Prostate Cancer Early Detection

Prostate cancer early detection depends on a deliberate sequence rather than a single test: a thorough physical examination including a digital rectal examination, a PSA (prostate-specific antigen) blood test ordered for a clear reason, recognition of the men at higher risk, and a biopsy only when suspicion is high. The aim is to find aggressive cancers in time without putting men through investigation and treatment they do not need.

That sequence is the core of the method set out by Dr. Nitin Shrivastava; at the time of this July 2024 session he was Senior Consultant - Urology, Uro Oncology and Robotic Surgery at Artemis Hospitals, Gurugram, India. He sees patients from African countries almost every day, and he built his approach around the decisions a referring physician makes before a patient ever reaches a urologist: whom to examine, whom to test, whom to biopsy and whom to leave alone.

This guide sets out the whole approach. Three companion articles go deeper: age-adjusted PSA levels, PSA density and velocity, when to do a prostate biopsy and how, and BPH treatment, repeat TURP and recovery after prostate surgery.

Why prostate cancer is rarely found by its symptoms

Most prostate cancers confined to the gland cause no symptoms at all, so waiting for symptoms means waiting for advanced disease. Dr. Shrivastava was emphatic on this point. When a man reports difficulty passing urine, the cause may be benign prostatic hyperplasia (BPH, the non-cancerous enlargement of the prostate that is common with age), a urinary infection, a stone or a cancer. These urinary symptoms are not specific to any one of them.

By the time symptoms that do point to cancer appear, the disease has usually spread. In his experience the warning signs of advanced prostate cancer include:

• bone pain, typically from spread to the skeleton;
• anaemia;
• swelling of the legs.

The practical consequence is that early prostate cancer is found by looking for it, not by waiting for it to declare itself. Where the incidence is high, as it is in western countries and in African countries, Dr. Shrivastava argues that two things must be present together: awareness in the general population and a high degree of suspicion in the general physician. He asks his own hospital team to run more cancer awareness programmes for exactly this reason, and he trains general practitioners not to skip the basic steps of examination.

The physical examination comes before any scan

A complete physical examination remains the foundation of prostate cancer diagnosis, and no scan replaces it. Dr. Shrivastava's rule for African practice is that any man aged above 40 or 45 who presents with a urinary problem should be examined from head to toe, including the abdomen, the scrotum and the lower limbs.

He is critical of a trend he sees in India and in western countries: doctors who no longer examine patients because high-quality MRI and PET scans are available. In his words, there is no replacement for a good physical examination.

Why the digital rectal examination matters

The digital rectal examination (DRE), in which the clinician feels the back surface of the prostate with a gloved finger through the rectum, is non-negotiable in his clinic. Any man above 45 who comes to his outpatient department with urinary complaints does not leave without one.

The examination matters for three reasons:

1. It can detect the cancer directly. A cancer that is palpable on the finger is a strong signal.
2. It is needed for staging. The clinical tumour classification of prostate cancer depends on the rectal examination. If the examination has not been done, the disease cannot be clinically classified.
3. It completes the picture. A palpable cancer together with swelling of the feet indicates advanced disease and a high probability that the cause is cancer, which is why he insists on examining the legs as well.

What is clinically significant prostate cancer?

Clinically significant prostate cancer is aggressive cancer that is likely to harm the patient, and finding it, not every cancer, is the purpose of every investigation. Dr. Shrivastava described prostate cancer as a disease with a very wide spectrum. At one end are indolent cancers that grow slowly and will not harm the patient. At the other are aggressive cancers that can kill within a few months.

He defines the two groups this way:

• Clinically significant prostate cancer is cancer that, by its nature, is aggressive and likely to harm the patient. It must never be missed.
• Clinically insignificant prostate cancer is indolent, will not grow aggressively and will not affect the patient's survival. Missing it, in his words, is all right.

This distinction drives everything that follows. Because PSA can be raised for many reasons, and a rectal examination can be abnormal in many situations, patients are often over-investigated and over-treated. The clinician's task is to strike a balance: never missing an aggressive cancer, while not treating every man who does not need it.

Who is at higher risk of prostate cancer

Some men warrant a lower threshold for investigation, and Dr. Shrivastava asked his audience to concentrate on a short list rather than on genetic testing. The higher-risk group includes:

• men of African descent;
• men with a family history of prostate cancer or of multiple cancers;
• men whose PSA density, a measure that relates PSA to the size of the gland, is above 0.15.

For men in this group he advises investigation from an earlier age, starting at 45. The detailed testing schedule, including a baseline PSA from the age of 40 for African patients and yearly tests from 45, is set out in the companion guide to age-adjusted PSA levels.

Prostate cancer screening versus early detection

Screening and early detection are different strategies, and the distinction shapes who should be tested. Screening means testing everyone, including men without symptoms. Early detection means testing men who have symptoms or who are at higher risk.

Dr. Shrivastava does not recommend routine mass screening for prostate cancer, on the grounds that it has not been shown to improve overall survival. Large randomised trials found that PSA screening reduces deaths from prostate cancer but has not clearly improved overall survival, while it does increase overdiagnosis; this is why most guidelines favour an informed, individual decision over population-wide testing.

High-risk men are different. Even a man with no urinary symptoms, if he has a family history of prostate cancer, can be offered a discussion about PSA testing and investigation.

Discussing PSA before ordering it

Dr. Shrivastava insists that a PSA test is a decision, not a reflex. Before ordering it, the clinician should be clear that the patient needs it and should discuss the risks and benefits with him. The benefit is that an aggressive cancer is not missed. The cost is that a high reading leads to a biopsy, a procedure with its own risks, and a positive biopsy leads to treatment. The patient should understand that chain before the first blood sample is taken.

What causes prostate cancer: genetics, weight and diet

Age is the strongest risk factor for prostate cancer, followed by African ancestry and family history. Among the factors a man can be asked about, Dr. Shrivastava regards family history and genetics as outweighing diet and lifestyle. Environmental and dietary factors also play a part, but the disease has so many contributing influences that no single dietary element has ever been pinpointed as a cause.

His reading of the evidence on lifestyle factors:

None of these dietary factors is established firmly enough to appear in clinical recommendations, and he was careful to say so.

Practical dietary advice

His advice is pragmatic and applies to men with BPH as well as to men with or recovering from prostate cancer:

• Control weight and cut refined carbohydrates. Reducing easily digested, quick sugars benefits the heart, the kidneys and cancer risk alike.
• Take adequate vitamins, preferably from food. Supplements, in his view, remain controversial.
• Eat a balanced diet, planned with a dietician, both for prevention and during recovery.

Why the urologist needs a dietician and a physiotherapist

Dr. Shrivastava believes a dietician should always work alongside the urologist. Urological patients often need guidance on kidney stones, high uric acid, hypertension and weight reduction, all of which are dietary problems as much as surgical ones. He would also add a physiotherapist to the team to encourage patients to exercise.

The same multidisciplinary logic extends to rehabilitation after prostate surgery. Physical medicine and rehabilitation does not treat prostate cancer itself, but he regards it as an integral part of the overall treatment, because patients need pelvic floor exercises after surgery to regain continence. That recovery pathway is covered in the companion article on BPH and life after prostate surgery.

Dr. Shrivastava's diagnostic checklist

Dr. Shrivastava closed his masterclass with a summary that serves as a working checklist for any physician evaluating a man for prostate cancer:

1. Do the rectal examination. It is a step doctors increasingly skip, and no scan replaces it.
2. Identify the high-risk patient. Men of African descent and men with a family history need a lower threshold.
3. Rule out a urinary infection before planning any investigation, because infection raises PSA.
4. Never act on a single PSA. At least two raised readings are needed before moving forward.
5. Biopsy when suspicion is high. If prostate cancer is strongly suspected, proceed to prostate biopsy.
6. Use MRI if it is available. It is best done before the biopsy, to target it, but can also follow it.
7. Know when not to investigate. In men who are very old, very sick or do not want major treatment, a biopsy is probably not appropriate. Discuss the risks and benefits of not investigating further and, in his words, leave them in peace.

The reasoning behind steps 3 to 7, including biopsy technique and the role of CT where MRI is unavailable, is explained in the companion article on prostate biopsy decisions.

How this approach differs from other prostate cancer guides

Dr. Shrivastava's masterclass is deliberately front-loaded: it concentrates on examination, risk selection and the decision to biopsy rather than on surgical technique. Readers looking for staging, Gleason grading and treatment by risk group will find them in the prostate cancer guide by Dr. Amit Goel, and a fuller treatment of advanced imaging and robotic surgery in the prostate cancer guide by Dr. Shafiq Ahmad.

The questions doctors raised with Dr. Shrivastava, from PSA in catheterised men to the role of CT, are recorded in the Live Discussion from this masterclass. More on the specialty is collected on the urology hub.