Should I Be Screened?

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.

There is no unanimous opinion in the medical community regarding the benefits of prostate cancer screening. Those who advocate regular screening believe that finding prostate cancer early offers men 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.

Those who recommend against regular screening note that because most prostate cancers grow very slowly, the side effects of diagnosis (a prostate biopsy) and treatment would likely outweigh any benefit that might be derived from detecting the cancer at a stage when it is unlikely to cause problems.

Recent studies of screening in large U.S. and European populations have suggested that the benefits of screening may not occur for 10 or more years after screening, given the long natural history of prostate cancer. These studies also suggest that a large number of men will need to be screened (over 1,000) and treated (nearly 50) to save one life from prostate cancer. PSA screening increased the number of prostate cancer cases diagnoses each year in the USA, and most of these new cases are 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.

In 2012, the U.S. Preventative Task Force recommended against the use of PSA screening for healthy men of all ages, stating that the harms of screening outweigh the benefits. In contrast, physician-led groups, such as the American Society of Clinical Oncology and the American Urological Association, maintain that PSA screening should be considered in the context of a man’s life expectancy and other medical conditions. Most experts agree that there is no role for PSA screening for men expected to live less than 10 years. Ultimately, decisions about screening should be individualized based on a man’s level of risk, overall health, and life expectancy, as well as his desire for eventual treatment if he is diagnosed with prostate cancer.

It should be noted that these recommendations apply to screening only, i.e. testing of healthy men without symptoms. Once the diagnosis of prostate cancer is confirmed by biopsy, PSA is still routinely recommended and used for risk-assessment and post-treatment monitoring.

When to Start—and Stop—Screening

When to start screening is generally based on individual risk, with age 40 being a reasonable time to start screening for those at highest risk (genetic predispositions or strong family histories of prostate cancer at a young age).

For otherwise healthy men at high risk (positive family history or African American men), starting at age 40-45 is reasonable.

Guidelines differ for men at average risk. Some recommend an initial PSA and DRE at age 40, and others recommend starting at age 50. In general, all men should create a proactive prostate health plan that is right for them based on their lifestyle and family history.

When to stop screening is also controversial. Some groups propose 75 as a reasonable cut-off age. Other groups suggest this is an individual decision based on life expectancy and overall current health.

You can find a useful resource for making these decisions at the U.S. Centers for Disease Control and Prevention site.

You can read more about these recommendations here: www.pcf.org/uspstf

Screening and Biopsy

PSA screening may reveal results that prompt a doctor to recommend a biopsy. However, the result may create more confusion as the PSA is mildly elevated. Fortunately, there are many other supplementary tests and considerations that can help a man who is undergoing screening decide if a biopsy is necessary, including:

  • The percent free PSA test (Less than 25% increases risk of having cancer)
  • PSA velocity or the rate of rise over time (faster increases risk of having cancer)
  • PSA density = PSA per volume of prostate (higher density increases risk of having cancer)
  • Digital rectal exam results
  • Different forms of PSA (e.g. pro-PSA)
  • Measuring other urine (MiPS) and blood tests (4K panel)

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, as well as investigations into using imaging, such as MRI, to help screen and target the biopsy for prostate cancer. Regardless, the PSA test remains an important tool in the diagnostic process.

PSA is not PSA!
It should be noted that these recommendations apply to screening only, i.e. testing of healthy men without symptoms. Once the diagnosis of prostate cancer is confirmed by biopsy, PSA is still routinely recommended and used for risk-assessment and post-treatment monitoring.

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