Most American patients who have prostate cancer are diagnosed before they experience a single symptom. That might come as a surprise if you’ve ever googled “prostate cancer” though.
Many sites, including some from high-profile medical groups, state prostate cancer is associated with lower-urinary tract symptoms, or LUTS, which include signs such as a frequent need to urinate. In reality, these symptoms only occur in a small percentage of prostate cancer patients, usually those with advanced disease.
By emphasizing the need to watch out for symptoms, public health messaging risks patients skipping regular screenings in the absence of clear signs.
One in eight men in the United States will be diagnosed with prostate cancer in their lifetime, according to the American Cancer Society. Most patients will be able to live with the condition, and won’t die from it, but prostate cancer is still the second leading cause of cancer death among American men. Regular screenings, which involve testing for levels of a prostate-specific antigen and followed, if needed, by an MRI and biopsy to confirm diagnosis, is critical for early detection and careful monitoring.
Before I was diagnosed with prostate cancer in 2010, I was unaware of its “silent killer” reputation. I never experienced LUTS. I dodged a bullet when screening revealed I have a low-risk case and needed to start on close monitoring, known as active surveillance. But if I had waited to watch out for symptoms before getting screened, I wouldn’t have known to keep an eye on my condition and — had I had a more serious case — might have ended up in big trouble.
Indeed, a recent article published in BMC Medicine points out that national guidelines and public health campaigns continue to promote the misperception that urinary symptoms are a major indicator of prostate cancer — despite the lack of consistent evidence to confirm this. The authors, including Vincent J. Gnanapragasam, a professor of urology at the University of Cambridge, argue that not only is this unhelpful, but it may even deter men from coming forward for early testing and detection of a potentially treatable cancer.
So why does the LUTS myth persist?
I think it is an accident of geography — the prostate is situated right next to the urinary system — as well as an ill-considered compulsion to list symptoms for a condition, even when no symptoms are likely to occur. It’s hard for patients to accept that this disease can be an asymptomatic silent killer and that patients may have no warning that a cancer is brewing in the gland.
Dr. Kevin Ginsburg, a urologic oncologist at Wayne State University in Detroit, told me he often has to explain this to his patients: “Prostate cancer and lower urinary tract symptoms are very different and only united by the fact that they both involve the prostate.”
If I had waited to watch out for symptoms before getting screened, I wouldn’t have known to keep an eye on my condition.
Some organizations are on target with their messaging and do emphasize the lack of early warning signs. The Prostate Cancer Foundation, for example, notes that “The growing tumor does not push against anything to cause pain, so for many years, the disease may be silent. That’s why screening for prostate cancer is such an important topic for all men and their families.”
However, that messaging is muddled by other health organizations and websites that get the story about symptoms wrong in a few ways.
Some mention prostate cancer’s silent risks, but then rush into listing LUTS without making it clear that these symptoms rarely occur in patients with advanced tumors. For example, the Centers for Disease Control and Prevention notes that “different people have different symptoms for prostate cancer” and that “some men” have no symptoms at all. Gnanapragasam, the lead author of the BMC Medicine article, told me the statement is not borne out by the evidence.
The situation is similar at Cancer.net, the patient information website for the American Society of Clinical Oncology, which correctly states that “most prostate cancer does not cause any symptoms at all” but then proceeds to lay out LUTS without advising men to discuss screening with their doctors by age 55, as recommended by the U.S. Preventive Services Task Force, regardless of whether or not those symptoms appear. (The American Cancer Society recommends starting those discussions even earlier: At age 50 for men who are at average risk, and age 45 for groups who are at high risk, such as Black men or those with a family history of prostate cancer.)
When I emailed the CDC to ask about its oversight, their spokesperson said that the agency would “continue to review the evidence” on symptoms and “will work to clarify the point that prostate cancer may be present but asymptomatic, which is why it is important for many men to discuss with their providers about screening for prostate cancer.”
Meanwhile, a Cancer.net spokesperson said it “reviews all content on its website with its editorial board of physicians, making updates and revisions as new evidence and guidelines are published.”
I think reviews are in order. I suspect these sites, on which patients depend, add symptoms in an effort to be helpful. But in doing so, they perpetuate the false notion that urinary symptoms are common in all patients with prostate cancer.
Worse still, other websites may mislead patients or simply misstate facts.
From what I’ve seen, there is no study showing a direct causative link between urinary symptoms and prostate cancer. The fact that these symptoms show up in a small percentage of prostate cancer patients may simply be a question of correlation rather than causation. Simply put: As men age, many develop an enlarged prostate and many develop prostate cancer. That doesn’t mean symptoms of an enlarged prostate indicate prostate cancer. In fact, 2021 literature review suggested the opposite; it found an inverse correlation between prostate size and prostate cancer.
But the National Cancer Institute, for example, states that the symptoms of an enlarged prostate “may be like symptoms of prostate cancer.” This can mislead patients to think that both conditions cause overlapping symptoms when it’s not clear if that’s actually the case.
City of Hope, a National Institutes of Health-designated cancer treatment center, makes similar misstatements on its website: “Because the prostate lies below the bladder and surrounds the urethra, most prostate cancer signs are tied to urinary symptoms.” According to Gnanapragasam, that statement is inaccurate.
Cancer Treatment Centers of America, a Florida-based network of oncology hospitals and outpatient centers owned by City of Hope, similarly says that LUTS are common in early-stage disease “because of the proximity of the prostate gland to the bladder and urethra, prostate cancer may be accompanied by a variety of urinary symptoms.” Again – there doesn’t seem to be causative evidence to back this up.
Patients should be screened well before any symptoms are detected. Health organizations, no matter how well-intentioned, shouldn’t contribute to misleading messaging that could lead men to avoid routine screening until their cancers have advanced or possibly even spread.
People need to understand that prostate cancer is a silent disease, especially in the early, curable stages. Lessening confusion around prostate cancer symptoms — and the lack thereof — could save lives.
Howard Wolinsky is a medical journalist. He covers prostate cancer on his blog “The Active Surveillor,” and as a contributor for “MedPage Today.”
Thank you for this useful clarification.
Unfortunately, the combination of ambiguous diagnostics and lucrative treatment options continue to drive the prostate business, the side effects experienced by individual patients be damned.
We need to evolve new protocols for screening using the right biomarkers and diagnostics. Maybe this will reduce overtreatment and morbidity.