As we learned in the installment on prostate cancer risk factors, the clearest predictors of a man's chances of getting prostate cancer usually come from his close family members, genetic lineage and age. So when you see a specialist, the first step they're likely to take is to get a thorough personal and medical history.
"So let's say that a man has a rectal exam with his primary care doctor that doesn't look normal, or a PSA [prostate-specific antigen] test that doesn't look normal," said Petar Bajic, M.D., a urologist and men's health specialist with the Cleveland Clinic. "He might be referred to a urologist like myself for further evaluation. That visit would entail asking a lot of questions about the man's medical history and urinary and sexual issues, and then performing a physical exam that would include a rectal exam. And if the man has had a PSA, we'd check that."
The digital rectal exam (DRE)
The digital rectal exam (DRE) for prostate disease is the butt of a million jokes, so to speak. However, it's important—and quite serious—when you consider DREs are relatively inexpensive and easy to obtain, and the results often provide the first indication that something is wrong.
The doctor has you remove your pants and underwear, lie on a table on your side with your top knee pulled to your chest, or you may stand and bend over the exam table, resting on your elbows. Then the doctor inserts a gloved, lubricated finger into your anus to press on the prostate gland through the front of the rectum wall. The entire process takes a minute or two.
The goal of the DRE is to try to detect unusual lumps, nodules or hard spots that might indicate a tumor. It's not a perfect test by any means and is mainly used as a very rough guide.
While the test is still very common as a front-line check of prostate health, many urologists these days aren't relying as much on the DRE for general screening of men who are at average risk. The American Urological Association (AUA) guidelines state the efficacy of the DRE is more relevant to cancer detection in higher-risk men than true average-risk population screening.
"[The DRE] is falling more and more out of favor," said Jayram Krishnan, D.O., who specializes in urologic oncology with the Cleveland Clinic. "We typically don't do it when I have a new visit. We've found that our detection sensitivity from our rectal exam is not very good or not good enough to detect if there's even anything wrong."
The prostate-specific antigen (PSA) test
Probably the most frequently ordered and useful early-detection test in the urologist toolkit is the PSA, or prostate-specific antigen, test. It involves a blood draw that's sent to a lab where technicians check for unusually high levels of a certain protein that may indicate something is wrong with the prostate.
However, it's important to understand that PSA is produced by both healthy and diseased prostate glands; PSA levels are often higher in men with prostate cancer. If your initial PSA test comes back elevated, don't panic yet.
When dramatically elevated levels of PSA are detected or there is a significant change in levels from one PSA test to another, your healthcare provider will likely order a second PSA test to ensure accuracy. The number may be high for many potential reasons, including but not limited to other prostate conditions, such as prostatitis or enlarged prostate, riding a bike that day, having recently ejaculated or even the DRE itself.
But the PSA test also has problematic issues and isn't considered conclusive. Even a few short years ago, an elevated PSA level might have meant immediately making preparations for a prostatectomy. These days, however, urological specialists approach diagnosis and treatment with a much wider range of options—not to mention more caution and deliberation than they did 30 years ago.
"There's a little bit of interpretation we have to do based on other possible reasons why a man's PSA might be elevated, because it's not a perfect test," Bajic said. "It can be elevated for a wide variety of reasons, and prostate cancer is only one of those reasons. So one of the important things that we like to do is monitor the PSA and see how it is over time. If someone's never had the test before and they're a hair over what's considered normal, but they have other issues like, let's say, benign prostate enlargement or a urinary infection, there may be other things we need to consider that may be elevating that number."