When Should Men Get Screened For Prostate Cancer? with Dr. Alfred Winkler

Faith: Welcome to Health Matters, your weekly dose of health and wellness from NewYork-Presbyterian. I’m Faith Salie.

What is the prostate? Many people aren’t entirely sure of the purpose of this gland until there is a problem. Prostate cancer is the most common type of cancer among men in the United States after skin cancer, and about one in eight men will be diagnosed with the disease during his lifetime, according to the American Cancer Society. 

The good news: it is also one of the most treatable types of cancer, with high survival rates. And yet there are many men who are afraid of what they think being evaluated for prostate cancer entails that they completely avoid the topic.

In honor of Men’s Health Month this June, I sat down with urologist Dr. Alfred Winkler from NewYork-Presbyterian and Weill Cornell Medicine to better understand the prostate and demystify prostate cancer. 

Faith: Dr. Alfred Winkler, thank you so much for joining us today.

Dr. Winkler: Thank you for asking me. It’s my pleasure

Faith: In researching to meet you, I saw this, it’s a very UK headline, and it said, almost one in five men, quote, lethally ignorant that they even have a prostate, new survey finds. What is this thing, the prostate?

Dr. Winkler: That’s a pretty dramatic description.

Faith: It certainly is.

Dr. Winkler: Only men have prostates. The prostate sits deep in the pelvis and its primary job, along with two other paired glands, called the seminal vesicles, is to produce ejaculatory fluid that provides transport for sperm. That’s its primary job.

Faith: Okay, so let’s get some basic information on prostate cancer. How common is it, for starters?

Dr. Winkler: So it’s the most common, visceral organ cancer in men, most commonly diagnosed. But what we’ve seen over the most recent decade is that the survival of men, even though a lot of men are diagnosed with prostate cancer, has fortunately increased.

Faith: Just to give people a sense of how common prostate cancer is and its trajectory with age. We don’t really hear about young men being diagnosed with prostate cancer. Do we?

Dr. Winkler: We don’t, and it’s incredibly rare, in a man, under the age of 40 to be diagnosed with prostate cancer. That’s really why, even in folks who are considered high risk, we do not start screening or evaluating for prostate cancer until age 40. That also speaks to the fact that it tends, in most cases, to be a very slow growing cancer. The thought process behind that is, the prostate cancer that we diagnose at age 72 or 73 or beyond tends to be a different type of prostate cancer, one that is slower growing and one that a patient can certainly live with, and won’t be a factor in the end of their life. We view that differently from a prostate cancer that we diagnosed in someone who’s 45 or who’s in their 50s. Those prostate cancers tend to be more aggressive and far more likely to reduce a patient’s life expectancy as compared to cancers that we would diagnose in someone in their 70s.

Faith: So you used the phrase high risk. Can you illuminate that for us? And how would you know?

Dr. Winkler: So the two biggest groups are really, folks who have a family history of prostate cancer in a primary, male relative: so that’s uncle, father, brother,

Faith: And it can be uncle on the mother’s side, even?

Dr. Winkler: Either side. And also, in patients who are of African American or Afro Caribbean descent, that group tends to have, more aggressive, cancer that’s diagnosed at an earlier age.

There are things that we can control about our risk for disease and things that we can’t. So in that population, we know that genetics plays a role. But there’s certainly an environmental component to that and that can be, literally where you live, what you’re exposed to, and also perhaps more importantly what you eat.

We’ve seen, over the years, a number of nutritional studies show, people lower their risk when they pay attention to their diet. That means be very mindful of your consumption of red meat. Be very mindful of your consumption of processed foods. Incorporate vegetables as a staple of most of your meals. Basically when you feed yourself, you’re giving fuel to your body and it’s important that is good fuel. Because that’s how your body maintains itself.

So if you don’t take care of your defense, you’re only putting yourself at risk for a whole host of issues, cancer being one of them.

Faith: Does a family history of any other types of cancer put you in an elevated risk group?

Dr. Winkler: So certainly, ovarian, and breast cancer and possibly colon cancer, but certainly ovarian and breast cancer.

Faith: So if you’re a man whose mother or sister or grandmother had ovarian or breast cancer, you’re in an elevated risk group?

Dr. Winkler: You’re considered an elevated risk group.

Faith: Have there been any specific advancements recently that have contributed to better outcomes for patients?

Dr. Winkler: What’s been great about the most recent technological advances are that it’s able to help us better assess which patients we need to be more concerned about, in terms of their risk of cancer and really deciding who needs a given procedure. Perhaps the biggest advance in the screening and diagnosis of prostate cancer is a blood test that’s controversial but still key, which is called PSA, Prostatic Specific Antigen.

That has been the primary tool for screening, but probably in the last 10 years, the best example of that is the use of MRI, specifically MRI of the prostate to better evaluate the risk or presence of prostate cancer in any given patient.

Faith: Why is the PSA blood test controversial?

Dr. Winkler: So it’s controversial because even though the name of it is literally Prostatic Specific Antigen, the test isn’t always terribly specific to prostate cancer. If we have a patient and we have a discussion about whether to get a PSA blood test and that test is elevated, that test could be elevated for reasons aside from prostate cancer.

It could be, for instance, from an inflammatory process that patients may have no symptoms from. It’s a great start and an important marker, but it’s not a test that we can use to assume certainly that someone has prostate cancer, but it does make us say that we need to really take a magnifying glass on that given patient and do a deeper assessment about whether they do have prostate cancer.

And so it’s gotta start with taking care of yourself and making the appointments and showing up to your appointments.

Faith: I think we have to ask about the traditional method of testing, which is a digital rectal exam, right? 

Dr. Winkler: I think by reflex, urologists don’t like to mention that early on in any conversation…

Faith: Okay.

Dr. Winkler: … about the prostate or prostate cancer screening because frankly, it’s the number one reason why men avoid this topic in the first place. The American Urologic Association, which is the primary group for urologists that come up with our guidelines for taking care of patients, it’s been decided, or at least suggested that the first screening effort in terms of prostate cancer for patients really should just be the blood test and not the rectal exam and I will say that the majority of my patients are quite happy that we can just screen them with a blood test. And I actually wish more people knew that because that’s really the number one reason why people avoid being evaluated in the first place.

Because of the location of the prostate, it’s very deep in the pelvis. And prostate cancer tends to grow not in the middle of the gland, but at the edge of the gland. At its earliest stages, it really doesn’t produce any symptoms. And the only way we really have a clue that there may be a cancer growing is through the PSA blood test. Just because you may happen to have changes in your urination, it does not mean that’s a sign of prostate cancer. But what I don’t want to happen is for folks to start having symptoms, like changes in urination and be afraid to go and seek evaluation because they don’t want to hear the diagnosis of prostate cancer, or because frankly, they’re afraid of a rectal exam.

Faith: How does someone know when they should start getting screened or tested if they don’t have a proactive doctor like you? And how often?

Dr. Winkler: You know by asking, so I would say the earliest that anyone, should be considered, being screened is at age 40. But how often you’re screened and at what age you start being screened is different for everyone. It’s different based on your age. It’s different based on your medical history. But you can only figure that out by having discussions with your care provider 

Faith: Prostate cancer is one of the more curable cancers, is that right?

Dr. Winkler: It absolutely is, if we can diagnose it early enough. Another great thing that we’ve seen is that we have more patients that we’re diagnosing early enough that we can actually put them on what’s called active surveillance. So if you have a cancer that’s non aggressive, it still sits in its gland or organ of origin, we do not have to essentially treat them. We can observe them with PSA blood tests. So in those folks, we do a PSA blood test every three to four months. And then we would do an MRI, about a year after their diagnosis. And typically within two years of diagnosis, we would repeat the biopsy.

These tools allow us to keep close watch so that if there is a change, specifically a change that makes us concerned about progression, we have more than enough time to act and still keep patients eligible for cure.

Faith: So let me just make sure I understand this correctly. Active surveillance means that you do detect cancer in the prostate, but it’s so slow growing that all you feel like you need to do medically is keep it under surveillance, just keep a watch on it? 

Dr. Winkler: Exactly.

Faith: Things seem very hopeful, even auspicious, with early detection and a slow growing prostate cancer. But that suggests there are conversely, more aggressive kinds of prostate cancers. Is that correct?

Dr. Winkler: That’s absolutely correct. Essentially, we can never tell someone for the overwhelming majority of cancers that they have cancer until we do a biopsy, which is taking a sample of that tissue. And examining that tissue under the microscope and doing certain tests on that tissue that tells us that tissue is cancer.

A way to understand that is when we take a biopsy, we look at that tissue, the more different that tissue appears from normal tissue, the more likely it is to be aggressive. It’s more likely to spread outside of the organ of origin. It’s more likely to not be responsive to certain treatments or might require more than one treatment to cure it or hold it at bay.

So we’ll get tests like MRIs or CAT scans, and look at the sites most likely for those cancers to spread, and do an evaluation to really decide, is that patient eligible for localized treatment, or has this cancer already spread?

Faith: Bottom line. Get tested.

Dr. Winkler: Yes. 

Faith: You mentioned early detection allows a patient many more choices as far as treatment. What are the other choices for treatment?

Dr. Winkler: We’re talking specifically about prostate cancer and there are three other categories of treatment that we offer patients. One is radiation therapy, to destroy the prostate cancer cells, and that can be delivered by, what we call external beam radiation, which is using a machine to deliver x ray or radiation through the skin to the organ. It also can be delivered, by placing little radioactive seeds within the prostate to kill the prostate cancer cells.

Faith: That’s so scifi.

Dr. Winkler: It is. The other treatment is removal of the entire prostate. And that’s done, typically nowadays, with robotic surgery. Probably the newest advance is what we call focal therapy.

And this is how we’ve really been able to tie together the advances of directed prostate cancer biopsies and the use of imaging like MRI. So what we do is we deliver a form of energy only to the areas that were detected to have prostate cancer to destroy that tissue. With focal therapy, you’re really focusing and targeting energy to those areas that are specifically demonstrated to harbor prostate cancer cells. So what’s important about that is, it’s probably the least invasive way to treat a cancer. It has proven to decrease the side effects.

Faith: And does any of these treatments interfere with a patient’s urination process or their sex lives?

Dr. Winkler: So certainly they can. And that is dependent on the type of treatment that folks opt for. And that’s really a function of the neighborhood in which the prostate sits. I mentioned that the prostate sits right underneath the bladder. And the urine tube goes through the prostate, so when the prostate is removed, there’s a reconstruction that involves reattachment of the bladder to the urethra, which can impact a patient’s urination anywhere from weeks to months.

The nerves that are important to, the ability, to, achieve and maintain an erection also run alongside either side of the prostate. When we do surgery to remove the prostate, as much as we can, we try not to disturb those nerves. But we have to also think about the function of the prostate, which is to produce the fluid that comes out during ejaculation. Men are able to achieve an erection, in many cases, so they’ll have what’s called a dry orgasm.

Faith: You know, as we talk about this, I wonder how much of a challenge, stigma is for your patients. It calls to mind a time before lots of people can remember when people didn’t talk about breast cancer. But then it became a pink ribbon thing, something not to be ashamed of. Do you feel like prostates and prostate cancer needs that kind of awareness?

Dr. Winkler: It certainly does, because it’s such a success story and we can do so much to help patients in a way that really, not only is life changing, but can have minimal negative impact on their lives. It’s just that we don’t see those male patients coming out and asking the questions and being evaluated. 

Faith: If listeners want to reduce their risk, what preventative measures do you recommend?

Dr. Winkler: First and foremost, go and see your primary care provider. You know, an old maxim I used to love to use, and I think it still applies, is that men are much, much better about taking care of their cars than taking care of themselves. So if we, as men, took care of ourselves with the same attention to detail, it would be a tremendous impact. So I think that’s where it starts. Specialists will see patients initiate their health care with us and we’ll uncover a whole host of other issues that they have, that could also be addressed if they went to their primary care provider. But number one is, Take care of yourself, go for your yearly appointments, get evaluated, ask questions. 

Faith: And June is Men’s Health Month. So honor June by honoring yourself.

Dr. Winkler: Honor June and September is Prostate Cancer Awareness Month. So those are two months that you would have an opportunity.

Faith: Dr. Winkler, happy Men’s Health Month.

Dr. Winkler: Thank you. And same to all the men out there who hear this—and people in their lives who love them.

Faith: Thank you so much for joining us.

Dr. Winkler: Thank you. My pleasure.

Faith: Our many thanks to Dr. Alfred Winkler. I’m Faith Salie.

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