Why Early Prostate Cancer Is Symptom-Free

Google keeps track of what is searched most frequently. Since prostate cancer is common, it’s hardly surprising that people who research aches or pains “down there” in the lower part of the abdomen search for “symptoms of prostate cancer.”

The most commonly googled question related to prostate cancer is, “What are the symptoms?” Given what's published online, however, you would think that prostate cancer has all sorts of symptoms: urinary problems, pain, sexual difficulties, even rectal problems. The truth is that in this modern era of PSA testing, prostate cancer has no symptoms whatsoever! Prostate cancer is a totally silent process unless it is very advanced.

Detecting Prostate Cancer With PSA Screenings

Now that we have PSA screening, it means that it is practically impossible for undiagnosed prostate cancer to cause discomfort, urinary problems, difficulty with erections, or any other symptom related to prostate cancer. This is not to say that men can’t have prostate symptoms from noncancerous causes, such as prostatitis, benign glandular swelling, urinary tract infections, or sexually transmitted diseases. But PSA testing can ensure that any symptoms that may be present are coming from something unrelated to prostate cancer.

Cancer is such a frightening word that I feel compelled to draw attention to the widely false reporting that prostate cancer causes symptoms. So if prostate cancer is practically guaranteed to have no symptoms, assuming the PSA has been tested and is in the normal range, why do websites provide a long list of symptoms caused by prostate cancer? How can so much misinformation exist?

Basically, these websites hark back to a bygone era, describing a situation that existed before PSA testing was available. The symptoms they list, like bone pain, changes in urination, fatigue, pelvic pain, only occur in men with advanced disease. These websites are not acknowledging that men with normal PSA (and testosterone) levels are unable to harbor advanced disease.

I mention testosterone because the one circumstance where prostate cancer could be advanced while the PSA remains low is when testosterone levels are also low. Having a marked degree of testosterone suppression, however, is quite uncommon. And it isn’t even necessary to have a blood test to know when testosterone levels are low. A really low testosterone level causes a total disappearance of libido, which easily gets a man’s attention and leads him to seek medical attention to determine what is going on.

Since PSA screening practically eliminates the possibility of being diagnosed with advanced prostate cancer, let’s review the standard operation procedure for proper testing. The threshold for PSA being “abnormal” varies, but generally a PSA above 4.0 in men over 60 should be further evaluated. Younger men whose PSA levels are above 2.5 should also probably have further evaluation.

In my world, working as a prostate cancer practitioner, it is hard to believe that men over 40 skip annual PSA testing. Surprisingly, however, statistics clearly show that many men make the mistake of not regularly checking their PSA. PSA testing is the only practical way to detect prostate cancer at an early stage (the finger in the rectum test has some value, but not much).

The Nuts and Bolts of PSA Screening

Prior to the FDA’s approval of PSA testing in 1987 (along with random prostate biopsy that same year), the behavior of early-stage prostate cancer was shrouded in mystery. Now, doctors are detecting and quantifying early-stage prostate cancer with ever-increasing accuracy.

Other PSA Roles besides Screening

Confusion about PSA can arise because it may be used for other purposes besides screening. Screening is the most familiar role and it is a big deal. Over 200,000 men are diagnosed annually because of PSA screening. However, there are other uses. One example is how PSA helps to define the cancer’s stage after prostate cancer is detected. In men with cancer, a PSA level under 10 is associated with a more indolent type of prostate cancer. On the other hand, a PSA level over 20 is characteristic of a more aggressive type of prostate cancer. PSA also plays an important role for cancer monitoring to determine the effectiveness of various treatments.

The Controversy About Using PSA for Prostate Cancer Screening

A delayed diagnosis of prostate cancer increases the chance of cancer spreading. How then, can anyone be opposed to PSA screening? Can an early diagnosis of cancer be bad? Surprisingly, experience has shown PSA is actually over-sensitive, leading to the unnecessary diagnosis of 100,000 men annually who have such harmless early-stage cancers that they are at practically zero risk for it spreading.

This would not be a problem if the medical system was prepared to simply monitor these harmless cancers. Unfortunately, due to these tiny specks of disease being called “cancer,” doctors and patients alike overreact and rush into unnecessary radical treatment, risking terrible problems with sexual and urinary function.

In fact, over-treatment of harmless prostate cancer has become such a gargantuan problem that in 2011, a government-sponsored team of experts, the U.S. Preventive Services Task Force, issued a dire warning recommending that routine PSA screening should cease. This task force concluded that the terrible cost of so many men being harmed by unnecessary treatment outweighed the benefit of lives saved by early detection. Many primary care physicians have taken this government recommendation to heart and have decided to forgo routine annual PSA screening since they believe it is causing more harm than good.

Multi-Parametric MRI Scans: The Salvation of PSA Screening

Rather than stopping PSA testing, there is a much better way to limit overtreatment. While an elevated PSA indicates that something is amiss with the prostate, it does not specifically indicate that the problem is cancer-related. The other causes of PSA elevation besides cancer are prostate enlargement due to aging, called benign prostatic hypertrophy, and prostate inflammation, called prostatitis. Neither of these conditions have anything to do with prostate cancer.

PSA Elevation From Large Prostate Glands

Big prostate glands produce more PSA than small prostate glands. The best way to measure the size of the prostate is by using a scan. Finding an oversized gland can be good news, providing a benign and reassuring explanation for why the PSA is high.

Until recently, the only way to sort through all these possibilities of PSA elevation was to puncture the prostate 12 times with a needle biopsy to remove tissue cores for evaluation under the microscope. Due to an inordinate fear of missing cancer, many doctors recommended random biopsy anytime the PSA was slightly elevated. One million men are biopsied in the United States every year. This aggressive behavior was perhaps justified when biopsy was the only way to find cancer.

We now know, however, that scans using multi-parametric magnetic resonance imaging (MP-MRI) are more accurate than a needle biopsy. The beauty of using a scan is that only men who have a suspicious abnormality detected by MRI need to undergo a biopsy. And importantly, the biopsy can be targeted. Only one or two cores are required. No more fishing through the rest of the gland with random needle sticks! Men with clear scans can avoid a biopsy altogether. Changing the policy from random biopsy to MP-MRI would solve the problem of over-diagnosis in men with high PSA.

A Suggested PSA Screening Protocol

It’s reasonable to start checking PSA yearly in men over the ages of 45. Men with a family history of prostate cancer or men who are African-American should start annual testing at age 40. Men over age 75 who are in good health should continue screening.

So what is the trigger level of PSA that should lead to performing a scan? As noted above, younger men who have small prostate glands (the prostate size can be roughly estimated by a doctor doing a finger examination) should consider doing a scan if the PSA is over 2.5. In an older man, particularly if the prostate gland as determined by the finger exam is big, a PSA over 4.0 is a reasonable threshold for obtaining imaging (if a nodule is felt, further scanning is warranted even if the PSA is normal). The PSA blood test has far surpassed the wildest dreams of the doctors who discovered it. Like any powerful tool, however, misuse can lead to over-treatment and unnecessary harm. 

So much of the misinformation on the internet implies that every ache, pain, or problem located near the prostate could be caused by cancer. The fact that the most frequently asked question related to prostate cancer is about prostate cancer symptoms indicates that the public is being led into all kinds of unnecessary anxiety.

Know this: As long as the PSA is in the normal range, in general, men can rest assured that any prostate-related symptoms they are experiencing are most likely originating from something unrelated to cancer. PSA testing detects early stage prostate cancer so reliably that when the PSA is normal, one can be sure that any prostate-related symptoms are due to some other cause.