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 and treating prostate cancer early offers men a better chance to cure the disease.
Those who recommend against regular screening note that because most prostate cancers grow very slowly, the side effects of 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 many men will need to be screened (over 1,000) and treated (nearly 50) to save one life from prostate cancer.
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.
The American Urological Association (AUA) changed and updated its screening recommendations on May 3, 2013. Better cancer specific blood and urine based tests are on the horizon. The PSA test remains an important tool in the diagnostic process. Men over 40 should discuss PSA screening with their physicians to determine if and when PSA screening is right for them, based on health and family history factors, they differ from those of the U.S. Preventive Services Task Force (USPSTF).
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.
Screening and Biopsy
A prostate cancer screening may reveal results that prompt a doctor to recommend a biopsy. There are many other supplementary tests and considerations that can help a man who is undergoing screening decide if a biopsy is necessary, including:
- Lower vs. higher free PSA test
- PSA velocity (rate of rise over time)
- PSA density (PSA per volume of prostate)
- Family history
- Prior biopsy findings
- Digital rectal exam results
- Different forms of PSA (i.e. bPSA, pro-PSA)
In general, a lower free PSA (percentage) indicates a higher risk of finding cancer at biopsy, as does a higher PSA velocity and PSA density.
Discuss these individual tests with your doctor to make screening decisions that are best for you.