How to detect prostate cancer?

In Switzerland,prostate cancer represents nearly 30% of male cancers. Every year, there are around 6,000 new cases, making it the most common cancer in men. Doctor Julien Schwartz, who practices at the Urology Institute of the Cecil Clinic in Lausanne, explains to us how prostate cancer screening is carried out, and according to which criteria it allows a precise and reliable diagnosis to be established.

Who is prostate cancer screening for?

Dr. Julien Schwartz explains that most patients who come to be screened for prostate cancer are referred by their treating physician, either because of a PSA level that is too high in the blood or following a suspicious digital rectal exam. or because they have a family predisposition: in fact, patients whose first-degree relative (brother or father) has had prostate cancer see their risk of suffering from this disease increase. It is therefore recommended that these patients take a screening test from the age of 45. On the other hand, for men who do not present an increased risk linked to their family history, screening for prostate cancer is indicated from the age of 50. In both cases, it is recommended to carry out the screening test once a year.

“It’s a proposal, it’s not systematic screening, unlike breast cancer,” emphasizes Dr. Schwartz. It is therefore very important to warn patients that in the event of a pathological PSA finding, they are exposed to the risks of investigation, with prostate biopsy and/or MRI in the event of suspicion of cancer, then possibly treatment by surgery and/or radiotherapy . In short, a “process that can be tedious, important and expensive”. As prostate cancer progresses very slowly, “in 95% of cases,” explains Dr. Schwartz, you should know that if cancer is detected, decisions made regarding treatment take into account the state of the prostate. health of the patient and his age: “If the patient has poor general health or if he is over 75 years old, we generally offer monitoring, possibly accompanied by hormone therapy,” continues Dr. Schwartz, because the benefit of the treatment is only felt after a period of ten years.

What tests are used to screen for prostate cancer?

• Urological history: the doctor first establishes a targeted urological history. The purpose of the history is to detect disorders that may indicate the presence of another condition affecting the prostate or bladder, such as the presence of blood in the urine, weak or irregular flow, urgent urges, etc.
• Digital rectal examination: the digital rectal examination allows the doctor to palpate the prostate through the wall of the rectum, in order to assess its size, consistency and shape. He can thus identify a mass or irregularities that could raise suspicion of prostate cancer.
• PSA test: this is a blood test to measure the PSA level. PSA or “prostate specific antigen” is a protein secreted by the prostate. Dr. Schwartz specifies that the time taken to obtain the results of this examination varies: if the urologist is equipped with a special machine, the results can be immediately communicated to the patient, otherwise it is necessary to wait a few days. Even in the case of patients who have been referred by their treating physician because of a high PSA level, the specialist doctor repeats the examination, because this increase may turn out to be simply the sign of a temporary condition.

It should be noted that, as part of prostate cancer screening, PSA testing and digital rectal examination are both necessary. An exact diagnosis cannot be made if only one of these tests is performed.

What happens if prostate cancer is suspected?

If the PSA level is abnormally high or the rectal examination suspicious, or both at the same time, the specialist doctor must complete the assessment with an MRI , an essential examination to help with the diagnosis. For people who do not have access to this type of examination (people with large builds or those suffering from claustrophobia, for example), on the other hand, a biopsy of the prostate is carried out directly. If the MRI reveals the possible presence of cancerous nodules, a targeted biopsy should then be performed.
When the biopsy is positive, the cancer cells will be characterized in order to determine an index to define the aggressiveness of the tumor (the Gleason score). Depending on the results, the treatment differs:

• If the cancer turns out to be small and not very aggressive, the patient is placed under “active surveillance”.
• If the cancer is significant, surgery and/or radiotherapy is then offered to the patient.

Rectal examination: a painful exam?

This medical examination may cause some apprehension. However, Dr Schwartz wants to be reassuring: it is a “routine, standard examination, which is not painful”. Prostate biopsy, on the other hand, can be “a little more unpleasant,” he adds. The rectal examination, for its part, is carried out in a very simple manner: after having ensured the patient's consent and having explained to him the reasons for carrying out this examination, the doctor gently inserts a gloved and lubricated finger into the anus in order to to palpate the prostate.

How to interpret the PSA level?

PSA DOSAGE: what you need to know…

• PSA naturally increases with age.
• Standards differ depending on countries and laboratories. In the USA, for example, the standards set are lower than in Europe.
• In Europe, the standard is set at 4 ng/ml. Beyond this standard, the PSA is considered too high.
• Between 50 and 60 years old, the values ​​considered normal are between 3.5 and 4.5 ng/ml.
• Between 60 and 70 years old, the values ​​considered normal are between 4.5 and 5.5 ng/ml.
• Before taking the blood test to collect the PSA, it is recommended to wait about a week after the digital rectal examination, as this examination can increase the PSA level. This may also vary depending on the laboratory.
• Attention ! A high PSA level does not necessarily indicate prostate cancer: it can be due to inflammation following sexual intercourse, intensive cycling, a urinary infection or a germ, or even a large prostate. or taking certain medications.
• Sometimes prostate cancer can be detected in a patient when their PSA level is low.
• In order to establish a precise diagnosis, the PSA dosage must systematically be supplemented by a rectal examination.

PSA dosage and rectal examination, two independent and complementary examinations.

Several scenarios are possible, explains Dr. Schwartz:

• A high PSA level and a suspicious digital rectal exam: if the MRI results confirm the presence of prostate cancer, the diagnosis becomes clearer and the assessment must be completed with prostate biopsies. On the other hand, if the MRI shows nothing abnormal, an aggressive cancer can probably be excluded and monitoring continues as normal.
• A high PSA level and a normal rectal exam: as the specialist points out, it is important to emphasize that the rectal exam alone does not allow a reliable diagnosis to be made. Therefore, in this case, an MRI is necessary, in order to reveal or not the possible presence of prostate cancer. Screening with a normal digital rectal examination and a high PSA level associated with an MRI revealing the possible presence of cancer is not rare, “it is even the most common case,” emphasizes Dr. Schwartz. “In these cases, the prevalence of PSA is highlighted,” he adds.
• A suspicious digital rectal examination and a normal or low PSA level: MRI may suspect the presence of prostate cancer. This is a scenario that occurs less frequently, but it does happen.

In all cases, only a prostate biopsy can confirm or deny the presence of cancer. However, it is important to note that a biopsy may eventually turn out to be negative; depending on the situation, the urologist will suggest a second set of biopsies.

Gone are the days when prostate cancer was a taboo subject.

For Dr. Schwartz, the days when prostate cancer was a taboo among the male population are well and truly over. Indeed, he observes that patients diagnosed with prostate cancer are well informed about the different possible treatments or the possibility of active surveillance. Men affected by this disease talk about it much more freely. Thus, the fears that still existed a few years ago, regarding the disease in general and the examination methods used for screening, seem to have diminished.

More information:

• Learn more about the prostate: www.hirslanden.ch/prostate
• Swiss Cancer League
• Association supporting people affected by prostate cancer

Doctor Julien Schwartz is a specialist in urology, with extensive training in operative urology. He is an accredited doctor at the Cecil clinic in Lausanne.

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