Prostate cancer is among the most common cancers in men, along with skin, lung, and colorectal cancer.

Dr. Alexander Berry, a Holyoke Medical Center urologist, was asked about the role of the prostate gland and what men should know about being screened for prostate cancer.

What is the role of the prostate gland in the male reproductive system and how important is this role in terms of fertility as well as overall health?

The prostate plays an important role in men’s health. The primary function is to produce 95% of the fluid that occurs with ejaculation. This fluid carries sperm to the cervix and provides energy in the form of sugar that allows the sperm to complete their “fantastic journey.”

The activity of the prostate is controlled by circulating testosterone.

As a male ages the prostate becomes more sensitive to testosterone and will keep growing. This is often called BPH, benign prostate hypertrophy, and can lead to common symptoms such as weakness of stream, getting up at night to void, and feelings of incomplete emptying.

When would a patient begin to get a digital rectal exam as part of a wellness exam? What can such an exam detect?

Typically, prostate exams are recommended to all men aged 50 or older. There are situations where a prostate exam would be recommended in younger men. Most commonly these would be men whose father or uncle had prostate cancer at a younger age, and those men who have prostate symptoms.

A digital rectal exam is a screening type of examination. Doctors are looking to tell if there are any significant changes such as increase in size or feeling a change in consistency.

It’s important to understand that many men who have prostate cancer will have a normal prostate on examination.

What is the Prostate-Specific Antigen (PSA) blood test designed to check and what would be considered a normal reading for the presence of this protein in the blood?

The Prostate Specific Antigen (PSA) is a protein that is released by the prostate and found in blood.

The protein is continuously released at a low level by normal prostate tissue. If the prostate tissue is infected, inflamed or altered in other ways the level of PSA found in the blood is increased.

Cancer cells cause damage to the prostate and are strongly associated with a rise in PSA.

For men aged 55 and under a normal PSA is considered to be 2.5 ng/ml, for those 55 years or older a normal PSA is around 4.0 ng/ml. There may be concern at lower levels of PSA if this represents a jump from a stable baseline trend.

Two years ago, the United States Preventative Services Task Force changed its recommendations on who among men between 55 to 69 should have the PSA blood test, saying this is a decision between a man and his doctor based in part on family risk factors and preference.

Would you explain the pros and cons around PSA screening?

All men with a prostate produce PSA. PSA can increase in response to infection, changes in prostate size and cancer. As men age the PSA typically will slowly rise as a result of the slow increase in prostate size due to BPH. Because PSA can rise due to reasons beside cancer this means it can be difficult to determine what the cause of a PSA rise is without doing a prostate biopsy.

PSA screening at an appropriate interval can help your doctor decide if you have a normal pattern of PSA rise, or if the rise may represent a cancer.

What we do know is that 95% of prostate cancers in men aged 55 or older have a PSA of 4.0 ng/ml or greater. The difficulty is that many men with normal enlargement also have a PSA greater than 4.0 ng/ml.

What do you advise your patients in terms of being screened for prostate cancer?

My advice to men is that you want to start to get your first PSA check around 45 years, then again at 50 years. Based on your family history and the pattern over time of your PSA levels you should have your PSA checked at a regular interval between the ages of 50 and 75 years.

In addition to a regular PSA check your prostate should be examined with a digital rectal exam on a yearly basis.

Is a biopsy always needed to confirm cancer when there is an elevated PSA level?

There have been a number of new different urine markers that are available to help determine the risk of prostate cancer in a man with an elevated PSA. Typically if a PSA is significantly elevated, I would recommend a prostate biopsy to check for prostate cancer.

For men with mild PSA elevation a DNA urine test will help guide a decision to get a biopsy.

Unfortunately, at this time there is no way to confirm if a man has prostate cancer without doing a prostate biopsy.

It is important to remember that prostate enlargement is a benign reason for elevated PSA. This is more common amongst older men and so the majority of prostate biopsies that are performed will show BPH rather than cancer.

Would you explain the approach of active surveillance for men with a cancer considered slow growing and whether you recommend it?

Active surveillance is a form of prostate cancer management that is commonly used.

Based on the PSA level, the type of prostate cancer, and the volume of prostate cancer that an individual has active surveillance might be an appropriate management option.

Men who have low risk, low volume prostate cancer can be closely monitored with a combination of imaging, PSA testing and genetic evaluation rather than undergoing prostate cancer therapy.

Active prostate cancer therapy carries a risk for erectile dysfunction and changes in urinary continence. For this reason, many men with favorable prostate cancer findings prefer active surveillance.

When would surgery or other options be advised for prostate cancer and what risks do they carry?

Prostate cancer therapy options include surgical removal and a variety of different forms of radiation therapy.

Surgery is typically offered as an option to younger men in the setting of higher volume or higher risk prostate cancer. Genetic evaluation of the prostate cancer biopsy and imaging findings on MRI can help determine if the prostate cancer is confined to the prostate itself.

In those situations, surgery can result in long term, durable control of the prostate cancer.

In the setting of older patients, those with prostate cancer that has just escaped the prostate or those with very high-risk disease, radiation treatment offers a better balance of control versus complications such as erectile dysfunction and changes to urinary performance.

In general, are most prostate cancers caught early today through screening and what are long-term survival rates?

Long-term survival with prostate cancers caught through a screening program are generally very good. For the majority of prostate cancers that are found at a relatively early stage treatment means there will not be a significant impact on life expectancy.

Do you see other tests being introduced any time soon in terms of screening for prostate cancer?

PSA testing and regular digital rectal exams remain the standard way to screen for prostate cancer.

Doctors are always trying to develop new ways to help screen for prostate cancer.

There are urine DNA tests that can help evaluate the risk for prostate cancer, and we know that MRI imaging can help increase the accuracy of prostate biopsy.

I incorporate both of these into my evaluation of a man for prostate biopsy, however neither technique is likely to be used in the primary care setting in the near future.

What are the most common conditions and their recommended treatments that affect a man’s prostate health besides cancer?

The two most common prostate issues that are seen are prostatitis and benign prostatic hypertrophy (BPH).

There is not very much a man can do to prevent BPH.

This is determined by a combination of age and genetics. Prostatitis is an inflammation of the prostate that can occasionally occur.

We are uncertain as to how it happens but regular fluid intake and bladder emptying seem to reduce its frequency.

Overall prostate health is maximized when prostate irritants such as coffee are taken in moderation.

There are pros and cons around prostate massage. Have you had many inquiries about it from patients? What do you advise?

Prostate massage exists in two main forms therapeutic and stimulatory.

Therapeutic prostate massage is occasionally used for men with recurrent prostatitis and pelvic floor pain. There are specially trained physical therapists in the region who will perform pelvic floor physical therapy and targeted prostate massage as part of a therapeutic program to treat chronic pelvic floor pain.

Every now and then patients do ask about stimulatory prostate massage.

There is a percentage of men for whom prostatic massage can be found to be stimulatory. The exact percentage is uncertain but appears to be around 10 to 15%. There appears to be minimum risk as long as this is performed in a gentle fashion.