Part I of a two-part series about prostate cancer diagnosis and treatment.
To be screened or not to be screened–that is the question men older than age 40 or 50, depending on risk factors, must decide with regard to a PSA test for prostate cancer. Men’s Health Network recommends that all men age 50 and older have a PSA test every year and that men with known risk factors be screened beginning at age 40. Known risk factors include African-American race and men with a family history of prostate cancer.
Men at higher risk and should begin screening at a younger age. But whether asymptomatic men should undergo regular PSA screening has been controversial almost since the FDA approved the test for prostate cancer detection in 1994.
Prostate cancer is the most common cancer among men in the United States, aside from non-melanoma skin cancers, and it is also the second leading cause of cancer death among men of all races. The American Cancer Society estimates more than 248,000 men will be diagnosed with prostate cancer in 2021, and more than 34,000 will die from it.
Why not just be tested and know definitively whether cancer is present so that it can be treated? It’s complicated. The prostate gland is a small male reproductive gland surrounding the urethra just below the bladder. It makes about one-third of the fluid that is part of semen. Both cancerous and non-cancerous prostate tissues produce a protein called prostate-specific antigen (PSA). A PSA test measures the amount of the protein in the blood. PSA levels of less than 4 nanograms per milliliter are usually considered normal, but levels above 4 may indicate the presence of cancer.
Also, a rapid unexplained increase in PSA, even within the normal range, may be a cause for concern. Doctors can also test for prostate cancer by feeling for abnormalities by way of a digital rectal exam (DRE). But, according to a 2005 study published by the National Institutes of Health, DREs are cannot detect all cancer. Only the back of the prostate can be felt, and not all tumors occur there. An MRI scan, a non-invasive radiologic exam, or a prostate biopsy must be performed to definitively diagnose the condition and determine how much it has progressed.
Most prostate cancers, though not all, are slow growing and may never cause a problem. Aggressive, high-risk forms of prostate cancer make up only about five percent of cases. Elevated PSA levels do not always mean cancer.
Other conditions, such as an enlarged prostate or prostate infection, can also elevate PSA levels. PSA tests can sometimes result in false positives and lead to unwarranted biopsies. In addition, treatment for prostate cancer if unnecessary, sometimes result in impotence, incontinence and/or bowel problems.
In June 2012, Patient-Centered Outcomes Research Institute (PCORI) funded a study to test a way to involve patients, along with other health care experts, in developing guidelines for cancer screening. One of the two groups the researchers created established guidelines for prostate cancer screening.
In a journal article resulting from the study, it was noted that all the patient participants felt strongly that “since the science is ambiguous and contradictory at best, the decision should be left to a patient and his doctor….” In 2013, the American Urological Association (AUA) commissioned an independent panel to review the published research on prostate cancer screening and develop a set of guidelines. The AUA reviewed and confirmed the resulting guidelines in 2018.
The guidelines do not recommend routine prostate cancer screening for men younger than 40. They recommend that decisions about screening should be individualized for men ages 40 to 54 that may be at higher risk, including African American men and those with family histories of prostate cancer.
For men ages 55 to 69 years, the AUA guidelines state the following: “the decision to undergo PSA screening involves weighing the benefits of reducing the rate of metastatic prostate cancer and prevention of prostate cancer death against the known potential harms associated with screening and treatment.
For this reason, the Panel strongly recommends shared (patient and doctor) decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.” Only about 10 percent of prostate cancers are diagnosed in men younger than 56 and there is evidence that some of these early onset cases can be more aggressive. The AUA does not recommend PSA screening for men 70 and older, but does state that some men over 70 in excellent health and likely to live longer may benefit from being tested.
As the AUA states, early detection allows for more conservative treatment, such as active surveillance, which does not cause complications. It also saves lives. If the cancer is detected before it spreads beyond the prostate or the immediate area, the prostate cancer survival rate is almost 100 percent.
That’s why Men’s Health Network recommends that all men make the decision to have PSA tests beginning at age 50 and that African American men and men with a family history of prostate cancer consider having the tests beginning at age 40.
MHN’s screening recommendations for men can be found at www.GetItChecked.com.