Surprisingly, there is a lot of debate about whether ordering the PSA test for routine annual prostate cancer screening is a good idea. This is partly because of the uniquely slow-moving nature of most cases of prostate cancer. It’s actually possible to live out a healthy life while you have prostate cancer that is not being treated (termed Active Surveillance)—particularly for an older man. But some prostate cancer cases present an immediate threat, and need to be treated.
Prostate Cancer Screening
There is controversy about the risks and benefits of prostate cancer screening. Benefits include early detection, offering a better chance to cure the disease if your cancer warrants treatment. It also may inform you that you don’t need your prostate cancer treated at all.
When to start screening is generally based on individual risk. In men with no unusual prostate-related symptoms:
|Begin Screening at Age:|
|40||If you have a family history|
|45||If you are African American|
|50||If you have no family history and are not African American|
|55-69||Discuss with your doctor|
|Over 70||Screening is not recommended|
This chart takes into account US Preventative Services Task Force (USPSTF) update screening recommendations issued issued in 2017. You can read more about these recommendations here: www.pcf.org/uspstf.
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 diagnoses each year in the USA, but many of these new cases were non-aggressive or low-risk prostate cancer. Very few men will die of these less-aggressive forms of prostate cancer in the first decade after diagnosis. It seems very strange to say that a patient might be better off leaving cancer untreated, but in some cases, it can be true.
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 that prompt a doctor to recommend a biopsy. However, the result may create more confusion. 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:
- Free PSA test (<25% Free PSA indicates greater risk of having cancer)
- 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)
- Digital rectal exam results
- PSA-based markers (for instance the prostate health index, 4K score)
- Other markers, a urinary PCA3 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 screening decisions that are best for you.
Better cancer-specific blood- and urine-based tests are on the horizon, and investigations continue into using imaging, such as MRI, to help screen 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 diagnostic process.