The 3 Screenings All Men Should Have Today
Opinion: What I Didn't Know About My Prostate Almost Killed Me
Editor's Note: Ed Manning is a media executive and prostate cancer survivor. He is currently working on a book about prostate cancer. The views expressed in this commentary are his own. View more opinion on CNN.
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Recently, a misfiring prostate launched Defense Secretary Lloyd Austin to the forefront of the headlines, followed by the deaths of Dr. Martin Luther King Jr's son, Dexter, and O.J. Simpson from prostate cancer. While their celebrity status drove the news, their underlying illnesses earned little more than a parenthetical shrug. In the blink of a news cycle, prostate cancer was again casually swept aside as among the best cancer to have.
Treatments are often downplayed as "minimally invasive," as if they were no more consequential than a teeth cleaning. As a prostate cancer survivor, I can report from painful experience that those misguided assessments are to men's health and longevity what ice was to the Titanic.
In the shadows of more celebrated organs afflicted by cancer, such as the heart, pancreas, lungs and breasts, mentions of the prostate are often waved off like the eccentric relative no one is comfortable inviting to Thanksgiving. Most men's knowledge of it extends no further than those riveting seconds during an annual physical when the doctor inserts their gloved finger into the patient's rectum to feel for abnormalities in the prostate. The exam isn't a great conversation starter, so few have much to say to the doctor once it's behind us. I wish I had, because if the prostate becomes cancerous, as I and over 1.4 million men found out in 2020, there is nothing physically or psychologically minimal about it.
For context, the walnut-sized prostate gland plays a pivotal role in the male reproductive system. It is essential in producing seminal fluid and, during sexual climax, its muscles contract, close off the opening between the bladder and the urethra (there is no "p" in orgasm), and forcefully release millions of stampeding sperm and fluids. It is flanked by two neurovascular bundles that are to healthy sexual function what Houston Control is to a shuttle launch. No nerve bundles and the rocket sits lifeless on the pad. That positioning makes treating the prostate complicated and lifts "nerve-sparing" to the top of every man's prayers as he contemplates radiation, surgery or high-intensity focused ultrasound (HIFU) treatments. As my wife told my surgeon as I shuffled off to surgery, "Take all the time you need."
Years leading up to my diagnosis, my doctors gave me two gloved thumbs up after my digital viewing. "Looks great," was the evaluation through my 50s. As I cruised into my 60s, that was downgraded slightly to "looks good," with an aside that my prostate was slightly enlarged.
"It's typical of a man your age," the doctors said. I had nothing to worry about. I was athletic, plant-based, sun-screened, fully flossed and free of trans fats, drugs, tobacco and asbestos. I should have been a poster boy for cancer-free. Missing from that annual banter and less-than-alarming prostate headlines were several arresting details. As the American Cancer Society notes:
• Prostate cancer is the second leading cause of cancer death in men.• One in eight will be diagnosed with it.• One in 44 will die from it.
Another point my doctors failed to mention was that no matter how thorough the annual digital screening, prostates can malfunction without any obvious symptoms such as a hardened or bumpy shell, blood in the urine, the need to pee frequently or erectile dysfunction. Cancer can sneak its way in undetected, and if not caught early, break free of the prostate and run unchecked through the body with a particular penchant for bone. For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year relative survival rate is only 32%.
Had I known any of those details, I would have kept a closer eye on possible symptoms, nutritional recommendations and testing options. In my case, it was a chance conversation with my wife that led to a diagnosis.
"You are peeing differently," she said. "That's why I want you to book your physical." Getting directly to the heart of the matter, I said, "You listen?" and then strategized about the best way to immediately change the subject.
"The bathroom door isn't soundproof," she continued, "and it sounds like things take longer to get going. You need to tell your doctor. It could mean something."
It did. What seemed trivial to me put my doctor on alert. He added a Prostate-Specific Antigen (PSA) test to my bloodwork.
"Changes in the way you urinate is something you should have told your previous doctor. Why didn't you?" my doctor asked, adding a reprimand on the tail end of his bad news. "And why didn't you have a PSA test before now? You could have caught this early."
I explained that changes in peeing were gradual and inconsequential enough to go unnoticed, like the frog in the heating pot of water. Given my lack of knowledge of the prostate's propensity to become cancerous, I didn't know what symptoms to look for. I assumed the digital exam had me covered. I never had a PSA test, because none of my previous doctors had ever ordered one. I never asked for one based on the substantive difference between my BA in English Lit and a medical degree.
Get Our Free Weekly NewsletterA PSA test measures the presence of prostate-specific antigens in the blood that can be indicative of cancer. In a perfect world, the score will read under four, according to the National Cancer Institute. At age 62, my first ever PSA score logged in at a harrowing 17. A biopsy confirmed somewhat aggressive prostate cancer, a diagnosis which stunned and terrified me. Six weeks later, after much research and deliberation, I underwent a radical robotic nerve-sparing prostatectomy. That so-called minimally invasive surgery took close to six hours and required multiple incisions. Recovery involved one week with a catheter, a couple of weeks of significant physical discomfort and three months before I was able to tackle even a light workout.
Three years after my surgery, I am in remission and, by the grace of a skilled surgeon and amazing advances in medicine, I don't suffer the dreaded side effects of incontinence or erectile dysfunction. But technically, I'm not cured. Even after surgery, radiation or HIFU, recurrence is not uncommon. Like most men post-treatment, I take a blood test every six months, at which point my anxiety skyrockets for the days it takes to get the results confirming whether or not I'm cancer free.
While physicians assure me I will "probably die of something else," I wish that in addition to the cursory "looks good" I had heard over the years, they had provided salient details about my prostate, warning signs and testing options. While it's too late for me to catch my own cancer early, I encourage anyone with a prostate or anyone who loves a person who has one to talk to a physician. Learn about testing options and the importance of nutrition and staying active. Understand the warning symptoms. Listen to your body or your significant other who might be a better listener than you. What I didn't know almost killed me. If I had known what to listen for, my former prostate and I might have happily grown old together.
What Is Prostate Cancer?
Early-stage prostate cancer does not usually cause symptoms. Some symptoms, like a rash and frequent urination, can occur as the disease progresses. This type of cancer is often detected through routine screening tests. Other tests can confirm a diagnosis and help providers determine treatment.
Prostate cancer develops in the prostate gland when healthy cells change, grow, and divide uncontrollably to form a tumor. Researchers don't know the exact cause of prostate cancer, but certain factors can increase your risk. About one in eight men will develop prostate cancer in their lifetime.
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Prostate cancers are grouped based on the type of cell they start in. A healthcare provider can examine the cancer cells under a microscope after a biopsy to learn the type a person has. This information helps a care team determine the best course of treatment. Adenocarcinoma The vast majority of prostate cancers are adenocarcinomas. These tumors form in the glandular cells that make prostate fluid. There are two types of adenocarcinoma: acinar adenocarcinoma and ductal adenocarcinoma. Acinar adenocarcinoma develops in the glandular cells that line the prostate. Ductal adenocarcinoma develops in the cells that line the tubes of the prostate and usually grows and spreads more quickly than acinar adenocarcinoma. Transitional Cell Carcinoma Transitional cell carcinoma is also known as urothelial carcinoma. This type of tumor begins in the urethra, or the tube that carries urine from the bladder to the outside of the body. Cancer cells then spread to the prostate gland. Transitional cell carcinoma can also begin in the prostate, but this is rare. Between 1% to 5% of all prostate cancers are transitional cell carcinomas. Small Cell Carcinoma Small cell carcinoma is a rare and aggressive form of prostate cancer that starts in the neuroendocrine cells of the prostate. Less than 2% of these cancers are small cell carcinomas. Squamous Cell Carcinoma Squamous cell carcinoma is an aggressive type of prostate cancer that starts in the flat cells that line the prostate gland. Less than 1% are squamous cell carcinomas. Most of these cancers do not cause symptoms in the early stages. Many symptoms of prostate cancer are related to the urinary tract because of where the prostate is located in the body, just below the bladder in the lower pelvis, wrapped around the first part of the urethra. Prostate cancer symptoms can include: Blood in the urine or semen: Occurs when the prostate gland puts pressure on the urethra and nearby blood vessels Difficulty urinating: Causes weak or interrupted urine stream Erectile dysfunction: Includes difficulty getting or maintaining an erection Frequent urination: Involves urinating more often than usual Nocturia: Causes excessive nighttime urination Urinary urgency: Causes a sudden, urgent need to pee Additional symptoms can occur if prostate cancer metastasizes (spreads) to other body parts: Numbness and weakness in the limbs: Occurs when prostate cancer spreads to the spine and compresses the spinal cord Pain in the back, hips, or chest: Happens if the cancer spreads to the bones Swelling in the legs or feet: Occurs when prostate cancer spreads to the pelvic lymph nodes Unintentional weight loss: Results from cancer cells burning more of the body's energy This type of cancer occurs when healthy cells in the prostate gland mutate (change), causing the cells to behave abnormally. The cells begin to grow and divide out of control and form a tumor. Some gene mutations are acquired, meaning they happen at random and are not passed down through families. Most gene mutations linked to prostate cancer are acquired. The reason why these mutations occur is not fully understood. Some gene mutations are inherited, meaning they are passed down from generation to generation. Inherited gene mutations account for as many as 10% of all prostate cancers. Lynch syndrome, for example, is an inherited cancer syndrome that increases the risk of this cancer and many other types of cancer. Prostate cancer is linked to inherited mutations in several different genes, including: Risk Factors Not everyone with inherited or acquired gene mutations will develop prostate cancer. Certain factors are known to increase the risk of the disease, including: Age: Prostate cancer is more common in older adults. Family history: Having a relative with a history of this cancer is associated with a higher risk of the disease. Geographical location: The incidence of prostate cancer is higher in some parts of the world, including North and Western Europe, Australia, North America, the Caribbean islands, and South Africa. Prostate cancer is often detected before it causes symptoms through routine screening tests. These tests include: Digital rectal exam (DRE): Healthcare providers perform a DRE during routine check-ups in people with a prostate after age 50 or sooner in those with known risk factors. They will insert a gloved, lubricated finger into the anus to feel the prostate and check for lumps and hard areas. Prostate-specific antigen (PSA) blood test: This test measures the amount of PSA in the blood. PSA is a protein made by cells in the prostate gland. Cancer cells produce more PSA than non-cancerous cells, so higher levels may be a sign of prostate cancer. Further tests and procedures may be ordered if a healthcare provider suspects you may have prostate cancer or you have symptoms of the disease. Other diagnostic tests include: MRI fusion biopsy: This test combines a magnetic resonance imaging (MRI) scan, transrectal ultrasound (TRUS), and biopsy into one procedure. An MRI fusion biopsy takes pictures of the prostate and surrounding tissues and obtains a tissue sample to analyze in a lab to look for cancer cells. Multiparametric MRI (mp-MRI): This is a standard MRI performed in combination with another type of MRI (e.G., diffusion-weighted imaging). This test takes pictures of the prostate and nearby tissues. Pictures from both scans are compared to look for signs of cancer. Prostate biopsy: A small tissue sample is removed from the prostate and examined under a microscope in the lab to check for cancer cells. Transrectal ultrasound (TRUS): This imaging test uses sound waves to take pictures of the prostate to look for signs of cancer. Stages An oncologist (who specializes in cancer) will stage the disease. Prostate cancer is staged based on where the cancer is located, the size of the tumor, whether it has spread, and how far in the body it has spread. There are two types of staging: Clinical: This staging is done at the time of diagnosis based on the results of your tests and procedures. Pathologic: The prostate is surgically removed and then examined in the lab. The oncologist learns more about the specific type of cancer and recommends the most effective treatments. There are four stages, and each stage is further divided into substages. The main stages include: Stage 1: Cancer is confined to one-half of one side of the prostate and is low-risk (slow-growing). Stage 2: Cancer is confined to the prostate, and the tumor is small but is at risk of growing and spreading. Stage 3: Cancer has spread outside of the prostate gland into nearby tissues or organs (e.G., bladder, rectum, pelvic lymph nodes). Stage 4: Cancer is advanced and has spread beyond the prostate to other, more distant areas of the body. Prostate cancer is highly curable when detected in its early stages. Treatments may be focused on preventing the growth and spread of cancer cells to prolong life and manage symptoms if prostate cancer is diagnosed in later stages or has returned (recurrence). A healthcare provider will consider the type and stage of the disease, your overall health, and personal preferences. Active Surveillance Active surveillance is a treatment approach that may be recommended for prostate cancer that is slow-growing and low-risk. This involves holding off on treatment until the disease progresses. Regular exams, imaging tests, and biopsies will be performed to check for signs that the disease has advanced. Surgery Surgery to remove the prostate gland is a standard treatment for prostate cancer. A healthcare provider may also advise removing the seminal vesicles and pelvic lymph nodes. There are several types of procedures that can be performed based on the stage of the disease and your overall health. These procedures include open surgery (making an incision in the abdomen) and laparoscopy (making several small incisions). Laparoscopy is less invasive, and recovery is usually faster than open surgery. Radiation Therapy Radiation therapy uses high-energy X-rays to kill cancer cells and prevent them from growing and spreading. There are different types of radiation therapy used to treat prostate cancer, including: External-beam radiation therapy: Uses a machine outside of the body to focus radiation directly on the tumor Internal radiation: Involves placing radioactive "seeds" into the prostate gland to destroy cancer cells Hormone Therapy Prostate cancer cells use sex hormones, such as testosterone, as fuel to grow and spread. Hormone therapy blocks the production of sex hormones or reduces levels of these hormones to starve the cancer cells so they die. Hormone therapy may be given as an oral medication or placed in the body through an injection. Surgical castration removes the testicles to cease all hormone production, but this is rare. Chemotherapy Chemotherapy (chemo) uses anti-cancer drugs to destroy cancer cells anywhere in the body. Chemo is not a curative treatment for prostate cancer. It may be recommended as an option for more advanced cancers to stop the growth of cancer cells to prolong a person's life and manage symptoms. Immunotherapy Immunotherapy (biologic therapy) uses medicines tailored for each individual to stimulate the body's immune system to fight cancer cells. Advanced prostate cancer that causes few symptoms and has stopped responding to hormone therapy is sometimes treated with Provenge (sipuleucel-T), a type of immunotherapy. Targeted Therapy Targeted therapy uses drugs that identify and kill specific cancer cells without damaging healthy cells. Poly (ADP-ribose) polymerase, or PARP, inhibitors are a targeted therapy that treats prostate cancers linked to BRCA gene mutations. These drugs prevent cancer cells from repairing their damaged DNA, which leads to death of the cells. There's no guaranteed way to prevent prostate cancer. There are certain risk factors for prostate cancer that cannot be changed, like your age, family history, and ethnicity. Adopting healthy lifestyle habits may help lower your risk: Eat a healthy diet: Eating a diet high in calcium, red meats, and processed foods may increase the risk of prostate cancer Aim to eat a nutritious, balanced diet rich in fruits, vegetables, and whole grains. Get regular exercise: Staying physically active can improve immune function and reduce inflammation, which may lower the risk of prostate cancer. Maintain a healthy body weight: Obesity has been linked to more aggressive forms of prostate cancer and an increased risk of death. Maintaining a healthy body weight may help lower your chances of developing the disease. Having prostate cancer can increase the risk of developing other health conditions, including: Diabetes: Hormone therapy used to treat prostate cancer can elevate the risk of diabetes. Heart disease: People who have had cancer are at a significantly increased risk of heart disease, particularly heart failure and stroke. Osteoporosis: Bone loss is a common side effect of hormone therapy treatment for prostate cancer. This can lead to an increased risk of osteoporosis and bone fractures. Other cancers: People who have had prostate cancer are at an increased risk of small intestine cancer, soft tissue cancer, bladder cancer, thyroid cancer, thymus cancer, and melanoma (skin cancer). Prostate cancer can affect every part of your life, including relationships, career, finances, and more. You may want to learn as much as you can about treatments and side effects so you can take an active role in your care. Sharing your concerns with healthcare providers and leaning on family and friends for support can help. Some people with prostate cancer find it helpful to join support groups to talk with others who understand what living with the disease is like. Most people with prostate cancer survive, thanks to advancements in screening tests and treatments. The five-year survival rate for early-stage prostate cancers is 100%, and almost 97% overall (including advanced prostate cancers). Most people with prostate cancer are able to have fulfilling lives.Thanks for your feedback!
Doctors Explain What Prostate Cancer Screenings Involve
IF YOU'VE NEVER had a prostate cancer screening, you may worry that it will be embarrassing and uncomfortable. Doctors say that's not the case, however. The tests are quick and essential for early detection of the disease.
"It's a very simple process," says Paul Gittens, M.D., a board-certified urologist and founder of Rockwell Centers for Sexual Medicine and Wellness in Pennsylvania and New York City. "I think a lot of guys are anxious because they're nervous that the results may indicate they have prostate cancer." They're also nervous about the infamous DRE (digital rectal exam), which docs say doesn't always have to be part of the test.
No matter how matter how worried you are about the test itself or the results, getting screened for prostate cancer is vital. "It's something that you really want to detect early, and with early detection, treatment would be administered earlier, and survival should be at a higher rate," Dr. Gittens says.
Prostate cancer is the second most common cause of cancer death among men, according to the American Cancer Society. This year, the organization projects that about 300,000 new cases will be diagnosed, and 35,250 men will die from the disease. Black men are about 70 percent more likely to get prostate cancer.
Often, getting screened just involves a simple blood test, and there's not really anything you need to do to prepare, explains Felix Feng, M.D., a radiation oncologist at the University of California San Francisco and co-founder of ArteraAI.
Finding the disease in its early stages means it's typically easier to treat, he says. "Treatment for earlier-stage disease can be less intensive and have fewer side effects than treatment for later-stage disease."
Here's what to expect when you schedule a prostate cancer screening:
"It depends on the risk factors that a gentleman might have," Dr. Gittens says.
The American Urological Association recommends most guys start getting screened for prostate cancer between ages 45 and 50.
But men who are at a higher risk for the cancer should get screened beginning at age 40. These groups include Black men, people with a family history of the disease, and individuals with certain gene mutations, such as the BRCA gene.
It's best to see your primary care doctor, who typically conducts the testing and then recommends you to a specialist if needed, Dr. Feng says.
What Prostate Cancer Screening InvolvesProstate cancer screening typically involves a blood test to detect levels of prostate-specific antigen (PSA). Dr. Gittens says it's a straightforward blood test.
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PSA is a protein that's produced by prostate tissue, according to the Mayo Clinic. The test can detect high levels of PSA, which might signal prostate cancer. High PSA could also suggest other conditions, like an enlarged prostate.
The PSA test is often paired with a digital rectal exam (DRE), where a doctor inserts their finger into the rectum to feel the prostate gland. "We look for any bumps or lumps or any signs of abnormality," Dr. Gittens adds.
"A lot of guys are hesitant of the rectal exam," he says, so if it's causing too much angst, doctors can sometimes skip it and just do a PSA, especially if it's your first screening.
A DRE alone isn't as effective as the PSA for detecting prostate cancer, Dr. Feng says. "However, it can sometimes identify cancers in men who have normal PSA levels."
So, many doctors prefer to do both tests, Dr. Gittens adds.
How to Prepare for a Prostate Cancer ScreeningA PSA is like any routine blood test, Dr. Feng says. But you should refrain from ejaculating for at least 48 hours before the exam. This could temporarily raise your PSA levels, which might trigger a false positive.
Also, avoid exercising before the test, which might affect PSA levels. If you have any signs of an infection, such as having to pee frequently or blood in your urine, Dr. Gittens says it's best to treat the infection before getting a PSA test.
The DRE doesn't require any preparation. But you should talk to your doctor if you're worried about it, Dr. Feng says.
What About At-Home Tests?A number of at-home PSA tests are available. While Dr. Feng says they can be convenient, it's best to get tested at your doctor's office.
"Test results should be discussed with your doctor," who can recommend the next steps based on the result, he explains.
It's also just a good idea to establish a relationship with a physician, Dr. Gittens adds. Doctors can recommend other necessary health screenings, like colonoscopies, and routinely check your blood pressure and cholesterol.
What Happens After Screening?If your PSA levels are high, your doctor will likely refer you to a urologist.
Dr. Gittens says he typically asks patients if they had sex before the PSA test or noticed any blood in their urine or feel like they need to run to the restroom frequently. Then, he usually repeats the PSA test and performs a DRE.
If the result still shows an elevated PSA, it's recommended that guys get an MRI or biopsy of the prostate, depending on the individual and their doctor's recommendations, Dr. Gittens says.
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"I favor the MRI, just to pick up any aggressive lesions," he explains. "Then if there is an aggressive lesion, you can just biopsy that area."
A biopsy involves inserting a needle into the prostate to collect tissue samples to examine for signs of cancer, Dr. Feng says. The procedure takes about 10 minutes.
If a biopsy shows that someone has cancer, doctors determine a patient's next steps.
"There's some prostate cancer that's really low grade, and we'll just watch it and no treatment is needed," Dr. Gittens says.
Patients with higher-grade cancer may need treatments, such as radiation therapy, surgery, chemotherapy, immunotherapy, or other therapies.
When to Get Re-ScreenedIf you're in a low-risk group and your initial screening is normal, you should get a PSA every two to four years, Dr. Gittens says.
But Black men and guys with a family history or genetic mutations for prostate cancer should be screened every one to two years, regardless of whether their previous PSA was normal, he emphasizes.
Regular screening and early detection ensure you get the treatment you need as soon as possible, which increases your cancer survival rate, Dr. Gittens says. "It's always harder to treat cancers when they're more advanced and more aggressive."
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