Urinary symptoms and prostate cancer—the misconception that may be preventing earlier presentation and better survival outcomes

Abstract

Background Prostate cancer is an epidemic of the modern age, and despite efforts to improve awareness, it remains the case that mortality has hardly altered over the decades, driven largely by late presentation. There is a strong public perception that male urinary symptoms is one of the key indicators of prostate cancer, and this continues to be part of messaging from national guidelines and media health campaigns. This narrative, however, is not based on evidence and may be seriously hampering efforts to encourage early presentation. Discussion Anatomically, prostate cancer most often arises in the peripheral zone, while urinary symptoms result from compression of the urethra by prostatic enlargement more centrally. Biopsy studies show that mean prostate volume is actually lower in men found to have (early) prostate cancer compared to those with benign biopsies. This inverse relationship between prostate size and the probability of cancer is so strong that PSA density (PSA corrected for prostate volume) is known to be significantly more accurate in predicting a positive biopsy than PSA alone. Thus, this disconnect between scientific evidence and the current perception is very striking. There is also evidence that using symptoms for investigating possible cancer may lead to higher proportions of men presenting with locally advanced or metastatic disease compared to PSA testing or screening programmes. Concerns about overwhelming health care services if men are encouraged to get tested without symptoms may also be overstated, with recent newer approaches to reduce over-investigation and treatment. In this article, we explore the link between urinary symptoms and prostate cancer and propose that public and professional messaging needs to change. Conclusion If rates of earlier diagnosis are to improve, we call for strong clear messaging that prostate cancer is a silent disease especially in the curable stages and men should come forward for testing regardless of whether or not they have symptoms. This should be done in parallel with other ongoing efforts to raise awareness including targeting men at highest risk due to racial ancestry or family history. While the current resurgence in interest and debate about prostate cancer screening is timely, change of this message by guideline bodies, charities and the media can be a first simple step to improving earlier presentation and hence cures rates.

Low-Value Prostate Cancer Screening Among Young Men With Private Insurance

“…Studies have not demonstrated a correlation between urinary symptoms and prostate cancer. 18-20 PSA screening during workup and treatment decision-making should be discussed in older men who commonly may experience LUTS secondary to benign hyperplasia; however, there is minimal indication to screen in young men due to the low risk for cancer. Similar to hypogonadism guidelines, professional recommendations for benign prostatic hyperplasia management range from deferring to prostate cancer screening guidelines to screening “when it would direct management,” the latter which leaves loose interpretation increasing risk for overscreening.…”

Efficacy of early screening for prostate cancer in an elderly patient with absence of urinary symptoms but a manifestation of a rare symptom: a case report

“…21 With the patient complaint of a rare symptom of prostate cancer, constipation without any urinary complaints he was immediately referred for prostate cancer screening. 18,[22][23][24] The prompt screening for prostate cancer revealed possible metastasis, whereby the case was referred to the Multidisciplinary Team for review and there it was determined that the cancer was localised and the patient was treated with hormonal and radiotherapy. Following which, the patient's PSA dropped below 1 and has remained at this level for 2 years.…”

“…This gap in knowledge may be a significant factor in the initial diagnosis in later stage prostate cancer and diagnosis after metastasis. 17,18 Further this misconception may impact a patient's decision to undergo further prostate screening. 19 The national health service in the UK website lists seven symptoms of prostate cancer, all of which are in reference to urinary tract symptoms.…”

Symptom appraisal and help seeking in males with symptoms of possible prostate cancer: a qualitative study with an ethnically diverse sample in London

“…Advanced-stage diagnosis may also arise from delays in the pathway to diagnosis. 9 Despite doubt surrounding the link between lower urinary tract symptoms (LUTS) and prostate cancer, 10 , 11 the absence of prostate cancer screening in the UK means that diagnosis most commonly occurs following presentation to primary care with LUTS, erectile dysfunction, or visible haematuria. 11 , 12 However, a multi-methods study of UK males showed that Black males may not fully disclose possible prostate cancer symptoms during initial consultation in primary care; in addition, the study found that GPs may delay investigation of males in this group, especially if patients have comorbidities, such as diabetes, that share similar symptoms.…”