Do You Really Need a Prostate Check?

Having a prostate exam might rank right up there with filing your taxes or cleaning the gutters (or maybe it even tops that list). But, it could be helpful to think in a different way about getting your prostate checked: It’s actually very similar to having a doctor check your neck for swollen lymph nodes—and it’s just as quick.

Prostate screening is important to consider for one main reason. “Prostate cancer is one of the most prevalent cancers affecting men,” says Yale Medicine urologist Preston Sprenkle, MD, “and, as you age, you’re at risk simply because you’re a man.” About 1 man in 7 will be diagnosed with prostate cancer in his lifetime.

Your risk is even higher if you are a military veteran and were exposed to Agent Orange, says Dr. Sprenkle, who is also the division chief for urology at the Veteran Administration Connecticut Healthcare System and an assistant professor of urology at Yale School of Medicine. Having a father, paternal uncle or brother who had the disease also increases your likelihood of developing prostate cancer. Black men are at increased risk, though researchers don’t know why. And many men don’t realize that having a family history of breast cancer may raise your risk, too, especially if you are a carrier of the BRCA 1 or 2 mutation. If you have any of these risk factors, you should be monitored more closely for prostate cancer because your chances of developing it are higher.

As you probably know, having a healthy prostate is pretty important for guys since it affects both your sexual and urinary functions. Since prostate cancer treatment can negatively impact both, Dr. Sprenkle answers questions below about prostate health through the decades. 

Men at increased risk of having prostate cancer should be screened as early as 45. There’s no way to tell if your prostate is healthy without screening. The screening involves a prostate-specific antigen (PSA) blood test and a digital rectal exam. 

I think most men are willing to do it, but some men are exceptionally opposed to it. They might be happy to hear that there are studies ongoing in the United Kingdom looking at using magnetic resonance imaging (MRI) as a screening tool to be able to avoid doing a digital rectal exam in the future. There is a large African immigrant population in London with a higher incidence of prostate cancer—they didn’t want to have the prostate exam because they had a lot of opposition to it. They were uncomfortable with it. 

A rectal exam is recommended but optional. We recommend both, but if they’ll just let you do a blood test, that’s better than not doing anything at all.  

If concern about the rectal exam is the only reason you’re not getting screened, talk to your doctor about it. We can discuss the risks and benefits. None of the evaluation tests are mandatory, but the reason we do that is that it improves our ability to detect cancer. So, if that’s why you’re not being evaluated, we can talk and decide if we can do other tests.

That’s one of the challenging things; having urinary symptoms is very rarely—almost never—a sign of prostate cancer. Having urinary symptoms means you should probably be evaluated for an enlarged prostate, also known as benign prostatic hyperplasia (BPH). We can treat your urinary symptoms and help you pee better. 

If urinary symptoms bring men to the doctor, we can discuss screening for prostate cancer. That’s important because not all men will go to a doctor until there’s something wrong with them. And prostate cancer screening really is the only way to detect prostate cancer, because it’s almost always asymptomatic. 

We have no evidence of that. They’re completely unrelated problems. The area of the prostate that causes urinary symptoms is usually a different part of the prostate than where cancer is likeliest to develop. 

Doctors divide the prostate into different zones. The zone that is associated with BPH—and the majority of prostate growth—is the transition zone. Prostate cancer occurs there much less often than in the peripheral zone, which is the outer area. 

Treatments for prostate cancer include surgery to remove the prostate, radiation therapy, and ablation therapies, as well as active surveillance. Some treatments are better for some men and some prostates than others. There are side effects for each, so it really requires an informed discussion to help each man make an educated decision. 

One thing we do at Yale is use an MRI of the prostate to evaluate the location of the prostate cancer for surgical planning. I’ve found it to be quite helpful. It’s not done everywhere.

We utilize active surveillance for men who have been diagnosed with a low-grade prostate cancer. The reason we monitor low-grade prostate cancer using active surveillance, rather than treating it aggressively, is that there are cancers that don’t need treatment.  

With low-grade prostate cancer, you’re more likely to have problems from the treatment than from the prostate cancer. Any treatment we do for prostate cancer is going to affect a man’s urinary and sexual function. It may affect it a little bit—or a lot. With this type of prostate cancer, we can tell you now that there’s very little likelihood the cancer is going to cause you any problems. We have a good and growing amount of evidence that low-grade prostate cancers, on average, progress very slowly and do not appear to spread to the lymph nodes. Active surveillance lets us detect higher grade disease and treat it at that point.

For us to do anything and treat it is going to change your quality of life. I think that’s a powerful thing. 

Something I say to my patients a lot is that, in treating prostate cancer, we end up trying to extend your quantity of life at the cost of your quality of life. And so, at some point, if the quantity is extended a lot, and we can minimize the effect on quality, that makes sense, but the equation is different for every man. How much decrease in quality of life are you willing to accept if we’re going to extend your life?

Realistically, a lot of guys who are 70 don’t have any sexual function anyway, so that’s not a huge loss for them. As men get older there’s definitely an increased chance of having erectile dysfunction (ED); the guys who have sexual function over 70 are very keen on preserving it. Even for the guys who don’t have good sexual function, who are on Viagra, for them it’s often even more important to preserve what sexual function they have.

It’s definitely not true that all men are incontinent and impotent after treatment for prostate cancer. Urinary incontinence is usually temporary. 

There can be a sexual impact for guys who have normal function. If the cancer is near their nerve bundle, they’re going to have a decrease in sexual function. If it’s not, and we can do bilateral nerve sparing surgery, studies show 70 (to 80) percent can get back their normal sexual function. It all depends on where the cancer is. But the truth is that we can’t predict very well who will be the 30 percent who will have—or still have—ED; some already do have ED because of age, diabetes, hypertension or renal failure.

It’s pretty rare. It’s less common that men in their 40s have prostate cancer, but, we also are very rarely screening them. The young men who come in to be screened tend to have one of those high-risk features. They most likely had a father who had prostate cancer, so they’re nervous about it. Or they’re African-American, and they’ve been flagged by their health care providers.

If you’re young, your quality of life is even more important to you right now. We know that, if diagnosed with low-grade prostate cancer, a person will need treatment at some time in life. If we can delay treatment—which could negatively impact urinary or sexual function—by several years, then we should do that and obviously discuss that there is a low but possible chance of metastasis developing during that time.  

The important thing to know is that, if you live long enough, you will probably get prostate cancer. If you live into your 80s, about 80 percent of men have some sort of prostate cancer. That doesn’t mean they’re going to die from prostate cancer because, as a percentage, very few men die from prostate cancer. It means it’s important to be aware of it and consider screening early, so if it’s a high-grade type, we can identify it and treat it. 

A lot. [Laughter.]

Yes, you’re right! I was not preselected for this career, though. My dad’s a doctor too—but he’s an allergist. There are a lot of funny urology names for sure. 

For more information about prostate cancer screening, contact Yale Medicine Urology.