You may have heard some conflicting information about prostate cancer screening. What kind of test is it? Do I really need it? Surprisingly, there is some debate about whether the PSA test for routine annual prostate cancer screening is a good idea. This is partly because, in many cases, prostate cancer is uniquely slow-moving. It’s actually possible to live a healthy life while you have prostate cancer that is carefully monitored, but not being treated (termed Active Surveillance). But some prostate cancer cases present an immediate threat, and need to be treated.
Prostate Cancer Screening
Generally, the first step in screening for prostate cancer is a prostate specific antigen (PSA) test, in which a small amount of blood is drawn from the arm and the level of PSA, a protein made by the prostate, is measured. There is controversy about the risks and benefits of prostate cancer screening, and recommendations have changed over time. Benefits include early detection, offering a better chance to cure the disease if your cancer warrants treatment. Early detection also may allow you the choice to monitor a slow-growing cancer instead of immediate treatment. There are no inherent risks to screening, but it’s important to consider timing.
When to start screening is generally based on individual risk. In men with no unusual prostate-related symptoms:
| Discuss Screening With Your Doctor Starting at Age: | |
|---|---|
| 40 | If you have a family history of prostate, breast, ovarian, pancreas, or other cancers, are Black, or have known BRCA 1/2 mutations |
| 45 | If you have no family history of cancer and are not Black |
It should be noted that these recommendations apply to screening only—that is, testing of healthy men without symptoms. If you have any symptoms, you and your doctor will determine what the next steps should be.
Ultimately, PSA screening decisions should be made on a case-by-case basis between the doctor and patient, based on a full examination of risk factors. Increasingly, doctors are discovering that many prostate cancers are genetic, that is, inherited through families. Read more about the genetics of prostate cancer risk.
When to Start—and Stop—Screening
The doctors and researchers who recommend screening argue that cases of prostate cancer found very early can be cured more quickly, with less chance of relapse or spread. Those who recommend against routine screening point to the slow-moving nature of prostate cancer and the side effects of surgical and medical treatment, which can be considerable.
The introduction of PSA screening in the US led to an initial increase in the number of prostate cancer cases diagnosed each year, even though many of these new cases were non-aggressive or low-risk prostate cancer. The issue was not that screening was harmful, it was that many of these low-risk cancers did not necessarily need immediate treatment. It seems strange to say that a patient might be better off leaving cancer untreated, but in some cases, it can be true. For a few years, the United States Preventative Services Task Force (USPSTF) recommended against PSA screening. We are now seeing more cases of advanced prostate cancer diagnosed in recent years. This may be a long-tail effect of that USPSTF recommendation. It has now been changed to note that for men aged 55 to 69 years, the decision to undergo PSA screening is an individual one and should be discussed with your doctor. USPSTF continues to recommend against screening for men aged 70 and over.
Obviously, the question of screening is a personal and complex one. It’s important for each man to talk with his doctor about whether prostate cancer screening is right for him. The discussion will include a man’s level of risk, his overall health, his life expectancy, and his desire for eventual treatment if he is diagnosed with prostate cancer.
Screening and Biopsy
PSA screening may reveal results—e.g., a high PSA—that prompt a doctor to recommend a biopsy. However, if the PSA is only mildly elevated, the next steps may not be clear. Fortunately, there are many other supplementary tests and considerations that can help you and your doctor decide if a biopsy is necessary, including:
- Digital rectal exam results
- Free PSA test (<10% Free PSA indicates greater risk of having cancer; <25% is concerning)
- PSA velocity or the rate of rise over time (faster increase means more risk)
- PSA density, or the PSA per volume of prostate (higher density means more risk)
- PSA-based markers (e.g., the Prostate Health Index or 4K score)
- Other markers, a urinary PCA3 or SelectMDx test
- Magnetic resonance imaging (MRI) of the prostate
It should be noted that these recommendations apply only to screening: testing of healthy men without symptoms. Once the diagnosis of prostate cancer is confirmed by biopsy, PSA is still used for monitoring the status of the cancer, and the interpretation of results depends on how the cancer is managed. Discuss these individual tests with your doctor to make decisions that are best for you.
Studies to inform the best use of cancer-specific blood-and urine-based tests are ongoing, and investigations continue into using imaging, such as MRI, to help assess and target the biopsy for prostate cancer. PCF is an active contributor in sponsoring these research studies. Donate to lend your support! Regardless, the PSA test remains an important tool in the screening process.