don't need to be removed.
Side effects of radiation therapy can include painful, frequent or urgent urination, as well as rectal symptoms such as loose stools or pain when passing stools. Erectile dysfunction can also occur.
Hormone therapy is treatment to stop your body from producing the male hormone testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting off the supply of testosterone may cause cancer cells to die or to grow more slowly.
Hormone therapy options include:
- Medications that stop your body from producing testosterone. Medications known as luteinizing hormone-releasing hormone (LH-RH) agonists prevent the testicles from receiving messages to make testosterone. Drugs typically used in this type of hormone therapy include leuprolide (Lupron, Eligard), goserelin (Zoladex), triptorelin (Trelstar) and histrelin (Vantas). Other drugs sometimes used include ketoconazole and abiraterone (Zytiga).
- Medications that block testosterone from reaching cancer cells. Medications known as anti-androgens prevent testosterone from reaching your cancer cells. Examples include bicalutamide (Casodex), nilutamide (Nilandron) and flutamide. The drug enzalutamide (Xtandi) may be an option when other hormone therapies are no longer effective.
- Surgery to remove the testicles (orchiectomy). Removing your testicles reduces testosterone levels in your body.
Hormone therapy is used in men with advanced prostate cancer to shrink the cancer and slow the growth of tumors. In men with early-stage prostate cancer, hormone therapy may be used to shrink tumors before radiation therapy, which can increase the likelihood that radiation therapy will be successful.
Side effects of hormone therapy may include erectile dysfunction, hot flashes, loss of bone mass, reduced sex drive and weight gain.
Freezing prostate tissue
Cryosurgery or cryoablation involves freezing tissue to kill cancer cells.
During cryosurgery for prostate cancer, small needles are inserted in the prostate using ultrasound images as guidance. A very cold gas is placed in the needles, which causes the surrounding tissue to freeze. A second gas is then placed in the needles to reheat the tissue. The cycles of freezing and thawing kill the cancer cells and some surrounding healthy tissue.
Initial attempts to use cryosurgery for prostate cancer resulted in high complication rates and unacceptable side effects. However, newer technologies have lowered complication rates, improved cancer control and made the procedure easier to tolerate. Cryosurgery is more frequently used as a salvage therapy for men who haven't been helped by radiation therapy.
Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form or both.
Chemotherapy may be a treatment option for men with prostate cancer that has spread to remote body locations. Chemotherapy may also be an option for cancers that don't respond to hormone therapy.
Biological therapy (immunotherapy) uses your body's immune system to fight cancer cells. One type of biological therapy called sipuleucel-T (Provenge) has been developed to treat advanced, recurrent prostate cancer.
This treatment takes some of your own immune cells, genetically engineers them in a laboratory to fight prostate cancer, then injects the cells back into your body through a vein. Some men do respond to this therapy with some improvement in their cancer, but the treatment is very expensive and requires multiple treatments.
No complementary or alternative treatments will cure prostate cancer. However, complementary and alternative prostate cancer treatments may help you cope with the side effects of cancer and its treatment.
Nearly everyone diagnosed with cancer experiences some distress at some point. If you're distressed, you may feel sad, angry or anxious. You may experience difficulty sleeping or find yourself constantly thinking about your cancer.
Several complementary medicine techniques may help you cope with your distress, including:
- Art therapy
- Dance or movement therapy
- Music therapy
- Relaxation techniques
Discuss your feelings and concerns with your doctor. In some cases, treatment for distress may require medications.
Coping and support
When you receive a diagnosis of prostate cancer, you may experience a range of feelings — including disbelief, fear, anger, anxiety and depression. With time, each person finds his own way of coping with a prostate cancer diagnosis.
Until you find what works for you, try to:
- Learn enough about prostate cancer to feel comfortable making treatment decisions. Learn as much as you need to know about your cancer and its treatment in order to understand what to expect from treatment and life after treatment. Ask your doctor, nurse or other health care professional to recommend some reliable sources of information to get you started.
- Keep your friends and family close. Your friends and family can provide support during and after your treatment. They may be eager to help with the small tasks you won't have energy for during treatment. And having a close friend or family member to talk to can be helpful when you're feeling stressed or overwhelmed.
- Connect with other cancer survivors. Friends and family can't always understand what it's like to face cancer. Other cancer survivors can provide a unique network of support. Ask your health care providers about support groups or community organizations that can connect you with other cancer survivors. Organizations such as the American Cancer Society offer online chat rooms and discussion forums.
- Take care of yourself. Take care of yourself during cancer treatment by eating a diet full of fruits and vegetables. Try to exercise most days of the week. Get enough sleep each night so that you wake feeling rested.
- Continue sexual expression. If you experience erectile dysfunction, your natural reaction may be to avoid all sexual contact. But consider touching, holding, hugging and caressing as ways to continue sharing sexuality with your partner.
Preparing for your appointment
If you have signs or symptoms that worry you, start by seeing your family doctor or a general practitioner.
If your doctor suspects you may have a problem with your prostate, you may be referred to a urinary tract specialist (urologist). If you're diagnosed with prostate cancer, you may be referred to a cancer specialist (oncologist) or a specialist who uses radiation therapy to treat cancer (radiation oncologist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be prepared. Here's some information to help you get ready and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements that you're taking.
- Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For prostate cancer, some basic questions to ask your doctor include:
- Do I have prostate cancer?
- How large is my prostate cancer?
- Has my prostate cancer spread beyond my prostate?
- What's my Gleason score?
- What's my prostate-specific antigen (PSA) level?
- Will I need more tests?
- What are my treatment options?
- Is there one treatment option you think is best for me?
- Do I need cancer treatment right away, or is it possible to wait and see if the cancer grows?
- What are the potential side effects of each treatment?
- What is the chance that my prostate cancer will be cured with treatment?
- If you had a friend or family member in my situation, what would you recommend?
- Should I see a specialist? What will that cost, and will my insurance cover it?
- Are there brochures or other printed material that I can take with me? What websites do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time later to cover other points you want to address. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?