The earlier that prostate cancer is detected, the easier it is to treat and the greater the chance for a successful treatment. Unfortunately, prostate cancer usually shows no symptoms until it reaches an advanced stage. Because of this, two early detection methods have been developed to search for early stage disease.
Early detection generally includes both a prostate specific antigen (PSA) blood test and a digital rectal examination (DRE). The prostate gland lies in front of the rectum, so only the back wall of the prostate can be examined by DRE. Without the PSA test, tumors located elsewhere in the gland could go undetected by the DRE. The introduction of the PSA test [prostate-specific antigen] in the 1980s enabled previously undetectable prostate cancer to be identified. The PSA test has become controversial because it lacks precision in identifying early prostate cancers, and this can result in unnecessary diagnostic tests and treatments, some with potentially significant side effects. There are, however, many men alive today who would not presently be with us were it not for PSA testing. It is imperative that individual men take responsibility for learning the pros and cons of PSA testing and make the decision that is best for their unique situation and family history.
A DRE involves the insertion of a gloved, lubricated finger into the rectum and pressing on the anterior wall of the prostate. Generally, your practitioner is feeling for nodules, which are firm, hard areas within the prostate. Nodules may, or may not, be cancerous; this can only be determined by a biopsy. Since only one wall of the prostate is accessible during the DRE, a PSA test traditionally is also performed. It is important that your blood be drawn prior to the DRE, as the manipulation of the prostate gland during a DRE can artificially increase the presence of the prostate specific antigen.
Prostate-specific antigen is a substance that is normally produced by the prostate gland, and a small amount of PSA occurs naturally in the blood. However, if the prostate begins to make too much PSA, it could be a sign of an enlarged prostate (also known as BPH – benign prostatic hyperplasia), inflammation, or cancer. The problem is, there is no clear-cut definition of a “normal” PSA level. Generally speaking, any significant increase from any number -- no matter how low -- usually warrants further investigation. Since rises in PSA more often than not are caused by something other than cancer, your physician may try to eliminate other possibilities first, such as infection, inflammation, or an enlarged prostate.
If a biopsy is recommended, and if that biopsy reveals the presence of prostate cancer, the challenge becomes choosing the proper treatment. This is complicated by two factors. First, all treatments carry potentially significant side effects. Second, some prostate cancers, perhaps most prostate cancers, are not life threatening. Unfortunately, the current state of medical knowledge does not yet allow a clear determination as to which cancers are life threatening and which are not. There are, however, an increasing number of indicators that allow for a very educated guess as to the risk for any particular individual. In some, perhaps many cases, close observation with no medical intervention at all may be the best strategy. It is in the best interests of both the man and his family, where medically appropriate, to take the time required to determine the best trade-off between treatment and side-effects. While prostate cancer is generally slow growing and allows time for the necessary considerations, this is not always the case. It is critical to make a joint determination with your doctor. If time allows, and it usually does, it is a good practice to secure a second opinion before proceeding with any treatment. A second opinion may be best if it comes from a physician who is neither financially nor otherwise related to the first doctor. It is also good to check more than one specialty, i.e., both surgery and radiation.
The key recommendation is that all men should personally be aware of the pros and cons of PSA testing and determine if and when PSA testing is appropriate for them. Note that we emphasize that it is the individual man’s responsibility: not his doctor’s or anyone else’s. The key to making that decision is information. Possible sources of information are provided at the end of this section.
People with above normal risk factors should consider both earlier and more frequent PSA testing. Factors that increase risk include, but are not limited to:
- Heredity. If a family member has been diagnosed with prostate cancer, your risk of contracting the disease increases. The younger the family member was when diagnosed, and/or the larger the number of family members diagnosed with this disease, the higher your risk.
- Race. African-Americans have an increased risk of prostate cancer.
Glossary of Terms