September is Prostate Cancer Awareness Month, and Dr. Amr Fergany, a board-certified urologist with Orlando Health Sebastian River Hospital says one message deserves top billing: a prostate cancer diagnosis does not automatically mean aggressive treatment is needed.
Fergany said the case for prostate cancer screening was once contested, but that's no longer true. "It is generally agreed that testing for prostate cancer in appropriate age groups is beneficial," he said.
For most men, that means starting around age 50. "We like to start testing for prostate cancer around the age of 50 for the normal risk population," Fergany said. "That would be the time to get an initial test, and then the subsequent tests would be tailored to the results of the initial test."
Men at higher risk — including those with a family history of prostate cancer or African-American men — should start earlier, he said, "maybe at 45."
There's no at-home test for prostate cancer, Fergany said, unlike some other cancer screenings. "There's no kit that can be sent at home where people can drop off a sample of something that can be tested like colon cancer, for example."
Screening instead involves two components performed at a medical office: a PSA (prostate-specific antigen) blood test, and a digital rectal examination.
Fergany said the exam can offer diagnostic information beyond the blood test alone, though it isn't recommended in every case, such as when a patient's PSA is very low.
Unlike many cancers, Fergany said prostate cancer usually gives no warning signs in its early, most treatable stages. "In today's era of PSA testing, most patients with prostate cancer do not have any symptoms at all," he said. "The only indication of prostate cancer is a blood test that is higher than normal."
Historically, symptomatic prostate cancer often meant the disease had already spread — frequently causing bone pain, Fergany said. Urinary symptoms, he noted, are rarely linked to prostate cancer and are more commonly caused by benign prostate enlargement, a separate and unrelated condition.
Fergany emphasized that a diagnosis doesn't automatically call for treatment. "A lot of prostate cancer is what we call not clinically significant," he said, "meaning it is not going to be a threat to patients' lives... and in that case, the risk of treating the cancer... is worse than the cancer itself."
Many patients are instead managed through active surveillance — regular monitoring without immediate treatment. "Patients do quite well with this management approach," Fergany said.
For cancers that do require treatment, options include surgery, radiation, and a range of less invasive focal treatments such as cryotherapy, high-intensity focused ultrasound (HIFU) and laser treatment, Fergany said. For cancer that has spread beyond the prostate, hormone therapy is the primary treatment, with chemotherapy and other modalities also playing a role.
Fergany said screening decisions and treatment choices should be made jointly between doctor and patient. "Most of the decisions as far as prostate cancer are concerned are decisions that are shared with the patient," he said. "We come up to a conclusion where the patient is comfortable with the decision that they are taking."
He cautioned that the value of screening declines with age.
"Generally speaking, if we are older, the utility of screening for prostate cancer becomes significantly less."