Chapter 1 12 Symptoms, diagnosis, and staging Early-stage prostate cancer usually causes no symptoms and therefore is only diagnosed after finding an elevated serum PSA ‘by accident’ in the majority of these patients. PSA is often measured when men present with urinary symptoms, which are often caused by benign prostate hyperplasia. More advanced prostate cancer, however, can present with genitourinary (GU) symptoms, such as weak or interrupted urine flow, difficulty with starting or stopping urination, frequent urination (most notably during the night, i.e. nocturia), and pain or burning sensation during urination. Metastasised disease can present with pain due to spreading of cancer to the bones. Regarding the value of PSA screening in asymptomatic men, there is still an ongoing debate. The arguments against the routine screening of PSA levels in males include the risk of over-diagnosis and unnecessary treatment of indolent tumours, consequently leading to financial, emotional, and physical burden.8,18 However, decisions against routine testing were largely based on criticised clinical trial data with insufficient follow-up time.8,14,19 Arguments in favour of routine PSA measurements include the risk of delaying diagnosis and consequently diagnosing more advanced disease, thereby negatively affecting survival rates.20,21 Because of an increase in the number of patients presenting with distant-stage prostate cancer since 2010, recommendations regarding PSA screening have changed.22,23 The current clinical guidelines recommend shared decision-making for PSA testing in men, balancing the benefits and harms based on individual characteristics (i.e. age, family history for prostate cancer, black males) and preferences.24 More recent evidence suggests that the long-term benefit of PSA screening is underappreciated, especially when considering Figure 1 – Trends in cancer incidence rates among males in the Netherlands. Image adapted from: Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organisation (IKNL).
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