Q&A: Internist shares screening tips during Prostate Cancer Awareness Month
Prostate cancer is the second-most common cancer among men in the United States, with one in eight men diagnosed with the condition during his lifetime, data from the American Cancer Society show.
It is also the second-most common cause of death from cancer among U.S. men, according to the society.
Shivaraj Nagalli, MD, FACP, an internist at Shelby Baptist Medical Center in Alabaster, Alabama, said that prostate cancer screening is “one of the most misunderstood topics related to men’s health among physicians” in internal medicine and primary care.
In recognition of Prostate Cancer Awareness Month, Healio Primary Care asked Nagalli to discuss misconceptions about the disease, current guidance from the U.S. Preventive Services Task Force in this clinical area, managing care for survivors and more.
Healio Primary Care: What are some common misconceptions that PCPs have about prostate cancer?
Nagalli: A common misconception is that a man’s PSA needs to be checked annually after he turns 50 years of age. The PSA is a fairly sensitive test and can be elevated in other conditions. If a patient’s PSA is elevated, the risks for subjecting patients to invasive investigations and diagnosing indolent prostate cancers should be considered before ordering a PSA and involving patients in shared decision-making.
Healio Primary Care: The USPSTF currently recommends that in men aged 55 to 69 years, the decision to undergo periodic PSA-based screening should be an individual one and based on a discussion with their provider about the potential benefits and harms of screening. What are some of these benefits and harms that PCPs should discuss with patients? What else should PCPs include in these conversations?
Nagalli: The USPSTF recommends health care providers to consider the risk factors of developing prostate cancer and patient’s comorbid conditions when weighing the benefits and risks of prostate cancer screening. The benefit of screening with PSA is that it is almost always elevated in patients with prostate cancer. Hence, a normal PSA test typically indicates a lesser probability of having prostate cancer at that point.
Other than prostate cancer, PSA can be elevated in other conditions such as prostatitis (infection/inflammation) and benign prostate hyperplasia. Following the detection of an abnormal PSA, investigations such as a prostate biopsy to rule out prostate cancer [sometimes follow]. These biopsies are invasive and are typically done via the transrectal route under ultrasound guidance. This may eventually lead to the diagnosis of noncancerous diseases of the prostate or even prostate cancer, which may have been indolent and may not have become clinically significant in a patient’s lifetime.
Patients may also need to undergo radical prostatectomy, which is often associated with complications such as urinary incontinence and erectile dysfunction. Hence, when the screening test is offered, the risks of these associated complications should be weighed against the benefits of detecting and treating prostate cancer.
Healio Primary Care: A previous study suggests there is a “considerable lack of evidence” supporting the use of a digital rectal examination (DRE) tool to screen for prostate cancer in the primary care setting. What tools do you recommend PCPs use for prostate cancer screening?
Nagalli: The evidence related to the use of DRE is controversial. DRE, often done in clinics, is done to identify prostate nodules. The presence of these nodules increases the probability of cancer, although it is not definite and need confirmation by doing a biopsy. However, the ability to find these nodules by DRE depends on the physician's experience and can be subjective and dependent on the examiner’s [skill level]. Hence, the data are not consistent regarding the use of DRE in diagnosing prostate cancers.
Healio Primary Care: Symptoms of prostate cancer closely align with those of benign prostatic hyperplasia, or enlarged prostate, and prostatitis. What are the characteristics that distinguish these conditions from one another that PCPs should be aware of?
Nagalli: The presence of blood in semen can favor a prostate cancer over benign prostate hyperplasia but is not uniquely it.
Prostatitis, when acute, may have a fever, chills along with painful urination and cloudy urine.
Healio Primary Care: What are some of the conditions and diseases that PCPs should watch for among prostate cancer survivors? What tips can you share about managing these patients?
Nagalli: It is common for prostate cancer survivors to experience side effects of treatment that they received such as urinary incontinence, impotence, obesity, CVD, diarrhea and gastrointestinal bleeding.
Patients with urinary incontinence can try anticholinergic medications, pelvic floor exercises and may need urological referrals to additional surgical options. Impotence may respond to medications such as sildenafil, tadalafil, etc., and may require placement of a penile prosthesis. Obesity and CVD are related to the androgen deprivation therapy used in prostate cancer. Exercise, weight loss, control of risk factors such as blood sugars and blood pressure are needed to prevent CVD. Radiation therapy can cause colitis, leading to chronic or intermittent diarrhea or rectal bleeding and adequate hydration and antimotility agents are necessary. A referral to a gastroenterologist may be needed in case of gastrointestinal bleeding.
References:
American Cancer Society. Key statistics for prostate cancer. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed Sept. 23, 2021.
Cleveland Clinic. Prostate cancer. https://my.clevelandclinic.org/health/diseases/8634-prostate-cancer. Accessed Sept. 23, 2021.
Naji L, et al. Ann Fam Med. 2018;doi:10.1370/afm.2205.
Prostate Cancer Foundation. Prostate Cancer Awareness Month. https://www.pcf.org/prostate cancer-awareness-month/. Accessed Sept. 23, 2021.
United States Preventive Services Task Force. Prostate cancer screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening. Accessed Sept. 23, 2021.
Urology Care Foundation. Benign Prostatic Hyperplasia (BPH). https://www.urologyhealth.org/urology-a-z/b/benign-prostatic-hyperplasia-(bph). Accessed Sept. 23, 2021.
Urology Care Foundation. Prostatitis (Infection of the prostate). https://www.urologyhealth.org/urology-a-z/p/prostatitis-(infection-of-the-prostate). Accessed Sept. 23, 2021.