Prostate cancer screening: when to think about it (and above all, how does it work)?

In France, screening for prostate cancer is not systematic as it is for colorectal, breast or cervical cancer. However, it is of the first male cancer in terms of incidence (50,000 new cases per year) and the third in terms of mortality after lung and colon cancer (8,100 deaths per year).

As it is a cancer whose incidence increases with age (it is rare before the age of 50 and the average age of diagnosis is 67), it is normal, from the age of fifty and/or because one presents risk factors, to wish to be screened – especially since obviously, the earlier the cancer is treated, the better it is treated.

What do you need to know before making an appointment with the doctor? What does the examination consist of for this screening which is therefore individualized and personalized? On the occasion of the European Prostate Daythis Friday, September 20, we take stock with the D^r Johann Barkatz, urologist and andrologist, hospital practitioner at the Besançon University Hospital.

Not always symptoms but known risk factors

To begin with, two things to know. First, the Prostate cancer is quite sneaky since it only causes symptoms very late. When there are urinary symptoms (frequent need to pee, weak urine stream, feeling of not having emptied the bladder properly, leaks, blood in the semen or urine), they are often linked to what is called “benign prostatic hypertrophy”, which corresponds to an increase in the volume of this gland that is the prostate.

Second, some people are at greater risk of developing prostate cancer than others. “These are men who have a first-degree family history of prostate cancer, meaning their father or one of their uncles had this type of cancer. Men whose mother had breast cancer due to a mutation of the BRCA gene (or who carry this mutation) are also affected”details Johann Barkatz.

The latter adds to the list men of Afro-Caribbean origin: “The soils of the French Antilles have been contaminated by chlordeconean insecticide used to treat many crops on a very large scale, which has been shown to be a major prostate carcinogen – many years after exposure.” Note that although this toxic product is no longer used today, the soil remains contaminated and the risk is still present.

For these men, it goes without saying that screening is recommended. And then there are also the fifty-year-olds who are starting to take an interest in their health, who are perhaps worried about having seen friends affected by cancer… If they wish, they too can, of course, undergo screening.

First step: PSA measurement and rectal examination

For all, go to a urologist. There, there is a side A and a side B to the exam. Side A is a blood test: “The first test performed is a PSA (prostate specific antigen) test.”explains the expert. A (slightly) high figure (between 3 and 4 nanograms per liter) indicates an increase in the volume of the prostate which, as we have seen, can also be linked to benign hypertrophy. This can also be the case occasionally after sexual intercourse, a rectal examination or even after cycling – so avoid these activities before your blood test. “We can perform several dosages and evaluate the kinetics, see if the rate changes”the urologist specifies.

And side B? It’s the digital rectal examination, a diagnostic procedure that is sometimes feared but nevertheless essential since it allows you to feel the prostate, to examine its upper part to possibly find a nodule, a roughness, an asymmetry… “It is not a painful exam but it can be unpleasant and uncomfortable.”says Johann Barkatz, who wants to be reassuring: “We don’t do this on a corner of the table, in the corridor in front of third parties, but in a closed consultation room. We take the time to put the patient in the right frame of mind, we use gloves, lubricant, we explain the procedure and we also discuss everything and nothing for the purposes of cognitive distraction.”

Additionally, the patient is asked to get into a specific position: “In France, it is never asked to be in the knee-chest position, that is to say knees and elbows on the examination table. It is in fact documented that this position is poorly experienced. For my part, I prefer the position on the back, knees bent. Some of my colleagues prefer the rifle dog position. It is a question of habit.”explains the practitioner. Note: the lubricant can sometimes stain a little. Even if paper and a sink are available, it may be advisable to bring a change of underwear.

MRI then biopsy

If the digital rectal examination is abnormal with an increased PSA (or not, moreover, because certain prostate cancers do not cause this antigen to rise), the doctor directs the patient to an MRI which can locate any suspicious areas, confirm the diagnosis of benign prostate pathologies or even show that there is nothing at all.

If there is nothing or it is benign, the investigations can stop there. Otherwise, it is appropriate to do a ultrasound-guided biopsy to take tiny pieces of prostate from areas deemed suspicious by the radiologist who performed the ultrasound. “In most cases, this examination is carried out under local anesthesia.”explains Johann Barkatz, who adds: “It is an examination that can be uncomfortable because we use an ultrasound probe that is placed in the rectum – using lubricant of course.”

Everything is done to limit discomfort and minimize a rare but nevertheless present risk of infection: before the examination, the patient must perform an enema and take antibiotics as a preventative measure, then he is kept under surveillance for two hours following the sample. In the days if not weeks that follow, he may notice a little blood in his sperm, in his urine or in the rectum: “It’s not a big deal, even if it can be impressive”our urologist explains.

Active surveillance is sometimes the only management

After this biopsy, there is the wait, which is inevitably a little stressful. It takes about three weeks to get the results – a period during which it is best to avoid searching for prostate-related content on search engines.

It is possible that the biopsy will come back negative and then we can relax. But of course, it is also possible that it will come back positive and indicate the presence of cancer. “We really need to remember that there are several types of prostate cancer. In the majority of cases, prostate cancer is non-progressive and it is not aggressive – that is to say, it is in its infancy and if it does progress, it can take years and years. Maybe the person will even have time to die at a very old age from something completely different.”dédramatise Johann Barkatz.

So, in this case, the treatment will be, at least at the beginning, active monitoring. And, thanks to monitoring, if the cancer progresses, it will be treated early with an often good prognosis. The idea, in this case, is to avoid imposing heavy treatments on the patient that would not be necessary – in short, to avoid overtreatment.

Of course, there are also more aggressive cancers, which evolve and present a risk. They require treatment, generally radiotherapy or surgery, combined with hormone therapy. In this case, and even if it is very difficult to formulate generalities, the diagnosis is often favorable, so much so that treated prostate cancers are now often thought of as chronic diseases.

Now you know everything (or almost everything) about prostate cancer screening. It’s up to you to decide, in conscience, whether you want to do it.