What to know about prostate cancer

0:01You're listening to Life Kit from NPR. Hey, it's Marielle. Do you know Montel Jordan? He's the singer-songwriter-producer of the absolute banger, This Is How We Do It. He's also a... Husband, father, pastor, speaker, author, Grammy Award winner, prostate cancer advocate. An estimated one in eight men will be diagnosed with prostate cancer at some point in their lives. Montel was diagnosed in early 2024, at age 55, after a routine screening and a biopsy. He and his wife spent months seeing doctors and getting their opinions. We didn't know how to tell our kids, and so we kept it between ourselves for months.

0:49Montel decided to have his prostate removed. But after that, his blood tests revealed that there were cancer cells left behind in his lymph nodes and in his prostate bed. So he just finished radiation treatment. I asked him about his decision to share his story publicly because I know from my experience that this is a very personal topic I would even go further when it comes to men and prostate cancer because of the functionality of what the prostate does it's a very personal thing that I don't imagine any man would want to probably talk about or disclose or share that information But he says he's sharing in the hopes that his transparency will save a life, that it'll get people to the doctor for their routine screenings.

1:35Because the thing is, most of the time, people with early stage prostate cancer don't have symptoms. I have never felt like I had cancer. There was nothing that I woke up one day and said, you know what, something doesn't feel right. I think I have cancer. Like there was no indicator. And I think that's one of the deceptive things that people think you feel like you have cancer. I feel like I've been having treatments. I feel like I've been taking medication, but I've never felt like I had cancer from the very beginning. Which is why it's so important to get routine screenings. On this episode of Life Kit, we get into the details on prostate cancer.

2:11We'll talk about what puts you at higher risk, what routine screening entails. It often starts with a blood test. When you should start doing those, and what happens right after a diagnosis. I'll be talking with Dr. Kelvin Moses, a professor of urology and director of the Comprehensive Prostate Cancer Clinic at Vanderbilt University Medical Center. And we'll hear some more from Montel Jordan at the end.

2:42All right, Dr. Moses, let's talk about how we find prostate cancer. Is it generally caught during routine screenings or when people notice a symptom? So it's usually no symptoms, asymptomatic. Fortunately for the vast majority of men in the U.S., they are found through screening or just incidentally they get a PSA randomly for whatever reason. Okay, so a PSA test, that's a blood test that can help diagnose prostate cancer. What does PSA stand for and what does it tell us? Yeah. So PSA is prostate-specific antigen, and it's just one of the components that are made by the prostate that are secreted into the bloodstream.

3:27It is in anybody who has a prostate. And there's even trace amounts in other glands that we've found over time, but the vast majority is coming from the prostate. For younger men, you know, in their 40s or 50s, a normal PSA is probably less than one. Whereas in the 70s, 80s, you know, two or three is a very reasonable number. Okay. So early stage prostate cancer generally has no symptoms. Are there any that people should look out for? Like anything having to do with urination, for instance? So any change in sexual or urinary function needs to be evaluated whether or not it's for cancer. So changes in urinary stream, slow stream, any blood in the urine should always be investigated.

4:13Erectile dysfunction, new onset should be investigated. The vast majority of men who present with those symptoms is because of benign reasons. Any symptoms like bone pain or blood in the urine or urinary obstruction or pelvic pain usually means that there's some advanced disease. And so those patients are presenting with metastatic disease. And that's about 10 to 15 percent. Depends on the population. Takeaway one. Early stage prostate cancer generally does not cause symptoms. But if you do notice symptoms, like changes in your urinary stream, blood in your urine, erectile dysfunction, pelvic pain or bone pain, talk to your doctor.

4:55These can be symptoms of lots of different conditions, but your doctor might order a PSA test as part of their workup. In general, though, with prostate cancer, you're going to be relying on routine screenings. When you should start those screenings, that's currently up for debate. That's the million-dollar question. So that leads to debates in the medical world and heated arguments. So there are several guidelines that various physicians follow. In the primary care world, so family physicians, internal medicine, they typically follow the United States Preventive Services Task Force recommendations.

5:32Patients and their physician should do shared decision-making, discuss risk and benefits of screening, and then if they wish to proceed, their recommended beginning age is 55 up to age 69. Most oncologists, cancer doctors, follow the National Comprehensive Cancer Network, NCCM. As full disclosure, I am the chair of the Early Detection Plustic Cancer Panel for NCCM. Our recommendations are to begin at 45 to 75. So our age range is expanded. We do make allowance for earlier screening for men at high risk. So black men, men with first degree relatives with prostate cancer, and then those with known familial genetic syndromes, including the BRCA gene, BRCA, which is more commonly known for breast and ovarian cancer.

6:28But in men, the BRCA gene is associated with earlier and more aggressive prostate cancer. And then we do make allowance for men older than 75 if they are in excellent health. What I tell men in general is if you're at average risk, probably should start around 50 if you want to get a baseline at 45 and then recheck at 50. And then for Black men, family history, genetic abnormality, probably should start at around age 40 or 45. Okay. It can help to get a baseline PSA test. Correct. Yes. Yeah. I found this fascinating when I was dealing with breast cancer. I had breast cancer last year and we did an episode on breast cancer screening and it's the same thing with mammograms.

7:11There are different guidelines and also different medical organizations will recommend that gynecologists do a physical exam in the office and then others will say, no, you don't have to do that. It's not important or like it rarely catches the cancer. But that's how my cancer was caught, you know, and I was too young to be getting routine mammograms. It was going to be another six years. It's the same story in prostate. As far as recommending rectal exam for prostate cancer, some of the guidelines don't even mention it. NCCN does make it an option. Really, you know, you have to look at what the target audience for the guidelines is and what they're staking it to, right?

7:56So there's professional state, there's personal state, there's financial states. And so the different guidelines speak to different populations. But there's stories like yours that happen in prostagance all the time. I've had men 36 years old. They just randomly got a PSA because of a life insurance screening and it showed up. Why would you have a cutoff? Why would you have a cutoff at the older side, like 70 or 75 after this point? You shouldn't get screening at all. So from their perspective, men older than 70 are very unlikely to die because of prostate cancer. The prevalence of prostate cancer in men older than 70, though, is actually quite high.

8:43If you go out and biopsy every 85-year-old man walking around, almost all of them have prostate cancer. That's wild. Virtually none of them will die of prostate cancer, but older men, when diagnosed with prostate cancer, can have very aggressive disease and would still need some treatment. If you screen too many and overdiagnosed, then it can lead to overtreatment, which can lead to harms due to overtreatment. And when they first looked at the prostate cancer outcomes 20, 30 years ago, most men were getting treatment and probably didn't need it. And they were using that as a reasoning for avoiding diagnosis.

9:27Okay, takeaway two. There's disagreement among medical groups about what age men should get prostate cancer screenings. Dr. Moses recommends that you talk to your doctor, discuss your personal risk factors. And then if you're at average risk, maybe get a baseline PSA test at age 45, repeat at 50, and do them annually after that. If you're at higher risk, you want to start earlier, maybe at 40. If you have a prostate, you could get prostate cancer. But the risk goes up as you age, specifically after age 50. Family history and genetics play a role in this too. If you have a parent, a sibling, or a child who's had prostate cancer, your risk is higher than the general population.

10:08That can also be true if you have a family history of breast cancer, ovarian cancer, or pancreatic cancer, because some genetic mutations can cause all of these. Black men have a higher risk of getting prostate cancer and also a higher risk of dying from it than men in general. Obesity can slightly increase your risk of developing prostate cancer. Smoking and drinking alcohol increase your risk. And there are some other known environmental risks, like exposure to carcinogenic chemicals, You may have come across these if you're a firefighter or a veteran, or if you worked on a farm with pesticides.

10:44So these are all things to bring up to your doctor.

10:50Well, let's talk about screenings. When you do decide to get a screening, are these done annually? For the most part, yes. People, if they're seeing their primary care doctor, they're getting their annual cholesterol check and blood pressure and sugar. And so they check their PSAs at the same time. You can do like every other year, but, you know, really for ease of follow-up, getting that annual PSA with your normal blood work is perfectly reasonable. Okay. So what should folks expect when they go in for a prostate cancer screening? What does it entail? So first you have a discussion, right? So you talk about what their overall health is, what their risk is of prostate cancer.

11:36What screening is, which is a blood test with or without the rectal exam, I will do a rectal exam. At a urologist, that's pretty much expected. Your primary care may not go right to doing a rectal exam unless there's any other indication. Is there something a rectal exam could tell you that a PSA test can't? So you can get an idea of the size of the prostate, which can inform maybe mild elevation of the PSA. You can feel nodules. Not every prostate cancer produces more PSA. And in fact, some of the more concerning prostate cancers actually have very low PSAs. Got it. I know that for some men, maybe for a lot of men, maybe for any of us, this kind of exam would be uncomfortable and it might stop them from going in for screening at all because they're thinking, well, I'm going to have to do that and I don't want to do that.

12:30Yeah. Nobody loves it. I mean, I tell men, I say, well, you know, if you don't want to get it done, that's fine. We can start with the PSA. And then if we need more information down the road, if we have to do a biopsy, let's say, then I can do an exam at that time. So it's not a deal breaker. I certainly would caution men to say, hey, look, you know, especially if you had higher risk for prostate cancer, don't let a moment of discomfort shorten your life. How long does it take? 10 seconds. You don't have to dwell in there too long, just a few seconds, just to kind of feel both sides, top to bottom.

13:08Make sure the tissues are mobile, and then you're done. You know what I like to do when I have to get some sort of uncomfortable test done? Like when I go get a mammogram or something, I get myself a little treat after. Treat yourself. Go have a treat. Ice cream is always good. All right, takeaway three. Prostate cancer screening typically involves a PSA test. That's just blood work. And your doctor might also want to do a rectal exam. That should take about a minute. And yes, it can be uncomfortable. And if that's stopping you from going at all, you can start with just the PSA test. The rectal exam can be helpful, though, because some prostate cancers don't produce an elevated PSA level.

13:50And also sometimes your doctor will be able to feel cancerous nodules on the prostate. We'll have more on prostate cancer with Dr. Kelvin Moses after the break.

14:11Okay, so it sounds like if you go get a PSA test and then it comes back elevated for your age, then your doctor is going to have some options. They might do some additional blood tests or urine tests. They might do some imaging. They might do a biopsy. Correct. If they do just imaging or blood tests, can they confirm it's cancer or do you have to do the biopsy to confirm that? So the biopsy is confirmatory for now. You need a tissue diagnosis before you can proceed with treatment. Okay. And then your doctor's going to say, here's what's going on. Here are some treatment options and the potential risks and drawbacks and benefits of each one.

14:57So when you diagnose, the first thing you do is what we call risk stratification. So again, depending on which algorithm you use, low, intermediate, high risk. And these are all for localized disease. After staging, particularly for high or very high risk disease, there's additional testing that you would do to make sure there's no metastatic disease, any prostate cancer that is spread to other places. Then once you've confirmed localized disease, you talk about the options for management. And over a 10-year period, most men can avoid treatment for prostate cancer without any significant progression or risk of metastasis.

15:41Besides radiation and surgery, what are the other types of treatment? Yeah. So for surgery, the vast majority in the U.S. are done robotically now, minimally invasive. Some people, including myself, still do open surgery. For radiation, there are different types of radiation, different dosages, different number of fractions. The flavor radiation you get, again, depends on your kind of disease. You can get implantable seeds, what's called brachytherapy, either alone or in combination with external radiation. And then for men with higher risk disease, unfavorable, intermediate, or high risk, you actually get hormone therapy in addition to the radiation therapy.

16:24In general, the vast majority of men who are getting treated for prostate cancer is some version of surgery or some version of radiation with or without hormone therapy. The other thing I want to ask you about is finding an oncologist. How do you actually get connected with an oncologist and at what point? Yeah. So the typical entry into the prostate cancer world is through a urologist because urologists do their own biopsies. Most oncologists who are seeing prostate cancer is usually for more advanced disease, metastatic or hormone resistant disease. When diagnosed with cancer, I tell patients, even my own patient, I say, you know, getting a second of pain is good because even if it's the same exact information, it's reassuring if you've heard it twice, or there's different information, it may let you know options that maybe someone didn't have.

17:18All right, takeaway four, if your PSA test comes back elevated, your doctor will probably order some additional tests, maybe a blood test, a urine test, some imaging, and possibly a biopsy. The biopsy is what you'd need to confirm prostate cancer. Now I'm going to say something that I also said in our breast cancer episode. As you wait for results, remember you do not have all the information yet. Try to take a deep breath. I know it's hard, but I can say from personal experience, the results will be what they are, whether you panic right now or not. Also, prostate cancer is often curable, and even folks with advanced disease are living longer and longer with it.

17:59The important thing is, you got the screening done, you're getting answers, and you'll take the next step when it's time. By the way, make sure you get a second opinion or a third opinion. Find the doctors you trust and feel comfortable with. With prostate cancer, you will generally have time to do this, and you won't need to rush. When I diagnosed someone with cancer, The first visit, I'm just laying out some basics and I give them some information. But I tell them to go home and come back and see me in a month because you need some time to digest it. Unless they have some serious cancer that we need to jump on.

18:32But for the most part, like I said, localized cancer. Give them time to think about it. Read reputable information and start thinking about, you know, how do you want to treat this? How aggressive do you want to be? What side effects are tolerable for you? who you're willing to accept versus others, and then come back and have that conversation where they actually can hear me. And ideally, they bring somebody with them who can also ask questions because it's easy to get overwhelmed and you don't hear everything, or maybe you heard what you want to hear. But you have somebody there who can write things down or ask questions and get the right information.

19:09One thing that a lot of folks experience when they get cancer is that they realize, I am so much stronger than I thought. I can face so much more than I thought. You find out what you have to do, and you do it. I felt that, and Montel did too. You got to have mental strength to navigate. Like me getting up every morning, going to do this, and still living life, and being here, and being present, and taking medications, and changing eating habits, and being here for my grandkids and staying active. Here's something else he's learned. People that have and that are fighting the disease don't need you to carry cancer.

19:52They need you to help carry them. And when I have a community and a tribe of people that can help carry me, it makes me be able to better fight and carry and battle and defeat this unwanted guest. Montel is currently working on a documentary about his experience with prostate cancer. It's called Sustain. He's planning to take it on the road next year. I'm going to screen the documentary in 30 cities, and I'm going to have men screened at the screenings. And those men who get screened at the screenings will have VIP access to the concerts in those 30 cities, and we're calling it the This Is How We Cure It tour.

20:33All right, time for a recap. Takeaway one. Early stage prostate cancer generally does not cause symptoms. If you notice symptoms, like changes in your urinary stream, blood in your urine, erectile dysfunction, pelvic pain, or bone pain, talk to your doctor. They might order a PSA test, a blood test that can help diagnose prostate cancer. Takeaway two, there's disagreement among the medical groups about what age men should get prostate cancer screenings. Dr. Moses recommends that you talk to your doctor, discuss your personal risk factors, and then if you're at average risk, maybe you get a baseline PSA test at age 45, repeat at 50, and do them annually after that.

21:15If you're at higher risk, you want to start earlier, maybe age 40. If you have a prostate, you could get prostate cancer, but the risk goes up as you age, especially after age 50. Family history and genetics play a role too, and black men have a higher risk of getting prostate cancer and a higher risk of dying from it than men in general. Smoking and drinking increase your risk of getting prostate cancer. Obesity can slightly increase your risk as well. And there are some known environmental risks like exposure to carcinogenic chemicals. Takeaway three, prostate cancer screening typically involves a PSA test, and that's just blood work.

21:54Your doctor may also want to do a rectal exam, but you can start with the blood test if the physical exam is what's holding you back. Takeaway four, if your PSA level comes back elevated, your doctor will probably order some additional tests. A blood test, a urine test, imaging, possibly a biopsy. The biopsy is what you'd need to confirm prostate cancer. And remember, prostate cancer is often curable, and even folks with advanced disease are living longer with it. All right, that's our show. Before we go, do you ever find yourself saying to a friend, you know, I heard on LifeKit. First of all, thank you for talking us up.

22:33And second, could you please tell another friend about us? Go ahead. Send them an episode right now. How about this one? Thank you. This episode of LifeKit was produced by Margaret Serino. Our visuals editor is Beck Harlan, and our digital editor is Malika Grebe. Megan Cain is our senior supervising editor, and Beth Donovan is our executive producer. Our production team also includes Andy Tegel, Claire Marie Schneider, and Sylvie Douglas. Engineering support comes from J. Ciz. Fact-checking by Tyler Jones. I'm Mariel Segarra. Thanks for listening.