Prostate cancer: evaluation, options and questions worth asking

Signs worth a conversation

Possible signs include trouble urinating, a weaker stream, frequent urination (especially at night), blood in the urine or semen, pelvic discomfort, erectile dysfunction, and, with more advanced disease, bone pain, swelling in the legs or feet and weight loss without trying. Most of these are more often caused by something other than cancer, such as an enlarged prostate (see the BPH pathway). The exact cause of prostate cancer is not known; it begins with DNA changes in prostate cells.

PSA and the rectal exam: what they do and do not mean

A PSA test measures a protein made by the prostate in a small blood sample. What counts as normal varies with age, race and health, so there is no single cutoff that applies to everyone. A high result is a reason for more evaluation, not a diagnosis: infection (prostatitis), an enlarged prostate and other causes can raise PSA, and normal results can miss cancer. A digital rectal exam lets the doctor feel for lumps or hard areas and can find things a PSA misses.

Screening is a shared decision with trade-offs. It can find cancers early, when they may be easier to treat. It can also find cancers that would never have caused symptoms or become life-threatening (overdiagnosis), produce false alarms that lead to biopsy, and a biopsy can cause fever, pain, blood in the urine or semen, and infection. Talk through your own risk and preferences with a clinician.

Confirming a diagnosis and staging

A prostate biopsy is done to diagnose cancer and to grade it (the Gleason score). When cancer is suspected or confirmed, further tests determine stage, how far it has progressed, and the best course. Advanced Urology offers PSMA PET/CT imaging, which can detect the spread of prostate cancer earlier than some traditional scans; it is used in selected situations such as advanced disease, a rising PSA or suspected recurrence. Stage, grade, your age and overall health shape which options make sense.

Treatment options and their trade-offs

Not every approach suits every person, and not every cancer needs immediate treatment.

• Active surveillance. Regular PSA tests, rectal exams and occasional repeat biopsies or imaging to check whether the cancer is growing, with treatment if it begins to. It is typically used for cancers that are slow-growing and unlikely to spread or cause symptoms, to avoid treatment side effects you may not need. The risk is that the cancer could progress and need treatment later.
• Watchful waiting. A different, less intensive approach: monitoring without treatment until symptoms appear or change, with treatment aimed at relieving symptoms. Fewer tests are used than in active surveillance.
• Both are used for some older men, men with other medical conditions and men whose cancer was found by screening. Whether either fits you is individualized: it depends on features of your cancer, your health and your preferences, not on age alone. Ask whether you are a candidate and what would trigger treatment.
• Surgery (radical prostatectomy). Removes the prostate, surrounding tissue and seminal vesicles, sometimes with nearby lymph nodes, for people in good health whose cancer has not spread beyond the prostate. It can be open or minimally invasive (laparoscopic or robotic), which may mean quicker recovery. The most common long-term side effects, of surgery and of radiation, are erectile dysfunction and urinary incontinence; surgical and anesthesia risks also apply.
• Radiation therapy. Delivered from outside the body or from radioactive seeds placed in the prostate, and a common alternative to surgery for localized or locally advanced cancer. Side effects can include erectile dysfunction, urinary incontinence and bowel effects.
• Hormone therapy. Prostate cancer often depends on testosterone to grow, so medicines (or, rarely, surgery) lower or block it. It is commonly used for advanced cancer or alongside radiation.
• Chemotherapy, immunotherapy and targeted therapy. Generally for more advanced disease. Chemotherapy often causes nausea, fatigue and hair loss; the vaccine-based immunotherapy sipuleucel-T usually causes mild flu-like symptoms; targeted therapies act on cancers with specific genetic changes such as BRCA mutations, with side effects that vary by drug.
• Palliative care. Symptom relief and emotional support at any stage, alongside other treatment.

Dr. Mally is trained in da Vinci robot-assisted surgery and is skilled in robotic prostatectomy. Whether surgery is appropriate depends on your cancer and your health. Radiation, hormone and other treatments are delivered with the wider care team, and he can talk through how they fit together.

Questions to bring, including for a second opinion

Some people choose a second opinion to confirm a diagnosis and treatment plan. A second doctor will want your test results, pathology report and scans, so bring them. Useful questions: What is my stage and grade? Is surveillance safe for me? What does each option typically do to urinary, bowel and sexual function? What happens if the cancer comes back? Who else should be on my team?

Ask the office how to arrange a review of your records and scans.