Prostate cancer is often in medical news because it is the most commonly diagnosed solid cancer in men, but recent reports of former President Joe Biden’s stage IV prostate cancer diagnosis has sparked renewed interest and questions.

Some of those questions were covered in a conversation on the Connecticut Public Radio program "Yale Cancer Answers" late in 2024 between Yale Cancer Center’s Michael Leapman, MD, clinical leader of the prostate & urologic cancers program, and YCC director Eric P. Winer, MD. Winer is host of the weekly radio show.

Screening, or testing, for prostate cancer is in the news. What should men know?

It’s an enduring topic that hasn’t been really settled. The PSA test goes back about 30 years to the early 1990s, when it became available. PSA stands for prostate-specific antigen, and it’s made by both normal and cancerous cells in the prostate. PSA is a biomarker, and it’s an amazing test, and it has transformed how we diagnose prostate cancer, transformed how we treat it, and shifted the lives and trajectory of cancer the lives of millions of people.

But interpreting it can be tricky. Infection or inflammation can also elevate PSA levels, and not all elevations mean you have prostate cancer. Overall, it’s a pretty good test.

Who should consider a PSA test?

This is always the cocktail-party conversation. The clearest evidence of benefit is for men between 55 and 69. Screening in that age group reduces the risk of dying from prostate cancer overall. Does that mean every person in every age group should get screened? Probably not.

If you have serious health issues or are older—say in your 80s—pros and cons may lean against screening. There might be more risk than benefit. You might find a prostate cancer and treat it and then the patient has deal with all the quality of life issues that they probably didn’t need to go through. The question is when do we stop? Ultimately, it’s a personal decision and something I advise people to discuss it with their primary care provider.

We do pick up aggressive cancers early, which is a big opportunity to cure—and that’s why screening can be so powerful.

Can you give us an overview of prostate cancer in the United States?

It is consistently the most commonly diagnosed solid cancer in men, with an estimated 300,000 cases diagnosed this year. In autopsy studies of older men, up to 50% of men in their 80s will have some evidence of prostate cancer cells—even if they passed away from another reason. On top of that, about 30,000 to 35,000 people die from prostate cancer each year. Still, the majority of men diagnosed do very well with treatment.

What about prostate cancer treatments? What are some major advances in recent years?

A lot has changed in how we treat localized disease. The mainstay treatments remain radiation and surgery, but there’s now a flourishing field called focal therapy or ablation. This uses different forms of energy to destroy parts of the prostate without removing it or radiating it. We also continue to improve robotic surgery, now with single-port prostatectomy, which involves a single incision of about five centimeters, allowing us to get into smaller spaces and operate with greater dexterity. It’s helping us get into smaller spaces.

How does a patient choose between surgery and radiation?

We’re fortunate to have multiple very effective treatments for prostate cancer. Surgery can remove the prostate entirely, letting us know exactly what’s there and offering the chance to add more treatment later if needed. Radiation, meanwhile, doesn’t require hospitalization and often has less of an impact on urinary continence. Radiation also can be coupled with a course of hormone medication to decrease testosterone.

Both carry a risk of side effects—such as urinary leakage or sexual dysfunction—because the prostate sits at a sensitive spot near nerves and the urinary tract. Ultimately, we try to tailor the decision to each individual’s needs and priorities. There has never been a head-to-head study comparing radiation with surgery. There are advantages and disadvantages with each option.

Men worry about treatment side effects—what are they?

The main two side effects that people are concerned about are incontinence and sexual dysfunction.

Because the prostate sits right below the bladder, anything we do there may affect urinary control. Men may experience leakage when they laugh, cough, or sneeze—sometimes temporarily, sometimes permanently.

Also, the nerves for erections run right alongside the prostate. Even with expert surgery or radiation, there’s a chance erectile function can be compromised; people can need medications like Viagra or Cialis at least for a period of time.

Our objective is cancer control and maintaining quality of life.

Some patients choose no treatment, or not right away, an approach called active surveillance, right?

Our approach has shifted. That’s because many of the prostate cancers we identify with screening are not aggressive.

If I have a gentleman come to me and he has an elevated PSA, we do some imaging to confirm whether there is something there. That has allowed us to avoid doing a biopsy to rule out significant cancer in a number of people, which is great. If we can do something non-invasively that’s a big win.

There’s been a real change in the last few years—people have really come around to active surveillance. At Yale, the people with low-risk prostate cancer, the majority are opting for active surveillance. There is lots of evidence that shows that there is no difference in survival among people who have surgery, radiation, or careful monitoring over 15 years of follow-up, with about a 99% survival in all those groups.

Monitoring is the key with nonaggressive cancers and offers us the opportunity for treatment in the future should something change. That window of opportunity for cure is still there if we need it. Active surveillance has really revolutionized our approach because we are reducing the risk of over treatment. It lowers unnecessary surgery or radiation for men whose cancers may never harm them.

Finally, what about younger men who develop prostate cancer?

It does happen. We see that more often as screening picks up. Younger men have different considerations, like fertility. The stakes are also different when preserving urinary and sexual function. So we tailor treatments accordingly, but it’s still less common than in older men.