Myths & Facts: Prostate Cancer

ONCE CONSIDERED rare, prostate cancer (PC) is now the most common cancer in men. Approximately 12.9 percent of men will be diagnosed with PC at some point during their lifetime, based on 2018 through 2021 data, excluding 2020 due to the COVID pandemic. In 2022, there were an estimated 3,518,978 men living with PC in the United States. Based on age-adjusted 2018 through 2022 cases and 2019 through 2023 deaths, the rate of new cases of PC was 120.2 per 100,000 men per year, and the death rate was 19.2 per 100,000 men per year (Figure). Between 2015 and 2021, the five-year survival rate was 97.9 percent. And, estimates for PC in the United States for 2025 are about 313,780 new cases and about 35,770 deaths.¹

The history of PC spans nearly 200 years. George Langstaff reported the first surgical case of PC in 1817. And, John Adams subsequently described the first histologically confirmed case of PC in the London Hospital in 1853, noting the condition as “a disease of very rare occurrence.”² Later advancements in PC occurred in the 20th and 21st centuries, mostly in terms of treatments such as hormonal therapies, surgical techniques, radiation and chemotherapy.³ Today, researchers continue to refine treatment approaches and improve outcomes for men diagnosed with PC.

However, while overall, the treatment of PC has taken huge leaps forward, there are still many myths surrounding the disease. And, since PC is lethal without treatment, it’s crucial that these myths be cleared up.

Separating Myth from Fact

Myth: All PCs are the same.

Fact: Actually, research shows there are at least 29 types of PC, which can be indolent, harmless or aggressive. And, there are four different stages of the disease, five different grade risk groups and more than 10 different combinations of Gleason score (a grading system for PC based on how abnormal the cancer cells appear under a microscope) ranging from 6 (low-grade cancer) to 10 (high-grade cancer).^4,5

According to the American Cancer Society, a staging system is a standard way for the cancer care team to describe how far a cancer has spread. The American Joint Committee on Cancer’s TNM system is the most widely used staging system for PC, the most recent update of which occurred in 2018. The TNM system for PC is based on five key pieces of information:⁶

• The extent of the main (primary) tumor (T category)
• Whether the cancer has spread to nearby lymph nodes (N category)
• Whether the cancer has spread (metastasized) to other parts of the body (M category)
• The PSA level at the time of diagnosis
• The grade group (based on the Gleason score), which is a measure of how likely the cancer is to grow and spread quickly determined by the results of the prostate biopsy (or surgery).

The main stages of PC range from I through IV. Some stages are split further (IIA, IIB, IIC, etc.). As a rule, the lower the number, the less the cancer has spread, and the higher the number, such as stage IV, means cancer has spread more. Within a stage, an earlier letter means a lower stage (Table).⁶

Myth: Only elderly men get PC.

Fact: The majority of men diagnosed with PC are older, but it does occur in younger men, with approximately 50 percent of all cases occurring in men younger than 65. “It’s not uncommon at all for men in their 50s and some in their 40s to have prostate cancer,” says Oliver Sartor, MD, a professor of medicine and urology at the Tulane University School of Medicine in New Orleans. It’s rare in men younger than 40, however.⁷

According to the MD Anderson Cancer Center guidelines, men at average risk of cancer should start talking with their doctor about the benefits and limitations of prostate screening beginning at age 50. It is recommended that men with a family history of PC start PSA screening earlier, at age 40 or 45.7 For African Americans or those who have a family history (father, brother, son) of PC, screening should include a digital rectal exam and PSA test every year starting at age 45. At age 50 to 75, it is recommended that all men get a digital rectal exam and PSA test every year to check for PC. At 75 to 85 years, a doctor can help men decide if they should continue screening. MD Anderson does not recommend cancer screening for men age 85 and older.

Myth: Men usually get PC if there is a family history of it.⁸

Fact: Men who have a brother or father with PC are two times as likely to develop the disease.⁹ Two family members with prostate cancer hikes the risk fivefold.⁷ However, most PCs occur in men without a family history of it. Other important risk factors include age, race, physical health and lifestyle.⁹

Myth: There is no relationship between PC and other cancers.

Fact: Research shows that hereditary (or familial) PC is not only associated with prostate cancer in first-degree relatives but also breast cancer, ovarian cancer and pancreatic cancer. According to Edward M. Schaeffer, MD, PhD, urologic oncologist and chair of the Department of Urology at Northwestern Medicine, “Individuals with a strong history of breast cancer, ovarian cancer and occasionally pancreatic cancer can have genes that increase their risk for developing prostate cancer.”⁹

Myth: A man doesn’t have PC if he shows no symptoms.

Fact: Actually, PC doesn’t always present with noticeable symptoms, and in its early stages, PC often has no symptoms at all.⁴

Most PCs are found at an early-stage, and early-stage PC often doesn’t cause symptoms. However, if there are symptoms at the early stage, they can include blood in the urine, which might make the urine look pink, red or colacolored; blood in the semen; needing to urinate more often; trouble getting started when trying to urinate; and waking up to urinate more often at night.

If the PC spreads to other parts of the body, which is called metastatic PC, stage IV prostate cancer or advanced prostate cancer, signs and symptoms can include accidental leaking of urine, back pain, bone pain, difficulty getting an erection (erectile dysfunction), feeling very tired, losing weight without trying and weakness in the arms or legs.¹⁰

Myth: Screening tests for PC aren’t beneficial.

Fact: Since symptoms do not often occur with early-stage PC, it is important for men to discuss their risk factors and whether they should be screened with their healthcare provider. And, while medical organizations have different recommendations regarding screening for PC, all agree the most important aspect of screening is to have a conversation with a healthcare provider about the benefits and risks of screening tests. The most common screening tests include:¹¹

• Prostate-specific antigen (PSA) blood test. PSA is a substance that can be found in blood. Elevated PSA levels are often found in men with PC; however, noncancerous conditions such as prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (enlarged prostate) can also cause PSA levels to increase.
• Digital rectal exam. With this test, the doctor feels for hard areas or lumps in the prostate by inserting a gloved, lubricated finger into the rectum.

If the results from either of these tests come back abnormal, further testing is often required.¹¹

One myth about PC is that PSA screening reduces prostate cancer mortality only by about one in 1,000. But, according to Andrew Vickers, PhD, of Memorial Sloan Kettering Cancer Center, PSA screenings have reduced deaths significantly more than that. “This number is frequently cited, and it makes it look like the benefits are small, but it is based on a misunderstanding of a well-known trial,” Dr. Vickers explains. “Experts disagree about the best estimate, but one study published in The New England Journal of Medicine gave a number closer to 10 in 1,000.”¹²

In another study that sought to determine whether PSA screening decreases PC mortality for up to 16 years and to assess results following adjustment for nonparticipation and the number of screening rounds attended, researchers found that PSA screening significantly reduces PC mortality, showing larger absolute benefit with longer follow-up and a reduction in excess incidence.

The multicenter population-based randomized screening trial was conducted in eight European countries and included 182,160 men, followed up until 2014 (maximum of 16 years), with a predefined core age group of 162,389 men (55 to 69 years), selected from a population registry. The rate ratio of PC mortality was 0.80 (95 percent confidence interval [CI] 0.72-0.89, p<0.001) at 16 years. The difference in absolute PC mortality increased from 0.14 percent at 13 years to 0.18 percent at 16 years. The number of men needed to be invited for screening to prevent one PC death was 570 at 16 years compared with 742 at 13 years. The number needed to diagnose was reduced to 18 from 26 at 13 years. Men with PC detected during the first round had a higher prevalence of PSA >20ng/ml (9.9 percent compared with 4.1 percent in the second round, p<0.001) and higher PC mortality (hazard ratio=1.86, p<0.001) than those detected subsequently. The researchers concluded that repeated screening may be important to reduce PC mortality on a population level.¹³

“Almost all men will get prostate cancer if they live long enough,” explains Dr. Vickers. “So we aren’t at all interested in prostate cancer as an endpoint. What we want to know is whether PSA can predict who gets the sort of prostate cancer that can cause symptoms and threaten a patient’s life. It turns out that PSA is very good at doing that.”¹²

Myth: If a man has a high PSA score it means he has PC.

Fact: While the most common cause of elevated PSA is PC, PSA levels increase with age and can reflect different conditions that affect the prostate.14 Because the PSA test is very sensitive, if a man’s PSA is low, he can be reassured that he is at low risk of having an aggressive PC. However, because the test is not specific, a higher PSA level doesn’t necessarily mean a man will get PC since there can be many other reasons it is elevated.¹²

Other conditions or factors that may raise a PSA level include:¹⁴

• Enlarged prostate (benign prostatic hyperplasia)
• Prostate inflammation (prostatitis)
• Urinary tract infections
• Urinary catheter
• Certain medications, including betamethasone and testosterone replacement therapy

Generally speaking, PSA levels for men who are age 60 or older should be at or below 4.0 mg/mL, and men who are age 59 or younger should be at or below 2.5 mg/mL. The average PSA for men in the younger group is <1.0 mg/mL.15 The likelihood of PC increases along with blood PSA levels. If a man has a relatively high PSA level (approximately 4.0 mg/mL or above), most physicians recommend repeat testing supplemented by other noninvasive tests, such as an MRI scan,16 to determine whether a biopsy is needed, and if so, what kind. A prostate biopsy is the removal of tiny samples of prostate tissue to examine it for signs of PC. There are three ways to perform a prostate biopsy:¹⁷

• Transrectal — through the rectum. This is the most common method that inserts a lubricated ultrasound probe into the rectum to guide the biopsy needle inserted into the prostate to take a sample.
• Transperineal — through the perineum (the skin between the anus and the scrotum). This is being used more frequently and involves inserting an ultrasound probe into the rectum to image the prostate while a needle is inserted into the perineum to collect prostate tissue.
• Transurethral — through the urethra. This is not used very often. It involves inserting a flexible tube with a camera on the end (cystoscope) through the opening of the urethra at the tip of the penis.

Myth: A prostate biopsy can cause PC to spread.

Fact: While a prostate biopsy can theoretically cause cancer to spread, it is extremely rare. When it does happen, it’s called “tumor seeding,” a process that occurs when the needle inserted into a tumor during the biopsy dislodges and spreads cancer cells. Tumor seeding may also be referred to as “needle tract seeding” because the cancer cells grow along the needle’s track.

Several studies have been performed that confirm how rare tumor seeding is. A study of more than 2,000 patients by researchers at Mayo Clinic’s campus in Jacksonville, Fla., dispelled the myth that cancer biopsies cause cancer to spread. The study showed that patients who received a biopsy had a better outcome and longer survival than patients who did not have a biopsy. According to the study’s senior investigator and gastroenterologist Michael Wallace, MD, MPH, professor of medicine, while the researchers studied pancreatic cancer, the findings likely apply to other cancers because diagnostic technique used in this study — fine needle aspiration — is commonly used across tumor types.

“This study shows that physicians and patients should feel reassured that a biopsy is very safe,” Dr. Wallace says. “We do millions of biopsies of cancer a year in the U.S., but one or two case studies have led to this common myth that biopsies spread cancer.” Rather, he says, biopsies offer “very valuable information that allow us to tailor treatment. In some cases, we can offer chemotherapy and radiation before surgery for a better outcome, and in other cases, we can avoid surgery and other therapy altogether.”¹⁸

Myth: Treatment for PC must be started right away after a diagnosis.

Fact: This is not always the case. Some men with early-stage, slow-growing prostate cancer may not need treatment right away. In fact, the stage of cancer is one of the most important factors in choosing the best way to treat it. For prostate cancers that haven’t spread (stages I to III), doctors also use risk groups (based on how far the prostate tumor has grown, PSA level, grade and prostate biopsy results) and sometimes special lab tests to help guide treatment options. If it is determined the cancer is in the very-low-risk stage, it is very unlikely to grow and spread, even if it isn’t treated. Instead, active surveillance is typically recommended. For men who have medical problems that might shorten their lifespan, surveillance might be an option as well because the tumors are unlikely to cause any harm, whereas treatments such as radiation and surgery can have side effects that can affect quality of life. Even men in the low-risk stage may be offered active surveillance, since very few of low-risk-stage cancers will spread to distant parts of the body. If the cancer starts to show signs of growing at some point, treatment can then be considered.¹⁹

Some common treatments for PC are:²⁰

Prostatectomy: an operation in which doctors remove the prostate. Radical prostatectomy removes the prostate, as well as the seminal vesicles (glands that produce the fluids that will turn into semen)

Radiation therapy (photon and proton): a procedure that uses highenergy rays (similar to X-rays) to kill the cancer. There are two types of radiation therapy:

1) External radiation therapy in which a machine outside the body directs radiation at the cancer cells

Traditional photon radiation therapy uses photons in the form of X-ray beams that release radiation along the entire length of the beam, which means they continue to penetrate into the body after passing through the tumor. This “exit dose” can potentially damage healthy tissues and organs near the prostate, including the bowel, bladder, penile bulb, testicles, rectum, urethra and bones in the pelvis and the hip joint, which can increase the risk of long-term complications and of developing new cancers in the future.

In contrast to photon radiation, proton therapy is a newer therapy that more precisely targets the tumor, limiting exposure to other organs and tissues and lowering the risk of future cancers in radiated areas. Proton therapy uses proton particles that can be set to travel a certain distance into the tumor and stop. This allows radiation oncologists to deliver the right dose of radiation to different parts of the tumor to effectively kill PC. Proton therapy can be used in most stages of PC, including early-stage, mid-stage, late-stage (locally advanced), PC that has spread to adjacent organs or tissues, PC that has spread to the lymph nodes (lymph-node positive PC) and PC that has returned after surgical removal and is detected through the PSA test, indicating biochemical recurrence.²¹

2) Internal radiation therapy (brachytherapy) in which radioactive seeds or pellets are surgically placed into or near the cancer to destroy the cancer cells

Depending on whether the PC has spread, there are other treatment options:²⁰

• Cryotherapy: placing a special probe inside or near the PC to freeze and kill the cancer cells (this is a less common treatment)
• Chemotherapy: using special drugs to shrink or kill the cancer after it has spread to other parts of the body (the drugs can be pills or medicines given through the veins or, sometimes, both)
• Biological therapy: works with the body’s immune system to help it fight cancer or to control side effects from other cancer treatments
• High-intensity focused ultrasound: directs high-energy sound waves (ultrasound) at the cancer to kill cancer cells (this is a less common treatment)
• Hormone therapy: blocks cancer cells from getting the hormones they need to grow (also called androgen deprivation therapy)
• Targeted therapy: uses drugs that attack cancer cells while minimizing damage to healthy cells (used to treat PC that has spread to other parts of the body and is no longer responding to hormone therapy)

Myth: PC treatment always causes impotence or incontinence.

Fact: Most men, but not all, experience erectile dysfunction immediately after surgery or radiation. But nearly all men with intact nerves report a significant improvement after one year. The risk of these side effects depends on the type of prostate cancer treatment, overall health, the extent of the cancer and the skill of the surgeon. And, if there are side effects, urologists and therapists can help men manage them, and most will see an improvement within one year. According to Dr. Sartor, one year after surgery, approximately 25 percent of patients will say their sexual function is fine, 25 percent will have mild dysfunction, 25 percent will have moderate dysfunction and 25 percent will say they have severe dysfunction.^7,9

If incontinence (bladder problems) occurs, it’s more likely minor leakage than major accidents, and in most men, the situation is temporary or treatable. “The majority of people do not have significant urinary problems,” Dr. Sartor says. For the best outcome after surgery, Dr. Sartor recommends looking for a surgeon who has performed the procedure many times — surgeons who are on their 900th procedure, for example, not their 41st.⁷

Studies have suggested that proton therapy may cause fewer side effects, such as impotence and incontinence, than traditional radiation, since doctors can better control where the proton beams deliver their energy. Studies have also shown that proton therapy does not significantly affect testosterone levels, while photon radiation treatments can lower testosterone. However, proton therapy is much more expensive than photon radiation therapy and is available only in specialized proton therapy centers.²¹

Myth: If PC reoccurs, it can’t be treated again.

Fact: Biochemical recurrence, or biochemical relapse, can range from 40 percent to 70 percent in patients whose PC is found in the seminal vesicles or other tissues on the edges of the surgical site. But, just because PC comes back, it doesn’t mean it can’t be treated again and that remission can’t be reached again.

New research from the University of Florida (UF) Health Proton Therapy Institute suggests proton therapy can be highly effective in treating recurrent PC following prostatectomy. In the study of 102 men who were enrolled on an outcome tracking protocol between 2006 and 2017 at the UF Health Proton Therapy Institute and treated with proton therapy after prostatectomy, the five-year biochemical relapse-free and distant metastases-free survival rates were, respectively, 57 percent and 97 percent overall, and compared favorably with other conventional radiation therapies.²²

Myth: PC is always fatal.

Fact: While PC is a serious disease, most men who are diagnosed with this disease do not die from it. In fact, the five-year survival rate is about 98 percent, which is why catching prostate cancer early is important because doing so significantly improves survival rates.¹¹

Dispelling the Myths Now

PC is a major health challenge in the U.S., and the second leading cause of cancer deaths among men.23 Unfortunately, men’s fear of PC often caused by the myths surrounding it leads many to avoid screenings, experience anxiety and depression at diagnosis, and leads to fear and avoidance of treatment because of side effects. But PC is slow-growing, and most cases are caught early. And, with the advances in treatment, most men live full lives without major side effects.