What You Should Know About Prostate Cancer

Updated October 19, 2023

Prostate cancer is the most common type of cancer found in men, other than skin cancer. In fact, the American Cancer Society estimates that one of every eight men in the United States will be diagnosed with the disease at some point in his life.

Fortunately, there are more and better treatment options today than ever before. With good screening and careful management, the vast majority of men with prostate cancer will survive the disease and enjoy a high quality of life after treatment.

Who Should Be Screened -- and When

One of the best ways to beat prostate cancer is to get regular screenings using the widely available prostate-specific antigen (PSA) test starting around the age of 45. By measuring the amount of PSA in a man's bloodstream, the test helps doctors discover prostate cancer earlier -- giving men a better chance for survival.

The test is not perfect. Some studies show that it misses up to 15% of cancer cases, while flagging some cancers so small and slow-growing that they pose no threat.

Still, the PSA test remains the best widely available tool for predicting prostate cancer. PSA screening is especially important for men with a family history of prostate cancer and for Black men, who have a 60% higher incidence of the disease compared to white men.

The American Urological Association (AUA) recommends that all men obtain a baseline PSA test between age 45 and 50. The results can help doctors tailor future screening frequency. 

What to Expect

If the PSA test shows an unexpectedly elevated level, it will be repeated. If the same result occurs again, magnetic resonance imaging (MRI) will be done to study the prostate gland. If any lesions are found during the MRI, your doctor will perform an MRI-ultrasound prostate fusion biopsy, which combines MRI images with ultrasound to get the most accurate image of your prostate. This helps your urologist accurately identify, target, and biopsy specific areas of the prostate rather than random areas. However, it is important to note that your urologist may take extra samples to ensure no spots were overlooked.

New Treatment Options

If the prostate biopsy reveals prostate cancer, there are many potential treatment options. In fact, treatment may not even be necessary for some low-grade tumors. If the disease is detected very late in life or if the cancer is slow-growing, doctors may recommend active surveillance -- carefully monitoring the cancer's course with PSA tests, physical exams, and occasional MRIs and biopsies to determine whether and when treatment is needed.

Treatment for more aggressive cancers varies depending on individual medical needs and personal preferences. Since patients usually have tumors scattered throughout the prostate, most therapies focus on eliminating the entire gland. 

Focal therapy, or selectively targeting and removing only the cancerous area of the prostate, is a new approach that attempts to keep the non-cancerous portions of the prostate gland. This may better preserve urinary and sexual function. Although several Duke surgeons offer focal therapy, it is not yet considered a standard procedure. Focal therapy can be offered as part of a clinical trial.

The most commonly used technique is nerve-sparing prostatectomy, in which surgeons remove the prostate while preserving the surrounding nerves that control erectile and urinary function. Many men who are fully potent prior to the operation can regain erections sufficient for intercourse after a period of penile rehabilitation. 

Robotic prostatectomy uses a precision robotic system to help surgeons remove the prostate through very small incisions. Surgeons can do the open operation through much smaller incisions and with fewer side effects than in years past.

Radiation therapy is commonly used to treat cancer that has spread beyond the prostate, and it can also provide an alternative to surgery. One of the more recent options is brachytherapy, in which physicians insert radioactive pellets into the prostate via thin catheters. The pellets destroy the prostate while minimizing the amount of radiation delivered to surrounding tissues.

Cryotherapy is another treatment option for localized prostate cancer. In this technique, fine needles are inserted into the prostate and frozen, forming ice bulbs that kill the prostate tissue. Cryosurgery is a minimally invasive, one-hour, outpatient treatment that maintains quality of life and can be repeated if necessary.

High-intensity focused ultrasound (HIFU) is another non-radiation thermal treatment option that kills cells with heat. This heat is delivered by inserting a special HIFU ultrasound probe into the rectum. Electrical currents can also be used to kill cancer cells -- this procedure is called irreversible electroporation (IRE). During this therapy, small needles are inserted into the prostate, and the current passed between electrodes creates small pores in the cells, killing them.  

Chemotherapy may be used to treat advanced cancers and cancers that do not respond to hormonal therapy. Doctors and scientists are continuing to discover more effective, less toxic chemotherapy regimens, many of which may be available to patients through clinical trials.

What If I Have a High PSA?

High PSA levels don't always mean prostate cancer. High levels can be caused by other factors, such as inflammation of the prostate or a large prostate, also known as benign prostatic hyperplasia. Based on your risk assessment, your primary care provider might reassure you, repeat the test, or refer you to a urologist. In the meantime, follow a healthy lifestyle with good nutrition, exercise, and adequate sleep.  

The Importance of a Second Opinion

Despite the range of treatments, many men are unaware of their options until they have late-stage disease, according to the Prostate Cancer Foundation. For optimal treatment, men with high PSA levels should seek out several opinions and obtain care from a multidisciplinary team of providers, including surgeons, radiation oncologists, and medical oncologists.

By receiving information and advice from several sources, men and their families can get the support they need to make the best decisions for them.

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