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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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And as always, if you found this episode useful, share it with somebody in your life. That's the way we can grow this podcast together and this movement of men who understand and know and care about their health. Thanks for listening.

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