Father’s Day marks the conclusion of National Men’s Health week, an annual observance established by Congress in 1994 to highlight the importance of prevention, early detection and treatment of male diseases. This week serves as a timely reminder to focus on one of the top five medical concerns for men: prostate cancer.
As the most commonly diagnosed male malignancy in the United States. and the second-leading cause of cancer mortality — after lung cancer — prostate cancer is projected by the American Cancer Society to cause 35,250 deaths this year. Despite its frequency, the prognosis is among the best of all malignancies: 95% of men diagnosed with the disease are alive 15 years after its discovery, and most of them die from natural causes.
Seniors have a higher incidence of prostate cancer, with about two-thirds of malignancies found in men 65 or older. Other risks include family history, genetic factors and ethnicity. Black men, for reasons not entirely understood, are 70% more likely to develop prostate cancer. Other causal factors include obesity and smoking — both can increase the hormones that cause tumor growth — and exposure to chemicals like Agent Orange, a Vietnam War era defoliant, or extinguishing foams used by firefighters.
The prostate is a walnut-shaped gland located deep in the pelvis, just below the bladder. It produces fluid crucial for sperm survival, including an enzyme called prostate-specific antigen (PSA). Tiny amounts of PSA also circulate in the blood, and abnormally high levels can be associated with malignancy.
There are no outward signs of early prostate cancer, but as the tumor enlarges, symptoms may include trouble urinating or blood in semen or urine. If undetected for years, prostate cancer can spread to bones, causing pain and unexplained weight loss.
Screening for prostate cancer can aid in early detection, but standard tests have faced scrutiny over the past decade. These tests include the digital rectal exam (DRE), where the clinician feels the size and contour of the gland from the rectum, and the popular but controversial PSA blood test.
Studies show that less than one-third of men with an elevated PSA (above 4 nanograms/milliliter) actually have prostate cancer. Benign conditions, such as prostate inflammation or enlargement, can falsely elevate the reading. The next step for those with a high number is often a prostate biopsy, which carries risks including infection, bleeding, anxiety, even transient erectile dysfunction. By 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against performing a PSA as part of an annual checkup. DREs were dropped too, deemed ineffective as a cancer screen. The USPSTF said that PSA screening should be reserved for those at highest risk, or offered on a case-by-case basis, a shared decision between patient and provider.
However, metastatic prostate cancer is on the rise, up 5% in the past decade, partially attributed to an aging population. Research suggests the USPSTF’s more relaxed screening approach may have played a role, prompting the organization to reassess its stance. In 2023, the American Urological Association updated its guidelines on prostate cancer testing and recommended a PSA every two to four years from ages 50 to 69; newly elevated test results are double-checked before any further evaluation.
Credit: Courtesy of the American Cancer Society
The majority of prostate cancers grow so slowly they often require little treatment. Watchful waiting, which typically includes periodic PSAs, is recommended for many seniors or those with serious health problems. Serial PSAs have been effectively used to monitor cancer spread in patients with known malignancy. Active surveillance is often suggested for small cancers confined to the gland; the patients get blood work, imaging studies and, if needed, needle biopsies. Studies show the outcomes in these cases are no different than if the patient was treated with surgery or radiation. Still, an estimated 40% of men are uncomfortable living with a slow-growing cancer and opt for early, aggressive treatment.
New screening exams have arrived on the scene: the Prostate Health Index, a more reliably accurate blood test; a genetic urine test for prostate cancer; and an updated prostate MRI to confirm the need for biopsy. There is also a spit test in the works, another genetic marker screen. Your medical provider will choose the option that works best for you.
You can lower your risk of prostate cancer by maintaining a normal body weight, exercising, cutting down on alcohol and quitting smoking. Lifelong sexual activity is protective, as are diets rich in Vitamin D and omega-3 fats, found in nuts, seeds and fish. Eat plenty of antioxidant-rich tomatoes and dark green leafy vegetables, and cut back on grilled meat.
Dr. Mary Jenkins, a contributor to the Herald and member of its board of directors, retired after nearly 40 years as a family practice physician in New York state.