By Dr. Kevin Wang
Now if you'll please drop your shorts and turn around…
No, that's not a line from a 70s gay porn video. That's something that I routinely asked a select group of patients who have scheduled a yearly physical with me. And no, these are not physicals that are done at my apartment or a back alley. These are physicals done in my office. The sort of patients who get this part of the exam are men who are at high risk for prostate cancer.
Before I go into the whole screening process, let's talk a little bit about prostate cancer.
Prostate cancer is the most common cancer in men. This form of cancer can be a relatively benign (harmless) sort with microscopic tumors located within the prostate to an aggressive (harmful) type that can be potentially fatal. Risk factors for prostate cancer include age (over 50), race (black men seem to be at higher risk than others), genetics (a strong family history), diet (high in fats and low in vegetables, fish oils and certain vitamins and minerals) and, believe it or not, ejaculatory frequency (the more you ejaculate – some say greater than 5x/week in your 20s – the lower the risk of prostate cancer).
Now with cancer of any type, no one patient comes in stating, "Ya know, Doc, I think I have this particular type of cancer." Symptoms may be vague or quite severe depending on the severity of the cancer. In prostate cancer, one may be completely healthy, have some urinary problems (increased urgency or frequency, excessive nighttime urination, difficulty forming a strong stream – but this may also point to a diagnosis of benign prostatic hypertrophy where the prostate gland is enlarged due to age, not cancer) or, in rare cases, have bone pain or neurologic (weakness) problems that point to severe disease.
So how did the medical community try to diagnose prostate cancer early? We started with the digital rectal exam. Starting at about age 45 to 50 (or younger depending on your risk factors), we'd ask you to drop your shorts, turn around and bend over. We'd lube up our pointer finger and massage your prostate feeling for any irregularities or asymmetry. If any problems were found during this exam, a biopsy (a procedure where they take a small chunk of tissue out) of the prostate would be done to determine if there's any evidence of cancer.
But what of the blood test, you ask? Well, in recent years, a blood test has been developed to help the screening process. The blood test looks for something called Prostate Specific Antigen or PSA. The higher the amount you have in your blood, the higher the risk is of your having prostate cancer. Unfortunately, elevated levels can also be present in benign (harmless) conditions like benign prostatic hypertrophy (explained above).
I, myself, am not a huge fan of this test. Why? Well, let's say I have a patient with an elevated PSA. I send this guy out for a biopsy that happens to find cancer. The urologist recommends that my patient undergo a prostatectomy (removal of the prostate gland). My fear is that the pathology report on the prostate gland is normal with small, encapsulated tumors. I've just subjected my patient to a lifetime of side effects from a prostatectomy (urinary incontinence and impotence). There also haven't been any conclusive studies that can tell me one way or another that the blood test is a "gold standard." I'll start using this test once it becomes as specific for prostate cancer as the Pap smear is for cervical cancer.
This isn't to say that laboratories around the world aren't trying to perfect it or come up with ways to make it more sensitive and specific. Some places measure the rate of rise of the PSA level hypothesizing that the faster it goes up, the higher the risk of a man developing prostate cancer. Others are simply perfecting the test.
This isn't also to say that I'm against the test. I've used it in patients who have had prostate cancer and have already undergone treatment. I use the test not to detect prostate cancer but to make sure it stays under control and that the PSA level doesn't rise.
So in the end, what do I do for my patients who are at increased risk? I inform my patients about the availability of tests, the pros and cons of each one, the consequences of our decisions if we act on the test results and the benefits of yearly screening. Some go for the rectal exam and bend over, others go for both the rectal and blood tests, while others refuse both.
Hmmm, sounds like I'm on the fence on this issue, doesn't it? I may be in the middle of the road on this one but I am 100 percent sure about one thing: please see your primary care physician regarding your health. You should check in with your physician regarding your current physical ailments and to prevent others from occurring. Prostate cancer is no laughing matter and as long as you stay ahead of it, the benefits of catching it outweigh the pain of a finger in the rear ;-).
That's it for this month's column. If you have any questions, comments or new information you'd like to share with our readers, please feel free to contact me at the e-mail address listed below. And as always, I hope you enjoyed the column and stay healthy!
