Search for tag: "prostate"

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Scot: Troy, I thought because we have a doctor here who's a recognized authority and he's an opinion leader, like people look to Dr. Tward regarding treating prostate cancers, that we could play a little game. You up for a game?

Troy: I'm up always.

Scot: All right. So this game is called "What do you know about the prostate and prostate cancer?"

Troy: Are these questions I'm answering?

Scot: Well, I thought I would start. I'd start by throwing out something I know like, for example, what is the prostate? What do I know about it? It gets cancer. That's about all I know.

Troy: That's all you know. That's a good start.

Scot: So this episode of "Who Cares About Men's Health" is one of our Men's Health Essentials episodes, and we're talking about prostate cancer. This is an important episode because as a man, if you understand this condition, it can help you have an informed conversation with an expert, if you do need to test or not, what it means if a test comes back positive, what choices you might have if it does come back positive, and it can really impact your lifestyle. So with me is, as always, co-host, Dr. Troy Madsen. Say hi, Troy.

Troy: Hey, Scot.

Scot: And Dr. Jonathan Tward from Huntsman Cancer Institute.

Dr. Tward: Thank you for having me.

Scot: And I'm Scot Singpiel. People ask, "What do you contribute?" I'm here to ask the dumb questions so our listeners don't have to. That's my job.

Dr. Tward, what is the prostate anyway?

Dr. Tward: Well, the tongue in cheek answer is a gland that's designed to make your life miserable as you get older, but actually what the prostate gland is, is a little gland that sits between the base of the penis inside your body and below the bladder, and the urethra actually runs through it. And what its function is, is it has a fertility role. It produces the fluid that a man would ejaculate and helps keep the sperm alive on the way into the partner. So it's important for fertility, but if you're done with that particular aspect of your life, it no longer is, I guess, functionally necessary.

But its anatomic location is such that it can create all kinds of issues as one ages, one of which is prostate cancer, as you mentioned. Also, with its proximity to the bladder and where the urethra runs through it, there's a tendency for it to enlarge with some men over age and can also cause urinary problems.

Scot: All right. So if I'm done having kids, why don't I just get it taken out? I mean, wouldn't I save myself a lot of heartache?

Dr. Tward: Well, I'm sure that would be very lucrative work for people in urology. However, the problem with just removing the prostate, which is, of course, one of the concerns with dealing with cancer in the prostate, is that the nerves that control erection are actually sort of plastered onto the underside surface of the prostate gland and it's very challenging to preserve sexual function, although it can be with a talented surgeon.

And likewise, when one removes the prostate at the level of the bladder and below the prostate, there are these two sphincters that help control urination. And so when you remove the prostate, there's a risk that you can leak urine.

So routinely removing the prostate gland is not something that we would endorse as a preventative measure because the quality-of-life issues on the back end of that procedure would be risky, which is, of course, one of the risks that we all have to discuss when talking about dealing with prostate cancer once it's diagnosed.

Scot: Troy, do you know when you're supposed to get screened for prostate cancer? What age?

Troy: I think that's the biggest question I have for Dr. Tward. Should I get screened for prostate cancer? I'm a man over 40. I've never been screened. My primary care physician has never recommended it. Am I doing something wrong here?

Scot: So just so everybody knows, I'm 50 and I think that's when it's supposed to start, right?

Dr. Tward: Well, even the idea of when is it supposed to start is controversial. Prostate cancer screening has been a controversial topic really over the past decade. And the reason why it's controversial is that when you look at screening programs versus non-screening programs, if the outcome you're measuring is death from prostate cancer over 10 years, it shows maybe modest at best, to little to no benefit.

And that led to a complicated recommendation, I believe, back in 2012, 2013 by the United States Preventative Services Taskforce that actually confused the picture, which kind of recommended against screening.

However, since that time, more information has been gathered and this particular topic is one that we could spend an hour on. But I think that most professional societies and informed physicians who work in prostate cancer would say that men at age 50 with no other underlying reasons to screen sooner should probably consider getting screened at that time.

However, if you have a family history of prostate cancer, like a first-degree relative or more than one second-degree relative that's had prostate cancer, it probably makes sense to get a baseline screening test at age 40 and see where you are. And if all is reassuring, maybe do it again in five years.

But these kinds of guidelines are set by various professional societies and they actually are not consistent, but most are pointing toward age 50 for most men.

Scot: So let me get this straight then. The whole point of screening is to save lives, whatever screening we might do, and you're saying that there's no compelling evidence to show or there's just a very modest increase in life-saving from getting prostate cancer screening.

Dr. Tward: Yeah. I think it's a myopic view to say that saving lives should be the only reason you do a cancer screen. I mean, that's the obvious reason to screen, but I think the less obvious reason and one that holds a much more powerful argument for me . . . we're talking about a quality-of-life issue. To me, the rationale for screening is not necessarily to keep somebody alive over the next 10 or 15 years. The rationale is to preserve their quality of life. Because if you can catch a prostate cancer early, you can start making decisions where you'll be able to talk about sparing sexual function, you'll be able to talk about sparing bladder function, and you won't merely be keeping men alive.

And so there's a much greater argument that preventing spread of the disease and keeping your therapeutic options open is, to me, the rationale why you want to screen and why you want to start at about age 50 unless you have family history.

Troy: But with this in mind then, what's the downside of screening?

Dr. Tward: The downside of screening is that most men using traditional metrics of screening are going to receive a biopsy that does not result in the finding of prostate cancer. So right now, what is most widely practiced across the country is to do PSA testing, and PSA stands for prostate-specific antigen. It's a little thing that normal prostate cells and prostate cancer cells produce that can be excreted into the blood. So it's very specific for, let's call it, prostate origin. We have these arbitrary thresholds where we say if it's above, let's say, the number four, you should consider getting a biopsy.

The problem with that is if you just look at all men across the country, in the United States, who get a biopsy just because their PSA is above four, three out of four of those men will not have prostate cancer detected.

And so the downside is anxiety, and you stick needles in people. That could also lead to complications, and infection, and hospitalizations. And with enough biopsies, actually, there's some evidence that you could start impacting sexual function, urologic function as well.

So the PSA test as a screen is, I would say, better than nothing, but it has its issues that a lot of people will just kind of go down a road of anxiety and needle pokes and not be found to have the cancer.

There have been some innovations in the last few years that can help us nuance that, but they're not yet sort of widely practiced throughout the United States and world, but there are ways to nuance those screens.

Scot: So again, let me see if I understand correctly. I could get a PSA test. The number can come in above the threshold. And in my mind, tests either tell you if you have something or you don't, but this test doesn't. If it comes in above the threshold, there's still a good possibility you're not going to have a cancer. But then if you take that number as, "Yeah, I better go to the next step," which is biopsy, actually, a lot of people don't.

Dr. Tward: Just having an enlarged prostate can make your PSA quite elevated. There are lots of men walking around out there with PSAs of 20 and 30 and the only thing wrong with them is that their prostate is three or four times larger than it was when they were a 30-year-old. And as I mentioned before, normal prostate cells make PSA, not just cancer. And so the bigger the prostate is, the more PSA.

There are also issues with just sporadic rises. You ejaculate, your PSA can go up. Someone manipulates your prostate with a digital rectal exam . . . if you got a digital rectal and then got a blood draw, your PSA will be elevated. You could have a prostatitis that could possibly elevate the PSA. So there are honestly just a host of reasons why this PSA would be elevated.

But of course, once you tell a man in a primary care office, "Your PSA is over four," their mind is going to go to the most worrisome thing and then you have to kind of investigate whether you want to pursue it.

Scot: Or their partner's mind or other people in their life.

Dr. Tward: Indeed.

Scot: So it's not a yes/no. It's a much more nuanced conversation and understanding. Troy, I think this really comes back to the conversation we had earlier in our last episode or one of our previous ones about being able to have an informed conversation with your physician to make informed and joint decisions.

Troy: It really does. I think, Dr. Tward, everything you're saying says that it really is a personal decision. And it sounds like it's not a hard and fast rule that you need to get screened at a certain point, but it's a tough decision. I'm thinking about this personally, and again, I've never been screened for prostate cancer. I'm not 50, but I'm well over 40 and I've wondered, "Should I get screened?" But that's the hard thing for me to think, "Well, if that number does come back, say, higher than four, then I have to get a biopsy." From what I understand, that's a pretty uncomfortable thing to go through.

What's your take? What do you tell friends, family members, patients? Do you typically say, "Yeah, do it," or what do you tell them?

Dr. Tward: Well, I think I'm at a point where I recommend screening, but it doesn't mean that you necessarily should automatically trigger biopsy just because you're above four.

I guess how I would perceive it is . . . I guess on the counterargument with the life-saving, we've seen a big shift over the past five years specifically as a result of decreasing screening where now we're seeing men with much higher stage cancers. And they are now receiving, I'll call it, multi-modality therapies to try to eradicate it. Instead of maybe a simple surgery or one kind of radiation, we have to throw the book at them.

So I guess what I'm advocating, to answer the question, is you should get screened, and that includes a PSA test, and honestly a digital rectal exam. And if there is a concern, then the discussion should go on to the next step with your urologist about the relative merits and whether or not there are some additional testings that we can do rather than willy-nilly going into the biopsy.

So there's just so much discussion, and what I would encourage is that a man gets screened. However, the first question they should ask their urologist they're referred to is, "Do I really need to proceed immediately to biopsy? Are there other tests we can do? And do you do a transperineal biopsy or a transrectal biopsy?"

Every step of the prostate cancer process from "Do you screen?" to "Do you biopsy?" to "Do you treat?" is a complicated array of choices.

Troy: I have a stupid comment, but . . .

Scot: All right. Stupid comments. Go ahead.

Troy: Okay. Well, I'm going to add this, Scot, because you didn't. I'm just going to clarify for all of our listeners. Many of them work in the tech industry. A digital rectal exam is not a virtual rectal exam. It simply refers to the use of the provider's digit. Just so people know what we're talking about. It's like, "Hey, what about the virtual rectal . . ." No. Anyway.

Scot: So we've talked about PSA tests, but we haven't talked about the finger exam, which you're not using anymore, are you?

Dr. Tward: Well, that's not fair to say. I think the digital rectal exam is complementary to the PSA test. However, digital rectal exams are very heterogeneous in detecting a cancer.

Scot: What does that mean, heterogeneous in detecting?

Dr. Tward: I guess what I mean by that is a practitioner's ability to feel something in the prostate varies amongst practitioners, number one. The length of their fingers differs. When you do a digital rectal, you can only really touch a small part of the gland. But it's basically a freebie. They don't charge you extra to get a digital rectal examination when you're seeing your doctor. But of course, men don't want things stuck in their rear-end.

However, I will tell you that there's no doubt in my mind if you're over 50 and you're seeing a doctor, they should do a digital rectal exam, because for maybe three seconds of discomfort, you might actually be able to detect something that's concerning.

Scot: So in addition to a PSA test? The PSA test does not replace the digital rectal exam at this point?

Dr. Tward: I wouldn't say it replaces it. I mean, if you held a gun to my head and said, "You can only choose one screen, what would you do?" I'd say, "Okay, give me a PSA test." However, like anything else, this goes into risk modeling. The more things you do to detect a risk, the more likely you are to have confidence in the result.

So a digital rectal exam has a certain ability to detect prostate cancers that PSA may not, and PSA has a certain ability to detect cancers that a digital rectal exam may not. Together, your confidence in a negative test or a positive test is much higher with the combination.

Scot: And before I go ask for one from my doctor . . . because how does that appear, Troy?

Dr. Tward: I'm here now. We could take care of this.

Troy: Let's do this on the air. This is like the pushup challenge, Scot, but just so much better.

Scot: It's a pushup challenge, all right.

Troy: If you want our listeners to do this, Scot, you should be the first one to do it.

Scot: So you'll notice now Scot's really interested in the evidence behind the digital rectal exam. What is the percentage that this is actually going to help? Because I heard that's actually kind of low.

Dr. Tward: It's low. But like I was saying before, part of the issue when dropping out the PSA screening is now we're seeing more advanced cancers. And actually, digital rectal can very easily detect those more advanced cancers. It's an easy thing to . . . I guess easy for me to say. Easy thing to do.

Scot: When I go into my annual physical, if I asked for that from my doctor and they're like, "Well, we really don't do that anymore," and I'm like, "Eh, but I'd rather have it," am I going to look weird?

Dr. Tward: No. You're not going to look weird. In fact, again, I don't see that the downside. I think the controversy around screening actually is revolving around PSA screening. I think there's not so much controversy at all around digital rectal exam. Again, most likely, that test will be negative. But if they do actually feel something firm and hard on the prostate, it's quite certain that that is likely to be prostate cancer. So it's worth doing.

Scot: Troy, did you know that . . . Well, first of all, if you're a man and you live long enough, you're going to have prostate cancer. That's just what it is. But did you know that you could actually have a slow-moving prostate cancer and it never impacts your life?

Troy: Oh, right. And that's one of the big things I've heard in terms of people advocating not to get screened. A lot of people will say, "You're more likely to die with prostate cancer than you are to die of prostate cancer." Meaning you may have prostate cancer and die of something else. Dr. Tward, I don't know if that's actually the case. That's something I've often heard cited as a reason to maybe not get screened.

Dr. Tward: I think there's truth to the statement that most people diagnosed with prostate cancer won't die of prostate cancer. But then again, there's a significant minority, 10% to 15% of people diagnosed with prostate cancer, who will die with prostate cancer.

What I'll say is that this inevitability that you'll be diagnosed with prostate cancer is sort of true in a technicality. And this is known from autopsies done, I believe, in Detroit where they took men who happened to require an autopsy for reasons unrelated to prostate cancer. And if you just take 20- to 30-year-olds and pull out their prostate for no reason and look to see if there's cancer in them, we'll technically see prostate cancer in about 10% of them, and then it goes up by roughly 10% per decade.

The point is these are cancers in a technicality that are indolent-behaving, and usually are growing so slowly they don't threaten. But we have ways of evaluating men with these early-detected cancers if we happen to detect them, to surveil them. And we wouldn't rush a guy right into treatment these days.

So thoughtful practitioners today, when they diagnose prostate cancer, the first question they ask is, "Okay, you have prostate cancer. Do we need to treat it or should we simply put you on an active surveillance regimen where we will treat it when we know it's required to?"

Troy: Well, a lot of what you've talked about, I think, is screening in people who just are asymptomatic, just is routine screening for prevention. Are there certain symptoms that anyone like myself or anyone else maybe in their 40s, or maybe prior to 50 years old, they might be experiencing where you'd say, "Wow, you really need to get screened for prostate cancer"?

Dr. Tward: The vast majority of men will be completely asymptomatic. The most common thing I hear is, "I had no symptoms. I can't believe it." But that's the norm. It is a very small minority of people who have cancers that are causing symptoms. And usually those cancers are, in fact, fairly advanced. If you're starting to have symptoms from your cancer, it's because there's probably a lot of bulk to the cancer and it's been growing in there for a long time, which, again, is the argument for screening. Those men who aren't screened, that's the state with which occasionally we identify it.

But the symptoms that when someone is symptomatic has, it's typically kind of frequency and urgency or weak stream if the tumor is near the urethra or bladder neck and pressing. But it could also be blood in the ejaculate if the tumor has extended up into these structures called the seminal vesicles or near the urethra. Again, though, those are pretty uncommon.

And in men with very advanced cancers who don't know, what's interesting . . . you can get to a point where you have 100 tumors in your bone and cancer all through your lymph nodes and prostate and not have known it, but then all of a sudden you're wondering why you've been tired for the last three or four weeks or maybe a bone hurts or something like that.

So those are the presentation of the very advanced cancers. Like, "I've got this pain in my spine. It's just not going away. It's kind of getting worse." That could also be a sign that you might have prostate cancer.

Scot: Is there a number one risk factor for it? Is it genetics?

Dr. Tward: Just having brothers, or fathers, or uncles with prostate cancer puts you at an elevated risk, which is why I advocate at age 40 to do your baseline screening.

Scot: And if I don't have a family history of more aggressive prostate cancers, then am I in the clear?

Dr. Tward: Well, I mean, I guess you're at a lower risk than someone who has that, but you're not in the clear. You still should very much consider screening for this disease.

Scot: Again, not yes/no. It's shades of gray.

Dr. Tward: Absolutely. Always.

Troy: And what about prevention? We talk about prevention for other cancers. Don't smoke to prevent lung cancer. High-fiber diet to reduce your risk of colon cancer. Anything that someone can do diet standpoint or anything else to prevent prostate cancer?

Dr. Tward: So I guess my short answer is there is no clear dietary intervention that we're aware of right now that clearly reduces your risk of developing prostate cancer. Where there's a connection, I guess, to prostate cancer is when you have a lot of body fat, you might have a lot of estrogen production, and that can kind of interfere with the hormone therapy pathways that may or may not lead to prostate cancer.

And I'm sorry for not being extremely clear here, except to say that prostate cancer is a testosterone-driven cancer. In other words, testosterone is sort of . . . let's call it the food supply for prostate cancer cells. And so things that interfere with your testosterone production could either put you at increased or decreased risk of, I guess, developing a prostate cancer. That's where weight and body fat sort of come into play.

But again, there hasn't been very clear proof that modification or getting under a certain BMI will lead or not lead to the development of prostate cancer per se.

Scot: But no downsides, really, to being under a certain BMI, right?

Dr. Tward: Well, there's no question that being under a certain BMI is healthy, but also, I guess if we want to relate it to the prostate cancer, if you are healthy and in shape, it's going to keep your options open for what treatments, if you need to provide them, are going to be offered. And not only that, but how you might recover from those treatments.

So one of the things that a man has to understand is that when they're diagnosed with prostate cancer, you don't just get put down a standard treatment path. You are given this large Cheesecake Factory menu. And I say that for those who've been at the Cheesecake Factory.

Scot: I hate that menu. It's so huge. Nothing against The Cheesecake Factory.

Dr. Tward: Delicious food, no doubt, and you think . . .

Scot: But that menu is overwhelming.

Dr. Tward: Yeah. It is overwhelming. And if you give somebody too much choice, they're overwhelmed. But what I'd say here in this case, especially as it relates to diet and exercise, is on the one hand you also want to keep as much choice open as possible so that you can nuance this complex treatment choice that you're going to hopefully make with some shared decision-making between your doctors, your family, and others to make one that is going to result in the best outcome and preserve your quality of life.

Scot: So staying healthy, never a bad thing.

Troy: Never a bad thing. But I'm going to ask this question because I know just about every guy listening has heard this, and maybe this is an urban myth. Does more frequent ejaculation reduce the risk of prostate cancer?

Scot: You were on Reddit. I saw that too.

Troy: It's probably on Reddit and everywhere else you've ever looked for preventing prostate cancer.

Dr. Tward: There have been correlative studies purporting to show that. And we're in the realm of sort of Level 2 evidence. There have also been correlative studies that have refuted that. I think that the most knowledgeable expert at this point would say there's really no evidence that that would reduce your risk of prostate cancer, but it might be good for the soul, depending on the individual. But I wouldn't use that as a strategy to reduce your risk of prostate cancer.

Scot: Here's how that started, Troy. I have a good idea how that whole thing started. Some guy got busted.

Troy: Some guy got busted. "It's all for protecting my prostate."

Dr. Tward: "I'm doing it for both of us."

Troy: Exactly.

Scot: Wow.

Troy: I had to ask.

Scot: We've talked a lot about screening, which is complicated. We've learned it's not black or white. We've learned that you should not necessarily jump to, if you come back positive, that, "I need to get treated for it." It's a more nuanced and longer conversation, a longer flow chart, if you will. Treatments are kind of the same way. What would you say about a man that is faced with that menu that you referenced?

Dr. Tward: Yeah, there really are at this point a huge number of treatment choices, and it's important to understand that some of those treatment choices are offered by urologists, some of those are offered by radiation oncologists, and others are offered by medical oncologists.

So what you really need to do when you're diagnosed with prostate cancer is make sure that you speak with all the relevant experts that might potentially have a treatment for you and not get all the information filtered through one particular provider.

Now, I will be the first to say that that most providers are as honest and want to do the best they can, but people do what they do and know their own specialty. So if you have a prostate cancer that's been diagnosed, and that's routinely done by the urologist, of course the first question should be, "Should you or should you not treat?"

But if you move down a path where you think treatment is warranted, I would think that that patient would want to talk to both the urologist and a radiation oncologist and maybe a medical oncologist as well just to make sure that they see a few different perspectives on it and hear the risks, benefits, and alternatives through those lenses.

Scot: Because we're dealing with some quality-of-life issues, those decisions could be very important as to what the rest of your life might look like.

Dr. Tward: Absolutely.

Scot: The types of things, some of the negative impacts that treatments have.

Troy: And let me ask just one question also with treatment. You mentioned you are seeing more advanced prostate cancers now. What's the treatment success in these cases, or is there much success?

Dr. Tward: Well, there is still success at the more advanced presentations. The problem is at the earlier presentations, for example, you get to use what I term a monotherapy. Maybe all you need is a radical prostatectomy and that's it.

But with the advanced presentations that we're seeing more commonly now, the real discussion centered around is if you're going to have surgery, you're also going to get radiation and anti-testosterone therapy as well. Or if you're going to get radiation therapy, we're also going to combine it with anti-testosterone therapy for maybe two years.

And so when you start adding two and three kinds of therapies at once to get the better outcome, you're, of course, risking the increased side effects and quality of life issues.

If you were to just get a radical prostatectomy, let's say, you might have downtime for a couple of days and be back to work in about two weeks and work a little bit on continence, but you kind of take your lick and you're done.

But if you now are saying, "And after that, we're going to do seven or eight weeks of radiation and six months of hormone therapy," you're kind of dealing with the effects of this higher stage for a lot longer.

Or conversely on the radiation side, we're at a point now where we can do a simple outpatient procedure, like Brachytherapy, one and done, go home, return to work the next day, or just five X-ray treatments. But in the advanced cases, again, "Oh, by the way, we're going to take all your testosterone away from you for two years."

Hormone therapy is something we really haven't focused on in this conversation much, but with the advanced prostate cancers and the metastatic prostate cancers, the backbone of the therapies is stealing all your testosterone. And in a men's health show, that's going to be a major item on the table.

So there are all kinds of issues that happen when your testosterone is at castrate level. Most people turn to the sexual side of it, which is important, but there's a host of other issues that include weight gain, bone density loss, muscle mass loss, risk of cognitive decline, increased risk of heart attack/stroke. These are very serious issues and they're very serious on a marriage, they're very serious on a relationship. And so these advanced presentations have a much greater impact on the man and his partner than they would otherwise.

Scot: Troy, after this conversation, where are you at on screening? I mean, you're not 50 yet. Are you going to get screened when you turn 50? Sooner? What are you thinking about?

Troy: This is so tough. It's such a tough . . . I mean, I still feel like it's just such a gray zone, but after having this discussion . . . Like I said, I had always thought, "Well, you don't need to get screened." And my primary care physician said, "Hey, you really don't need to get screened." And I knew about the U.S. Preventive Services Taskforce recommendation of not getting screened. But after hearing this, I am definitely leaning toward getting screened.

I mean, it certainly makes sense that, Dr. Tward, like you said, it's not just about mortality, which was their primary outcome, how many people die. There are so many other factors to consider.

So the next time I see my primary care physician, I will put this on the list. And I find that's what this show does for me. It creates my list of things I need to ask my primary care doctor about. So this is on the list now.

Scot: I think I'm going to get tested. I've had people encourage me to get tested, but I think what I've really gained out of this is when that result comes back, it's not a definitive yes or no. There's a nuanced conversation that has to happen after that.

I very well might have cancer detected, but it could be one of these slow-moving ones. Dr. Tward said you're really good at kind of being able to gauge over time if it becomes more and more aggressive. So that really makes me feel a lot better.

And this podcast is going to be the source of information that I'm going to use for people in my life who maybe have a different plan in mind, because I really think that this lays out a lot of great information to help men and other people in their lives make decisions.

Dr. Tward: Screening just gives you information. It doesn't condemn you to anything. And that's the take-home. The more information you have about your health, the more likely you are to make wise decisions about things that are important for you and your family.

And so I do advocate getting screened. That doesn't necessarily mean I advocate once you get screened that you necessarily go on to the next step. You just have to discuss it with providers who know what they're talking about.

Troy: And that's a great point. I think too, personally, I'd rather know what's going on and what are my options and what can I do to deal with it than just being in the dark and then just getting blindsided sometime down the road. So I think that's a great point.

Scot: Troy, Dr. Tward was telling me that in recent years there has been really an advancement in . . . is it treatments, or is it a screenings, or both?

Dr. Tward: Well, all. I mean, on the screening side, as we alluded to, we've kind of had this threshold of if your PSA is over four, you should get a biopsy. But now we're at a point where we have additional tests that you can do to kind of decide if a biopsy is likely to yield fruit. These are molecular tests. Some of them are done in the urine. There's a company that's FDA-approved called SelectMDx that could look at a urine assay and tell you what is the probability if you actually get biopsied that you'll find cancer. There's also something called an OPKO 4K test that is kind of a . . . let's call it a more robust PSA screen that likewise . . .

So I think where I personally am . . . and I am exactly 50 years old and I'm at that stage myself where I am pondering this. I'm absolutely going to get a PSA test. However, if it came back elevated, there's clearly no way that I'm going to go directly into a biopsy. The next thing I will do is ask for some additional molecular testing and also imaging, like perhaps MRI, to help guide the decision of whether or not I should have needles stuck inside me.

Troy: I like that. That actually really makes me feel so much better because I've always heard "PSA elevated, biopsy." And I've heard about the biopsy. It's something that goes in the rectum. It's got these little prongs that pop out and into the prostate. It just sounds so uncomfortable. So I like that there are additional steps to avoid that if that PSA is elevated and then make that decision on the next step.

Scot: And as we've talked in past episodes, if your physician or provider is not offering those, have that conversation. Ask, "Hey, I understand that there are some other things we could do." Again, you could use this podcast as a source of reference or you could just ask, "Aren't there other things that we could do?"

Dr. Tward: Absolutely.

Scot: Just have those honest conversations with your provider.

All right. Dr. Tward, thank you very much for coming in. That was a lot of information, but I think it's important information for us as men to have because prostate cancer can radically impact your life, if not in mortality, in quality of life. And being told you have cancer can be really, really scary, and the treatments can be really, really scary, but knowing that there's some in-between before you have to get to some of the scary parts has been very useful. So thanks for being on the show and thanks for caring about men's health.

Dr. Tward: My pleasure. I really appreciated this opportunity, and I hope that this is valuable to the men out there. And don't be shy to talk to your doctors about this problem.

Scot: Hey, you're still here. Cool. This is Scot from "Who Cares About Men's Health." Well, I hope that Dr. Tward made the case why you should get screened and then what to do afterwards if the result comes back positive.

Prostate cancer, dealing with it at a later stage, just is not fun. A lot of terrible side effects. It's just not enjoyable to go through, as you heard some of them on the show. So get screened if it's that time, and then just take it nice and slow and figure out how you're going to progress after that point using the information in this podcast.

This episode was one of our Men's Health Essentials, health topics that impact you, particularly as a man. It could be very unique to men or just ones that we struggle with more than perhaps women.

So if you like this show and you want to hear some other Men's Health Essentials, just go to our podcast page, whocaresmenshealth.com, and you can scroll through there.

Reminder, we also have episodes focusing on the Core Four. If you're looking to improve your nutrition, activity, sleep, or your mental health, those episodes will help.

And then we have our side show where we do talk about health, but it's a little looser, and it's a kind of more in abstract terms, and it's just actually discussing the concept of health and men and how we process it and how maybe we can process it a better way.

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Interviewer: For men who have been diagnosed with an enlarged prostate, there are a lot of treatment options, but it can be a little overwhelming. And some men fear about the side effects of those treatment options. We're going to sort through that today.

Dr. Stephen Summers is a urologist at University of Utah Health, and he's going to help us better understand the treatment options available for an enlarged prostate and, more importantly, understand what you would want to weigh as a patient when you're having a discussion with your physician or urologist about those different treatment options. So you were telling me that sometimes men put off treating an enlarged prostate because of the fear of side effects. So let's start there. Treatment options have side effects. Do they all have side effects?

Dr. Summers: Unfortunately, any treatment option will have side effects. So the first one, I guess, that has the fewest side effects is lifestyle modification. So if you can lose weight and improve your diet, cut out caffeine, you may have some benefit. But once we start talking about medications and surgical treatment, it's a matter of weighing the side effect with the benefit that you expect to see.

Interviewer: Okay. So can you talk us through that a little bit? So, if I understand, the hierarchy is lifestyle changes first. And you've given us a great reason to want to do that to avoid the side effects of medication. But then it would be medication next. So talk us through, what are some of the options there?

Dr. Summers: Yeah. There are three categories of medications. But primarily, we start with alpha blockers. And the most common medication used is a medication called Flomax or tamsulosin. It works to open up the prostate and the bladder neck to allow the urine to flow through a little bit easier. For the most part, it's well tolerated, but the side effects that bother men with taking that medication can be dizziness. And so you get up all of a sudden, you may have some lightheadedness or a possibility of fainting. And the other one is something called retrograde ejaculation or a sexual side effect. And that is when a man orgasms, instead of having the semen come forward out the end of the penis, it goes backwards into the bladder. And that certainly can be concerning to a lot of men and is one of the main side effects of a lot of different treatments for prostate enlargement.

Interviewer: Is that something I should be concerned about?

Dr. Summers: No. It is a concern if you're planning to father more kids. Obviously, that is an important part of reproduction. But in terms of your overall health, it doesn't make a big difference. It doesn't impact the sensation of orgasm too much, but it's highly individual. In some men, that can be a real bother.

Interviewer: Yeah. Sure. Like I would imagine a lot of these side effects are going to be very individual.

Dr. Summers: Sure. Yeah. The other medications that we use, there is a medication that falls into a class called 5α-reductase inhibitors. There's a medication called finasteride or Proscar or Avodart or dutasteride,. These medications get at the effect of testosterone on the prostate. So they block the effect of testosterone on the prostate growth and over time can cause some shrinkage of the prostate. They are very slow medications to work, and you have to continue on those medications for life once you start them if you're going to experience the benefit of the treatment for them. The main side effects with those can be erectile dysfunction, problems with mood, energy level. It can cause occasional breast enlargement in men. And it does have the side effect of causing hair regrowth. So the medication that was commonly prescribed called Propecia is in this class of drugs. But there are more substantial sexual side effects, I will say.

Interviewer: Why would a man choose this particular treatment then over maybe the first one?

Dr. Summers: No. That's a good question. So, oftentimes, they're combined. So we will use both medications. There's pretty good data out there to suggest that both of them work almost synergistically together than using either one alone. The other advantage with the finasteride, that we were just talking about, is it does reduce the progression of symptoms and severity of the disease, and so you can reduce the risk of progression to the point where one might need surgery by about half. And so there are clear benefit with that.

Interviewer: And you said the one that you have to take for life, say I started, at six months later, I'm like, "Ah, these side effects, I can't live with these." Am I able to then take a different treatment option?

Dr. Summers: Sure. You can always change the treatment option. There is some controversy though, and I think it's important for men to know that there have been some men that have had persistent side effects even after stopping that medication.

Interviewer: Okay.

Dr. Summers: So some of those sexual side effects have lasted even once they've come off of it. Now, that's a very small percentage of men, but certainly, if you're one of those patients, that's going to be a concern for you.

Interviewer: Yeah. And then there's a third category of drugs as well?

Dr. Summers: Yeah. The other category of drugs works primarily on the bladder. It relaxes the bladder, so it treats the symptoms of the disease, but does nothing really to the prostate. And so you're really putting a Band-Aid on treating the symptom, the frequency, the urgency, the getting up at night, but you're not really addressing the problem. So a lot of times we'll use those medications in combination with these other drugs to help lessen or minimize the symptoms as we're focusing on the problem of the prostate itself.

Interviewer: All right. So it sounds like that, you know, you need to have a conversation with your physician about the risks and benefits of the medication. At that point, if that doesn't work or is it possible that a man just might not choose to do the medications because of the side effects that they would move on to surgery. Let's talk about that as a treatment option.

Dr. Summers: You bring up a great point. Sometimes we consider surgery even before medications when you're trying to minimize some of those side effects. So there are a couple of new or recently developed treatments that I think are important to highlight here. And I highlight them specifically because they do not have those sexual side effects that are so common with the medications. And we call them minimally invasive surgical treatments. They're done in the office with a local anesthetic. So it's a very quick recovery with little downtime or little missed work.

The first of those treatments is something called a UroLift. That is a device that is implanted in the prostate that holds back that prostate obstructing tissue and opens up the channel to allow the urine to flow through easier. The advantage with it is it's done relatively quickly in the office. A lot of men do not even have to have a catheter following that procedure, and it doesn't have any of the sexual side effects. So there's no risk of erectile dysfunction, there's no risk of retrograde ejaculation, and there's no risk of urinary incontinence following that procedure. Unfortunately, not all men are candidates for that procedure. It depends a little bit on prostate size and anatomy. But it can be a great option for a lot of men.

Interviewer: And are there other surgical options that you discuss with your patients?

Dr. Summers: Sure. I think it's important to really know all of the options, and so I like to review everything with my patients prior to entertaining any one of them. Another office-based procedure that we do is something called Rezūm. Rezūm uses steam or water vapor therapy in an effort to shrink or ablate and remove prostate tissue. And so, similarly, it's done in the office under a local anesthetic and with some mild sedation. We go in and I inject the prostate with the steam. And depending on the size of the prostate, you may get anywhere from 4 to 10 or even higher injections. And that steam destroys the prostate tissue, shrinks it down and opens up the urinary channel. Men following that procedure do have to have a catheter for a few days. The recovery can be a little bit longer, but there are no restrictions. You're able to go back to work as soon as you're able to tolerate things. It similarly does not have any risk of sexual side effects, including erectile dysfunction or retrograde ejaculation, and no risk of incontinence.

Interviewer: Is this one a little bit more of an option for men than the previous one? Because you said the previous one, you know, some men would not necessarily be a good candidate for it.

Dr. Summers: Yeah. So it has the ability to tailor the treatment a little bit more to a broader range of prostate anatomy, so different prostate sizes and three-dimensional constructs of the prostate. But both of them are, you know, often used interchangeably, and both are good options for a lot of men that are hopeful to avoid some of the bigger surgeries.

Interviewer: Is there a reason why a man might pick one surgery over the other if they were eligible for either one?

Dr. Summers: A lot of times it comes down to the recovery. It comes down to experience, provider preference too, and duration, you know, how long we've been doing those treatments and what's the long-term data and retreatment rates for each of those. So, you know, it gets into a little bit more in-depth discussion that I try to tailor to the individual. When they come seeking one of those treatments, we kind of look at the data and say, you know, "This is what I have that's published based on this treatment. And how does that fit with kind of your expectations and the symptoms that we're looking to treat?"

Interviewer: Getting close to wrapping this up, are there other options that we haven't covered yet that we should?

Dr. Summers: You know, I think one of the common questions I get in surgical treatments that a lot of men that talk about it is the TURP, and that stands for transurethral resection of the prostate. For some reason, men affectionately call it the rotor-rooter. It's an older treatment -- it's better around, you know, almost 100 years -- where urologists go in and using a resection knife in the operating room, with the patient asleep, we hollow out the prostate. It's still a commonly practiced procedure. Most urologists do a lot of them. It still has its place. And technology, of course, has improved as have the side effects. So we've, you know, gotten better at that procedure. But I think a lot of men come thinking that is their only option. And, unfortunately, they have, you know, all had a friend that has had this done and has had maybe a complication, and they fear and procrastinate putting off treatment because of some of the side effects of this older treatment option.

Interviewer: So did I miss something there? I guess I assumed that the surgeries would remove the prostate. And I don't know that I heard any of the things you talked about actually explicitly say removing the prostate.

Dr. Summers: Yeah. That's a common question we get too, and it's a bit confusing when you look at pictures of the prostate. So most of the treatment for benign prostate disease does not remove the entire prostate. We're removing the inside glandular portion of the prostate that's obstructing the urine flow. That is contrasted and much different than an operation that we do for prostate cancer. So if a man has prostate cancer, most of the time that cancer is on the outside of the prostate, and we have to remove the entire prostate. Whereas with benign prostate disease or BPH, that growth or enlargement is on the inner part of the prostate that's obstructing and pushing on the urethra.

Interviewer: And then does that affect the function of the prostate? Is it no longer functional at that point?

Dr. Summers: Once you remove the whole prostate, yeah. Certainly, it's no longer functional. In terms of removing a portion of it, you do lose some function. The function of the prostate is to secrete supporting fluid in your semen for sperm. And so, for most men that were treating prostate enlargement, that is less of an issue. But certainly, if you're a younger patient still planning on fertility or have fertility concerns, then we need to weigh that in with what treatment options we're considering.

Interviewer: Final question. How can a man go into this meeting with their urologist, armed and ready to have this conversation, other than listening to this great interview, of course?

Dr. Summers: Yeah. I think just being open and honest about what your symptoms are, kind of what your priority is, knowing that there are side effects and risks with any of these treatments, what's important for you. Is it that we're treating your nighttime symptoms? Are we improving your flow or your frequency? If you can identify what really bothers you the most, then I can tailor the treatment to fix or improve that symptom. It's really hard to certainly change things and reverse things to make it a 100% better, but if you can tell me what bothers you most, then I can highlight that and incorporate that into our treatment.

Interviewer: Frequent urination, the feeling that you always need to go to the bathroom, a weak stream dribbling, waking up in the night to go to the bathroom could all be the symptoms of an enlarged prostate. It's called benign prostatic hyperplasia, or an enlarged prostate, and it's more common than a lot of men realize.

Dr. Stephen Summers is a urologist at University of Utah Health and he's going to give us the information we need to help you if you're suffering from any of those symptoms.

So the first question that I do want to ask has nothing to do with the symptoms, but it has to do with a kind of a misconception. Is an enlarged prostate and prostate cancer the same?

Dr. Summers: No, they're not. It's interesting because I get this question frequently and a lot of men come to me with concern for possible prostate cancer with some of those urinary symptoms you were just talking about.

Certainly, you can have both conditions at the same time. You can have prostate cancer as well as an enlarged prostate causing urinary obstruction and the symptoms that we relate with that. But they're really two separate issues that both need to be addressed and handled often simultaneously. The age groups that are at risk for prostate cancer also happen to be the men that are most often suffering from lower urinary tract symptoms or the symptoms that we most commonly associated with BPH.

Interviewer: Just because I have those symptoms doesn't necessarily mean that it's prostate cancer. That sounds like it could be a fear that men have. Out of the men that come to you with those symptoms, how often is it prostate cancer versus just an enlarged prostate?

Dr. Summers: Yeah, prostate cancer is an extremely common cancer. That said, most of the men that I see with those symptoms do not have prostate cancer. And so, certainly, we ask questions to find out more history and evaluate them for prostate cancer, but we're also looking at other things. Aside from benign prostate enlargement, men can have infections that can cause similar symptoms. You can have a scar or a blockage in the urethra that causes similar symptoms.

BPH is the most common thing that causes all those symptoms and the most common thing I see with men, but it's important that you speak with your doctor and even see a urologist to evaluate for some of those other causes as well.

Interviewer: Sure. Is this true? Some men with those symptoms just figure that it's a part of getting older and there's really not anything that can be done about it. Does that happen a lot?

Dr. Summers: Yeah, so just as we were talking about the increased prevalence of it, a lot of men may not be bothered by the disease itself and their symptoms are very mild. And at that point, they may be right. It's a fact of getting older and their symptoms wouldn't lead to any long-standing problems.

The hard thing is there is a subset of men who have worsening symptoms and maybe have those symptoms younger. If those symptoms are left unchecked or untreated, it can lead to long-term problems.

For example, if a person has a prostate enlargement that obstructs the bladder from emptying, over time the bladder changes and the muscle itself gets thickened, it becomes stiff, it's less pliable, and ultimately the bladder fails and doesn't work. And so then a person is left without a functional bladder and they cannot urinate. Even if we were to go on and treat the prostate, they still cannot urinate and they may be dependent upon a catheter.

Interviewer: Wow, that is a reason to get that thing looked at, isn't it?

Dr. Summers: It certainly is. And I can't tell you how many times I've had men come in who have ignored the symptoms for a long time, thought it was no big deal. Maybe they have a work environment where they can use the bathroom as is out in the wild or whatever. And lo and behold, they have a pretty significant problem. And at some point, those changes become irreversible and no matter what I do, I can't change that.

The other step even further than that is if once the bladder fills, then the urine backs up and you start having kidney problems as a result. And I've seen men with kidney failure that need to go on and have dialysis or even a kidney transplant all because of their prostate problems and their urinary problems that they've neglected for so long.

Interviewer: The symptoms that we talked about, the frequent urination, feeling that you always need to go to the bathroom, a weak stream, dribbling, waking up in the middle of the night, do these all kind of come on at once, or is this more of a gradual thing, so much so that maybe some men don't even notice that there's an issue right away?

Dr. Summers: That's a great question, Scot. It's that gradual, insidious onset that I think can be deceiving to a lot of men. Symptoms may start out very mild and they're so slow changing that you get used to it. You adapt to it. And it may be that you don't even notice that you're having those symptoms, and it's a loved one often that will point out and say, "Boy, you're going the bathroom a lot more frequent than you used to," or, "It's taking you a lot longer," or, "It seems like we can't go through the store without you looking for a restroom." And it's those kinds of comments that I think are very important to hone in on and remind people that there may be a problem that needs to be evaluated.

Interviewer: So it can oftentimes be just kind of this slow onset, so much so that you don't even notice. Then when it becomes to the point where it's critical, does that kind of generally hit just all at once? How does that play out? Do you get what I'm asking?

Dr. Summers: I get what you're asking. Yeah, it can go both ways. So sometimes men may not have . . . they may have symptoms that they ignore for any number of years, and then there's an inciting event that triggers a major problem. So that event can be in a urinary infection, it can be surgery, it can be the start of a new medication, and all of a sudden, they get to the point where they may go into what we call urinary retention, where they cannot urinate at all. And that becomes an emergency and one where we see patients in the emergency room in extreme discomfort.

Other patients, it's very slow and they get to the point where they're getting up four or six times a night. And that's when they come in kind of seeking help because the symptoms have just gone on for so long that it's interfering with their sleep.

So it goes both ways. Certainly, I think the earlier that you can address the problems, the much easier it is to fix. And more importantly, you can avoid some of those long-term effects that we talked about on the bladder and the kidney function.

Interviewer: I was reading some stuff online that some men that get this that it kind of just all of a sudden hits, then you're using a catheter to help drain the bladder, and that doesn't sound like a whole lot of fun. And it sounds like if you kind of get in early enough, not only can you avoid some of the potential downsides you talked about earlier, but maybe a lot of pain in a particular moment if you get to it early enough. Is that true?

Dr. Summers: That's certainly true.

Interviewer: Yeah. Okay. It doesn't sound like a lot of fun.

So it sounds like one of the major risk factors is just, as you get older, the prostate just naturally starts growing. So I saw something . . . I think you said, what, 60% of all men over 60 tend to get it, and then the older you get, it goes up and up and up, right?

Dr. Summers: It does.

Interviewer: So, other than that, are there any risk factors that might cause a man to get this?

Dr. Summers: The prostate continues to grow as we age, and it's highly influenced by androgen levels. And that is, in large part, influenced by genetics. And so, if a person has a higher genetic predisposition or family history of prostate disease, they're much more likely to have similar type symptoms.

Interviewer: Lifestyle too can impact it, right? Because I know that that is one of the treatment options, which we'll get to in a second briefly, because we do have a special podcast we're going to do just on treatment options. But like obesity or diabetes or not enough exercise, those types of things can contribute as well. Is that a major contributor or not so much?

Dr. Summers: Yeah, it certainly can be. Take obesity for example. So obesity, it's unfortunately very common in our society. And with that, you get increased pressure that's put on the bladder, which is only going to make those symptoms worse. And so, if a person can lose weight, then you can markedly reduce some of the frequency and urgency symptoms.

Similarly, different diets. Caffeine is a common culprit for many of us. And the more caffeine that you consume, it has both a diuretic effect as well as an irritant to the bladder and will only cause increased frequency. And so, if you're already having some baseline urinary frequency and difficulty with those symptoms, you add any of these lifestyle components onto that, things are only going to get worse.

Interviewer: And some of those lifestyle changes you have seen make a difference for some men.

Dr. Summers: Yes. So weight loss, exercise helps, limiting caffeine, limiting alcohol. Spicy foods can wreak havoc on the bladder.

Interviewer: So everything but the spicy foods is just stuff that should be doing anyway, right?

Dr. Summers: Yeah. I mean, it's interesting. Healthy living really translates into so many different things across the spectrum of our health.

Interviewer: So lifestyle changes, is that generally the first thing you do, or what's that hierarchy in general look like?

Dr. Summers: Yeah, you're exactly right. So oftentimes we'll talk about lifestyle modification, losing weight, changing diet. Exercise is our first-line therapy because it's low risk, and it has other benefits. When that fails or your symptom improvement isn't where you would like, then we talk about medications. Once you start getting into medications, it's a balance of dealing with side effects with the benefit of the medication. And there are several different classes of medications we use to treat prostate disease. And then we move on toward office-based procedures and surgical treatments for the prostate.

Interviewer: So, when it comes to an enlarged prostate, it's something that all guys are going to get. Maybe some will start showing the symptoms we talked about and some will go on affected. It sounds like you want to go to somebody as soon as you start noticing those symptoms. The quicker, the better. I would imagine you run some tests just to verify that that's actually what's going on, and then you would discuss some treatment options. So it sounds like it's not a one-size-fits-all sort of a treatment.

Would you recommend going to a urologist first if you're noticing these symptoms, or start out with your general practitioner or family doctor?

Dr. Summers: I think you can certainly start with your general family doctor or general practitioner and at least raise the question about your urinary symptoms. Some of the early interventions, the medication and the lifestyle modification, can certainly be prescribed by your general practitioner. I think when your symptoms are more severe a urologist is more ideally suited to treat your disease at that point.

Interviewer: We're here with Dr. Jeremy Myers. He is a specialist of urological surgery. So, Dr. Myers, what exactly is a urethral stricture?

Dr. Myers: Well, a urethral stricture is, quite simply, a scar in the urethra, which is the pee channel running from the bladder and out the penis. And it almost exclusively happens in men. It's very rare that it occurs in women. And so that's where we deal with it most.

Interviewer: And what can cause some of these scars?

Dr. Myers: Most of the scars are what we call idiopathic, which means they just come up. And they come up in a particular area of the urethra, below the scrotum. But you can also get the scars from a bad infection, such as a sexually transmitted disease, which is very rare. And you can also get it from trauma. The classic trauma that can cause it is when a man lands on the perineum, like on a rail skateboarding or snowboarding.

Interviewer: Yeah, and the saddle injury, I think, is something I read too, right? Horseback riding?

Dr. Myers: That's exactly right. In the West, we see this from horseback riding and sometimes from ATVs. And, sometimes, it's accompanied by a pelvic fracture when it arises from trauma, but this is a small portion of the strictures. Almost all of them just arise for no known reason.

Interviewer: Since these structures are kind of internal, and it's not something you necessarily see, how does a person or a man, kind of . . . How do . . . What are some of the symptoms of having a stricture?

Dr. Myers: The strictures are pretty rare, and so it's very often that they're misdiagnosed or not recognized for some time. I remember talking to an internist once, and they said, "Oh, I didn't even realize that could happen." So they're not really on the radar a lot for the medical community as a whole. So patients are often diagnosed as having a prostate infection or a voiding dysfunction or a urinary tract infection, and then their symptoms don't get better, and then they're sent to a urologist who can diagnose the stricture.

Interviewer: So, essentially, they have difficulty passing urine and other complications because the urethra is actually smaller or not flexible, is that what happens?

Dr. Myers: That's exactly right. The urethra narrows down in a lot of cases just to a pinpoint, and so, the most obvious symptom of that is a very slow flow. And most guys will tolerate a slow flow alone. But there's a lot of other symptoms that come up. Men can have urinary tract infections. And then also, their bladder stiffens because it's squeezing so hard against the scar and so they have to urinate more frequently and may have urgency of urination. And so, a guy might be up four or five times a night urinating, and it may just be due to the blockage.

Interviewer: So, if it's commonly misdiagnosed, what does it take to actually diagnose a proper stricture?

Dr. Myers: Well, the suspicion is increased for a urologist in a younger man, who really should be voiding very well. In older men, the symptoms may be attributed to a large prostate. That's really common. But in a younger man, we can diagnose it or suspect it based upon their flow. And so, when someone comes to a urologist, we typically have them pee in a special toilet that allows us to measure their flow, and if they have a very slow flow and they're a younger man, then it's suspicious. They might have a scar. And where we go from there is pretty variable. The strictures can be diagnosed with a special x-ray of the urethra, or more commonly, a urologist has a scope that's flexible just like a catheter, and he'll pass, or she'll pass the scope up the urethra and then be able to visualize a scar. And that's a very easy way of diagnosing the scar.

Interviewer: So after it's been diagnosed, what are some of the options available to treat and kind of give some relief to these people?

Dr. Myers: The options basically fall into a couple categories. One is using a scope to either break open or to cut the scar, and that's the . . . the medical term for that is a dilation or urethrotomy, and they work about the same. Essentially, a urologist passes the scope up to the area of the scar and then uses dilators to sequentially stretch the scar and break it open, or they'll take a tiny knife that comes out of the scope that they can visualize and they'll kind of cut the scar almost like a Mercedes sign.

Typically, after this, a patient will have a catheter for a few days, and then the catheter is removed. And the hope was stretching or cutting the scar is that the urethra will heal over the catheter and will heal to a reasonable size where the patient is not having any symptoms. The unfortunate part of dilation or internal cutting is that it's rarely successful, and it probably only works in maybe 20% to 30% of cases. The studies on it are pretty mixed about its success rate. And so it's minimally invasive in the sense you'll only have a catheter for a short time, and it just uses a scope in the urethra. But, unfortunately, it's rarely a long-term solution for men.

So the other way that we treat urethral strictures is to do an actual surgery, where we cut into the body, and that's called a urethroplasty surgery. And that's what we specialize at the University of Utah in. Essentially, the idea of a urethroplasty is we cut over the scar in the body, which is mostly in the perineum, which is the area between the anus and the scrotum, and then we very carefully find the area of scarring by just passing a catheter down the penis and feeling where the catheter stops within the urethra. And then we cut out the area of the scar, and we create a very fine connection or anastomosis between the two ends of the urethra that are freed up and stretch. And that cures the stricture.

So that's a surgery that can take anywhere from two to four hours depending on how the surgery is done and what's required. And the catheter has to be in a longer time, and you can imagine an incision below the scrotum can be pretty tender. So it's much more invasive, but it's also much more successful. And the success rates of those surgeries are about 80% to 90%, just depending on the types of surgeries.

Interviewer: Well, that's significantly better results then. And how long of a healing process is that?

Dr. Myers: So, usually, the catheters are in for anywhere from two to four weeks, just depending on the nature of the stricture and what has to be done to fix it. And so, during that time, the catheter is really pretty uncomfortable, and most men will be off work during that time, or if they do non-physical work, they can maybe go back to work after a couple of weeks. The recovery is not like a hernia, so you can't tear open the repair but, usually, when a catheter is in, guys don't want to be doing anything too physical at all because of the discomfort of the catheter. So I'd say the realistic recovery where men are really feeling quite a bit better is about a month or so, and that's why it's much more invasive than the internal cutting, where the recovery really is just five or seven days.

Interviewer: So it, you know, it's an invasive procedure, and it sounds like there's going to be a bit of a recovery, but, you know, when it's all said and done, you know, what are some of the satisfaction rates of some of your patients?

Dr. Myers: We've actually studied this really well at Utah in conjunction with a number of other centers in the country, and if you look at satisfaction with a surgery, men rate themselves as satisfied or very satisfied with the surgery in about 87%. And, most of the time, when they're not satisfied with surgery, they have some side effects, such as a sexual side effect, which is, fortunately, pretty rare or the surgery fails them and, obviously, you wouldn't be satisfied with the result. So that's a very . . . a powerful number to give men when they're considering a pretty invasive surgery is that 85% or more are satisfied or are very satisfied with the results.

Another thing that men experience is their urinary symptoms, and then some men also have a lot of anxiety and depression related to the stricture. And this can be anxiety about not being able to urinate, not having the normal function that men have or anxiety about being in a public bathroom or needing to find the bathroom urgently. And the rates of depression and anxiety are much higher in men with strictures. And we did a study where we showed that these rates normalize and get much better after a stricture surgery. So, overall, a lot of things get better. The urinary symptoms get better after the surgery. So it's a good surgery even though no man would ever want to think about undergoing a surgery like that. It's a very personal and private spot, but it really fixes the problem with a pretty good certainty.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: It never used to happen but now you have to get up and go to the bathroom once or maybe even more times every night. Dr. Gary Faerber is a urologist. What could be going on with that? Could it be one thing or is it a lot of things?

Dr. Faerber: Well, it could be a number of things. Probably the most common along these lines comes from older men who can . . . you know, who are worried that these might be the signs of prostate cancer. That's the most sinister, you know, thing that they can think about.

Interviewer: So we're talking older, how old, 50?

Dr. Faerber: Oh, yeah, men in their 50's, 60's, 70's, yeah.

Interviewer: So like up until this point, they could sleep through the night and not need to go to the bathroom and all of a sudden now . . .

Dr. Faerber: Right.

Interviewer: Does it just kind of happen all of a sudden or is it just kind of over time like . . .

Dr. Faerber: Oftentimes, it's a gradual thing, you know. Initially, they may get up once a night and then it's two times and three times and . . .

Interviewer: So if that starts happening, then there could be something going on?

Dr. Faerber: Absolutely, yeah.

Interviewer: Could it just be that they've started drinking water late at night?

Dr. Faerber: That's . . .

Interviewer: Is that the first thing you look at?

Dr. Faerber: Sure. We certainly do keep track of how much fluid they take and when they take it in just to get a sense of whether this is a normal thing just because the amount of fluids that they drink, or is this, you know, not quite so normal.

Interviewer: All right. So if it turns out to be not quite so normal, let's talk about what some of the possibilities could be.

Dr. Faerber: It's probably related to their prostate. And it's not because they have prostate cancer but in most cases, it's because they have benign or normal enlargement of the prostate gland. And when that happens, it causes some changes in how the bladder functions. And they may not be emptying all the way. The bladder may become a little bit more overactive and therefore, they can't hold the urine as much as they used to when they were younger. And all of those reasons may result in them having to get up at night.

Interviewer: So an enlarging prostate's just part of life. As you age, it's going to happen, if I understand correctly.

Dr. Faerber: Yes.

Interviewer: So nothing to be concerned about really?

Dr. Faerber: That is exactly right. If you're 80 years old, 100% of you men will have benign enlargement of the prostate. So it is a normal aging process.

Interviewer: All right. So that's kind of the most common thing. What do you for that then?

Dr. Faerber: It depends on how bad it is. For example, if it's not too bad, you can do some behavioral changes. For example, just don't have that big glass of water before you go to bed or don't have a lot to drink in the evening. And to be honest with you, most men try that initially. You know, they experiment a little bit and they said, "Yes, I've done that."

Interviewer: Yeah, by the time they get to you, right?

Dr. Faerber: Right, exactly. And then, I'll do an exam on a gentleman and see how big his prostate gland is. And then, we then also look to see how well he empties. So we'll have a gentleman void and then we can do an ultrasound of the bladder to see how much urine is left in because we want to see whether or not they're emptying all the way or whether they're just sort of emptying a little bit but most of the urine is left in the bladder. And if that's the case, then you can understand that it doesn't take very long for the bladder to refill and then they feel the urge that they have to go again and . . .

Interviewer: All right. And that is caused by the . . . not emptying all the way is caused by the enlarged prostate?

Dr. Faerber: That's exactly right.

Interviewer: So if they're not emptying all the way, is there anything you can do?

Dr. Faerber: I tell men that enlarging prostate is sort of like, you're sort of pinching off a garden hose where the prostate, as it enlarges, it narrows the channel where the urine comes out of the bladder. And there are different ways of managing that and there are different types of medications that are available nowadays.

Interviewer: Do some men choose to do nothing and just continue to get up at night?

Dr. Faerber: Yes.

Interviewer: And that's completely acceptable as well?

Dr. Faerber: Yes. You know, if we find that they're actually emptying their bladder, then that's perfectly fine. And I would assume there are a lot of men out there who are very comfortable at getting up once or twice a night, and it's really not affecting them physically or emotionally or socially.

Interviewer: So that need to get up and go to the bathroom once or more each night could be an enlarged prostate. What are some of the other things? Let's not go too in-depth but I just kind of want to do a quick of what else it could be.

Dr. Faerber: Right. We do know that as we all get older, and this has to do with not only with men, but with women too, is that the bladder becomes overactive. We all know, myself included, that when I was 18 years old, I didn't have to pay attention to my bladder when my bladder told me it was full.

Interviewer: Right. Twelve-hour road trip, 8 hours in, you could still go another 4 hours, yeah.

Dr. Faerber: Right. It was no big deal. And I was always that, you know, chuckling at my mom and dad who had to make these more frequent bathroom breaks.

Interviewer: You chuckle no more.

Dr. Faerber: Right. Exactly. I do not chuckle anymore. I understand completely. So as we get older, our functional bladder capacity goes down. And that's a normal aging process. There are some medications which can help with some of those patients where it's really a problem. But in most cases, we don't need to really do anything about it. Oftentimes, if I can just reassure patients that, "If it's not bothering you, it's not bothering me so we don't need to do anything about that." So normal aging process is one.

Two is could there be something within the bladder which makes the bladder more irritable, for example, bladder tumor or a bladder stone or something else like that, that may need to be checked. Oftentimes, if that's the case, it's associated not just with having to get up at night but there may be blood in the urine or they may have frequent urinary tract infections, or something else like that which would tell us that there may be something more going on than just an overactive bladder.

Interviewer: Yeah. And of course, if the bladder symptoms accompany any other symptoms like you said, that's when, probably . . .

Dr. Faerber: . . . you really need to get concerned. Yes, absolutely.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 1, 2019
originally published: April 12, 2017

Announcer: Is it bad enough to go to the emergency room? Or isn't it? You're listening to "ER or Not" on The Scope.

Interviewer: You're having a hard time peeing. Is that a reason to go to the ER or not? Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Of course "ER or Not" is a game where we decide whether or not something is worth going to the ER or not, so having a hard time urinating. Like, I mean it's difficult to get a stream going. ER or not?

Dr. Madsen: So this is one where it really depends kind of on the context of this. If you're a 65-year-old male and you're having a hard time getting a stream going and you feel like your bladder is about to explode, then you absolutely need to go to the ER and this is a common thing we see in the ER where older men will get an enlarged prostate and then they just cannot pee. Nothing will come out, and then you push on their belly and it feels like they've got a basketball in their belly. It's just their bladder is so full and the bottom line is, these people need to have a catheter placed. Something up there to get the urine past that obstruction, past the prostate, get the urine flowing, and so it's absolutely a reason to go to the ER.

Interviewer: All right, so if it's your grandpa or your older dad? Yes. Not the case for women?

Dr. Madsen: Often not, and often in other people they're describing a sense that they have to pee and they just can't go, but in these individuals it's often because they are just going so frequently because they have a urinary tract infection and that creates a sense of just what we call . . . the medical term is urgency. It's exactly that. It's this urgent sense that you need to pee again and again and there's really nothing in there, and that's a pretty common thing with a urinary tract infection. That's something you can go to an urgent care, they can just do a quick urine test on you, say, "Yeah, you've got a urinary infection. Here you go. Here are some antibiotics. This will clear up in two or three days."

Interviewer: But that sensation of having a completely full bladder is not there. It's just the fact that you try to go and nothing comes out. People start to assume, "I must be blocked."

Dr. Madsen: Right. Exactly.

Interviewer: But it's just empty. It's just nothing there.

Dr. Madsen: It's empty.

Interviewer: Yeah.

Dr. Madsen: They just have this feeling like, "I need to go. I need to go," and then they just keep trying and trying and trying, but it's not like these individuals who come in who you push on their belly and, for a 65-year-old man, it feels like he's pregnant. He's got like this mass in his belly. We'll put a catheter in some of these individuals and get a full liter out. Just a huge volume of urine. It's just backed up in there causing lots of pain and discomfort and just nothing's coming out.

Interviewer: Other . . . So urinary tract infections, can that affect a man as well? So like somebody my age, in their 40s, has a hard time going?

Dr. Madsen: It can. It's less common in men, and usually when men get urinary tract infections, we think, "Could there be something else going on that's causing this?" Where in women, it's much more common, the reason being simple anatomy. The urethra is longer in men than in women. It's easier for bacteria to work their way up into the bladder for women, so that's why it's more common. So yeah it does happen, but often in men, especially older men, I start to think, "Could there be something else going on? Maybe an infection in the prostate." Start to think a little bit broader, rather than just saying, "Here's some antibiotics. This should talk care of itself."

Interviewer: What about other blockages, like stones or something like that?

Dr. Madsen: So kidney stones, the interesting thing with kidney stones, they start in the kidney and they cause pain as they work their way down the ureter -- down the tube that goes from the kidney to the bladder -- but once they hit the bladder, the urethra, so the tube that leads out from the bladder is bigger than the ureter, so once they get there it's really kind of weird and unusual that they would get stuck in the urethra and cause it so you can't pee.

Interviewer: Got you.

Dr. Madsen: So most people it's going to be in one of the ureters. You've still got the other side working. You've still got that kidney producing urine. The urine's still going to the bladder. So it's not quite so often I see with kidney stones where people say, "I just can't pee." I mean, usually they're just writhing around in pain because of the severe pain there, but they're still urinating regularly and I can't say I've ever seen where a stone's been so large that it made it's way down in the bladder and then got stuck in the urethra so they just couldn't get anything out.

Interviewer: All right, so just to be sure here, if somebody's having a difficult time peeing, if it's an older man it could be an enlarged prostate, definitely go to the ER. For everybody else, it's probably not a blockage. It's probably a urinary tract infection. Go to an urgent care.

Dr. Madsen: Probably.

Interviewer: And we've covered everything?

Dr. Madsen: Exactly, and you've got to, again, kind of take the whole thing in context. If you're talking about someone that has a lot of medical issues and you're thinking they can't pee because . . . they're just not peeing because they're in kidney failure, then that's another issue entirely. With those individuals it's not so much that they feel like, "I have to pee." It's more just like, "Hey, I'm not peeing."

Interviewer: Oh okay.

Dr. Madsen: It's just their body's not producing urine because their kidneys have stopped working.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with out physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

updated: September 21, 2018
originally published: November 7, 2016

Kim: Prostate cancer is the second leading cause of cancer death in men, but how do you know if you are one of those men with a high risk of developing the disease? That story is up next on The Scope.

Announcer: With the latest news and research from Huntsman Cancer Institute this is the Cancer Care Update.

Kim: A new study finds that when it comes to prostate cancer, your family matters. You could be at higher risk not only if your father had it, but even if a relative you have never even met had it. Lisa Cannon-Albright at the Huntsman Cancer Institute is the senior author on the study published in The Journal Prostate.

Lisa: My goal was to try to use available information to estimate a particular man's risk of prostate cancer, and the data that I wanted to use was his own family history.

Kim: Instead of asking thousands of men their family history, Cannon-Albright and colleagues used a resource called The Utah Population Database. It contains a computerized genealogy linked to medical information for over 7.3 million Utahans including those that have cancer. She says what they found was that having a first degree relative such as a father, brother or son, doubles your risk for getting prostate cancer. But surprisingly risk also increases by having a second or third degree relative such as an uncle, grandfather, cousin, or even great-grandfather with the disease.

Lisa: Most people would agree that if you have a first degree relative affected with prostate cancer that your risk must be higher than it is for other men in the population. But we found that second degree relatives and even third degree relatives, if you have them in your family history constellation you are also at increased risk.

Woman: So even just one?

Lisa: Yes, even just one.

Kim: Cannon-Albright says Doctors should not only pay attention to the men on your father's side of the family, but also on your mother's.

Lisa: The relative risk was exactly the same whether the family history was on your mother's side or your father's side.

Kim: Knowing your family history and whether this increases your risk for prostate cancer will help your doctor develop a health monitoring plan specific for you. For Cancer Care Update, I'm Kim Schuske with Huntsman Cancer Institute.

Announcer: For more resources from the cancer care and research experts, Huntsman Cancer Institute, go to HuntsmanCancer.org. The Cancer Care Update is a co-production with TheScopeRadio.com University of Utah Health Sciences Radio.

Dr. Tom Miller: Screening for prostate cancer.

Dr. Blake Hamilton: Oh my.

Dr. Tom Miller: Why the oh my?

Dr. Blake Hamilton: This is a very controversial subject.

Dr. Tom Miller: This is Dr. Tom Miller. We are going to be talking about prostate cancer screening next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Tom Miller: Hi, I'm here with Dr. Blake Hamilton. He's the medical director for the urology clinic, and he's also associate director for the division of urology. Let's talk about it. Is prostate cancer screening with P.S.A. testing something that's time has come and gone?

Dr. Blake Hamilton: No, I don't think so. It's a shifting environment to be sure, but I think it still has relevance.

Dr. Tom Miller: You know, the national guidelines, or a couple of the guidelines out there now say that you really don't need to screen men for prostate cancer using the blood test, the P.S.A., prostate specific antigen test. That's based on a couple of large studies, I believe. The outcomes of those studies, one in Europe, one in the United States, didn't back up the idea that using this test could save lives best that the studies showed.

Dr. Blake Hamilton: We have to go back and understand the history of P.S.A. P.S.A. is a protein that's produced by the prostate. It has a role. It has a function. We learned many years ago, three decades ago, that it goes up in prostate cancer, and when you treat prostate cancer it goes down. It became used as a marker for recurrence of treated prostate cancer. It continues to be very reliable. It's one of the best blood markers that we have for cancer.

Dr. Tom Miller: No question. I think we all know that we find more prostate cancer using this test. The question is does it save lives in the long run.

Dr. Blake Hamilton: The two studies that you refer to, depending on how you interpret them, show that there was not enough difference between the group that was screened and the group that was not screened. There are several problems with those studies. One is that they may not be mature enough. They had an average follow up of eight, nine, ten years, and the arms are separating. If we get to 15 years I think we'll see a difference. I think we'll see a clear separation between those two arms. The other problem is there are some methodological problems in how the patients were accrued. It's complicated. I think the real issue is that some people with prostate cancer will suffer immensely and die, and many will not. What we really need to do is do a better job of trying to predict who needs treatment and who doesn't. I think that what's happened over the last couple of decades is when men are diagnosed with prostate cancer based on P.S.A. screening they automatically have gotten treatment. So, in a sense as a community we've over-treated men with prostate cancer.

Dr. Tom Miller: I think part of the concern is also the potential complications of the surgery or the other treatments available for prostate cancer. I mean it's not a benign procedure, and there are outcomes that are difficult for the patient. I think that is coloring the judgment of some of the task force groups that are looking at screening guidelines currently.

Dr. Blake Hamilton: The problem is you still have some 250,000 men who will be diagnosed with prostate cancer this year in the United States. There will be some 35,000 of those who will die from prostate cancer. To say that prostate cancer screening with P.S.A. has come and gone would be throwing the baby out with the bathwater. What we need to do is keep the screening but make better decisions about when to biopsy and when to treat prostate cancer. Already we're seeing a significant decline in the number of men who are being treated, and that's appropriate. But, we've got to keep looking for the ones that are going to be lethal cancers, because they're real.

Dr. Tom Miller: Let's talk practicalities. Are you saying that we should continue to follow the past guidelines which say begin screening in men at the age of 50, and then continue screening every year with P.S.A. testing?

Dr. Blake Hamilton: There are now many alternatives to that.

Dr. Tom Miller: Right.

Dr. Blake Hamilton: One alternative, which comes from the U.S. preventive services task force, is to not screen at all. The American Urological Association has modified their guidelines to suggest that we screen maybe not every year but every two years in men between the ages of 55 and 70 where we think that we'll find the highest yield in the patients for whom it will really matter. Screening in 80 year olds, not important. Screening in the younger generation, not enough data to show evidence that it helps or makes a difference.

Dr. Tom Miller: Younger generation meaning 50 years old and above?

Dr. Blake Hamilton: Less than 55.

Dr. Tom Miller: Less than 55.

Dr. Blake Hamilton: Although there are many researchers who would argue that between 45 and 55 should be included. The guidelines as we have them now would be that those men in that 15 year window, and screening not as intensely as we have in the past, but not to give it up.

Dr. Tom Miller: Let's say that your P.S.A. is elevated. What should the patient do? Should they go then to a urologist who specializes in prostate cancer? A lot of this, as you say, is going to depend on the expertise of the specialist taking care of this type of problem.

Dr. Blake Hamilton: I think most urologists have the ability to evaluate an elevated P.S.A. and make a decision on a biopsy. There continue to be a variety of opinions out there. If you have a single elevation in the P.S.A. I think it's reasonable to wait some time and repeat it and think about what that means.

Dr. Tom Miller: So, screening is something that you believe we should continue. You think it's a good idea.

Dr. Blake Hamilton: Yes, I think we should continue screening but do it judiciously and appropriately, and then think carefully without automatic treatment of those who are diagnosed with prostate cancer.

Dr. Tom Miller: A final thought. What about that time honored rectal exam? Do we still have to do that on patients? It's the brunt of so many jokes.

Dr. Blake Hamilton: Yes, it is. Unfortunately, there are some bad prostate cancers that have low P.S.A.s and are only found on physical examination, so we're going to continue doing that exam, Tom.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: You've been diagnosed with prostate cancer. What next? We'll talk about that on The Scope.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: For men that have been diagnosed with prostate cancer, figuring out the right treatment option can be really overwhelming. Dr. Jonathan Tward specializes in prostate cancer at Huntsman Cancer Institute. Dr. Tward, what treatment option would you recommend for a man just diagnosed with prostate cancer?

Dr. Tward: It's really an equally important question in a cancer that often won't take someone's life, Should they be treated? Because the treatments themselves can just as easily impact someone's sexual health, urologic bother, or bowel bother. One of the problems with prostate cancer, which is sort of unique to prostate cancer and different from other cancers, is that unlike other cancers where there's a very defined treatment paradigm, this particular cancer has many treatment options, and it is overwhelming to a lot of men who are faced with a new diagnosis of a relatively early stage cancer. Should they choose a surgery? Should they choose one form of radiation therapy or another radiation therapy? It's a big struggle for a patient who is contemplating their mortality to also have to go through the various treatment options and side effects because, honestly, when you start parsing treatment options for prostate cancer, there are essentially 20 different little ways of skinning that cat. It can paralyze people with this anxiety over 'Am I choosing the right thing? Am I not choosing the right thing?' So one of the things that I advocate for to a patient who is diagnosed is if they have an early stage prostate cancer, which is 80 to 85 percent of new diagnoses, they should speak to a urologist because the urologist will specialize in the surgical management of that disease. However, they should also speak to a radiation oncologist who specializes in the curative treatment of that disease with radiation therapy because they have non-surgical treatment options that are just as curative as the surgical option. But you're starting to choose on subtleties of different side effects.
When you're talking about sexual function, especially, this can become very important. There are certain ways of doing the surgery that will guarantee that you have erectile dysfunction whereas there are other ways of doing the surgery that will improve the probability that you don't. Or you might decide that radiation therapy in the form of external beam treatment or seed implants may have a favorable sexual function preservation rate relative to surgery, maybe, at the expense of an increased risk of a bowel bother. So men struggling with these treatment decisions are trying to balance risks of side effects to their urinary functions, risks of side effects to their bowel, and risks of side effects to their sexual function. And that's what is very challenging in terms of making treatment decisions.

Interviewer: And it doesn't sound like there's any easy way to really pick one. It sounds like you just kind of got to go through the options and then decide what's important to you.

Dr. Tward: Right. There is no way, and the reason that I advocated speaking both to your urologist and radiation oncologist is that a urologist, and rightfully so, should be biased towards 'You should get surgery' and may kind of communicate that perspective to the patient whereas a radiation oncologist may be biased that you should get radiation. But ultimately, you want the patient to hear the experts in those fields kind of discussing the details with therapy. If they're fortunate and maybe have friends who have gone through the different kinds of treatments, they can ask one friend who's had one form of treatment and another friend who's had another if they have that luxury. Or they can join a men's group where they can easily talk to men who have had different perspective. They can even include their primary care doctor in that decision making to help them kind of go through this decision and make an informed decision.

Interviewer: So there are men's groups that actually help support this sort of thing?

Dr. Tward: There are men's groups. The men's groups are not as active as, let's say, breast cancer groups.

Interviewer: Sure.

Dr. Tward: Women are very motivated to have survivorship groups and support groups, and men historically have been a little less motivated, but they do exist.

Interviewer: And you think they're a good resource?

Dr. Tward: I think they're an excellent resource, especially because it's one thing to hear a doctor tell you what you think and what you might feel, but it's another thing to hear it from someone who's gone through it. As much as I think I know about prostate cancer and what it feels like to get radiation therapy or what it feels like to get surgery, it's never been done to me. So I think there's extreme value in talking to people who have endured our therapies and the possible side effects.

Interviewer: We're your daily dose of science, conversation, medicine. This is The Scope, the University of Utah Health Sciences Radio.

Interviewer: If you're a man and you live long enough, prostate cancer is going to likely be part of your life. It can be really confusing. When do you get screened? What does a positive screening mean? What should you do then? We're going to talk about these things and more coming up next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Prostate cancer is one of the most common men's cancers, and although it likely won't kill you if you're diagnosed it can have very negative impacts on your quality of life. That's why you should get screened. Learn about the facts now with Dr. Jonathan Tward from Huntsman Cancer Institute. He's a prostate cancer expert. Let's start out with how effective is prostate cancer screening?

Dr. Jonathan Tward: We think that we are usually picking up the diagnosis 10 to 15 years in advance of when someone might feel a problem.

Interviewer: Oh, really? So, it's a cancer that's easily detectable?

Dr. Jonathan Tward: Easily detectable, although even that is controversial. We do have a screening test that helps guide us on whether or not we should do additional testing like a biopsy to prove it, but we are in fact able very early on to detect prostate cancer.

Interviewer: Is there a certain age where I should start becoming more aware of it?

Dr. Jonathan Tward: Guidelines are kind of evolving right now in terms of what age people should really start concerning themselves with thinking more about it. As a general principle, we think that around age 50 men should start bringing it to the forefront of their thinking. Digital rectal examinations are one common way to screen for this cancer. The PSA test is another thing. We usually start advocating that at age 50. What is interesting is that if you look at autopsies on people, starting at age 30 10% of people will have prostate cancer in their prostate and won't know it. This is if you just happen to autopsy someone killed for another reason. The risk goes up by about 10% per decade of life, so by age 50 one would expect 30% of people to have cancer in their prostate, and it goes up by 10% each decade. Once you are in your 60s or 70s you almost have a greater than 50/50 chance that you harbor this cancer. Many of these cancers will not require treatment. Some of them can be safely observed. This is part of the problem with screening. We often detect cancers in men that can be safely observed and sometimes over-treat them, and on the opposite side of the coin we often pick up very aggressive cancers that absolutely need to be treated to preserve quality of life such as urologic bother.

Interviewer: It sounds like you could have prostate cancer and it's not a problem.

Dr. Jonathan Tward: That's true. In fact, the vast majority of people being diagnosed today have no physical symptoms of the cancer because it is being detected with this 10 to 15 year lead time from the PSA test.

Interviewer: So could I go my whole life having prostate cancer but never needing treatment because it just never turns into anything?

Dr. Jonathan Tward: Chances are you will do that.

Interviewer: Wow. Really? Should that concern me?

Dr. Jonathan Tward: Well, I do think it should concern you. It sort of goes back to this issue of one in six men are being diagnosed with cancer. But, if you want to talk about it from a different kind of number, we diagnose in the United States approximately 250,000 men with cancer each year. Maybe about 35,000 die of the disease. What that implies is that the majority of people are either cured or able to live well with their cancer although they might have to live with side effects of their treatments, and maybe only 10% or 15% actually die of the disease. But, part of the problem with prostate cancer, and I think the confusion especially when it talks to should we screen and should we treat it, is when you look at these statistics, death from prostate cancer, it's clear that we're very good at keeping men alive with prostate cancer. I argue that the reason we should try to screen it, and treat it, and cure it is to try to prevent men from living a lifetime of side effects from the cancer or from the treatment. To me that is really the utility in identifying this cancer.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: June 12, 2019
originally published: December 6, 2013