Guidelines around prostate cancer screening can often generate more questions than answers, as there have been cultural shifts over the years around concerns of over-screening and potential negatives resulting from under-screening.
“We want screening to pick up the kind of clinically significant prostate cancers [that] patients need to know about,” said Hayley Silver, MD, urologist at Endeavor Health who acknowledged that patients often receive inconsistent messaging around screening.
The prostate-specific antigen (PSA) test measures the level of PSA (a protein produced by cells of the prostate gland) in a man’s blood. PSA level is often elevated in men with prostate cancer. However, other conditions, including non-cancerous prostate enlargement, inflammation, infection, etc., can cause a higher PSA. The results of an initial PSA test can guide future recommendations.
When should men begin screening?
Screening with a PSA blood test is generally recommended for men between the ages of 55 and 70, said Raj Bhanvadia, MD, urologist at Endeavor Health. For average risk patients, screening is recommended every 1-2 years.
For patients who have a family history of the disease (one or more first degree relatives with prostate cancer) or inherited mutations of BRCA1 or BRCA2 genes, PSA screening should begin at an earlier age. African American men also face a higher risk for prostate cancer and should consider earlier screening as well.
For patients with higher-than-average PSA scores for their age, additional screening methods, including prostate MRI and other biomarker tests, can be used to further stratify overall risk.
What are the benefits of screening?
Since prostate cancer often has no symptoms in its early stages, screening can help detect the disease before it spreads, when it's more likely to be treated successfully.
“Screening gives men the opportunity to be in the driver’s seat for their health and make better decisions about further testing and treatment, choosing an approach that best fits their values,” said Dr. Bhanvadia.
Screening for many men in their 50s also opens the door to address other urologic concerns that may or may not relate to a cancer risk but can have major impact on quality of life, said Dr. Silver.
“Eighty percent of men will deal with some kind of uro/bladder issue in their life and in the long-term, the sooner you identify the problem, the better the options are for resolving it and improving overall health,” said Dr. Silver.
Whether it’s urination or sexual function problems, many men are uncomfortable talking to their doctor about it. However, bladder health and sexual function issues can be a manifestation of other diseases including diabetes, neurological and heart conditions.
“It’s never too soon to talk about these issues with a urologist and I hope we can move toward removing the stigma in talking about these concerns. I meet patients on a weekly basis who say they wish they had been referred sooner,” said Dr. Silver.
What happens after screening?
Initial screenings can help physicians determine overall risk for prostate cancer by comparing a patient’s PSA level to the average score for their age. The goal is not to find low-risk, slow growing cancers.
The results of the initial PSA test can guide future recommendations. For example, a PSA score can be low enough that the next screening is not recommended for another 2-4 years. The PSA test may also be used in conjunction with other diagnostic tools to accurately diagnose and manage prostate conditions.
“It’s amazing how much the culture and practice of screening has changed in the last 10 years. I try to provide as much information from a global perspective to help patients through a shared decision- making process around screening,” said Dr. Silver. An individual’s risk tolerance also plays into the conversation, she added.
What is active surveillance?
Even when prostate cancer is present, treatment may not always be necessary. Historically, early detection efforts led to over-diagnosis and potential negative impacts on quality of life with treatment that may not have been warranted for slow-growing cancers.
The acceptance of active surveillance as a viable option to immediate treatment has made the screening decision an easier one for many men.
Active surveillance includes regular PSA testing and periodic prostate biopsies, and provides an active way to monitor cancer for appropriate patients. Your doctor may order tests to make sure the cancer does not grow or become more aggressive.
“Some men with slow-growing cancers may be better off with active surveillance, which involves monitoring the cancer closely without immediate treatment,” said Dr. Bhanvadia. “The goal of active surveillance is to be able to maintain your current sexual and urinary quality of life without compromising cancer control. A urologist can provide personalized recommendations based on an individual’s risk factors and preferences,” he added.
If the situation changes, some men may decide to start treatment. Fortunately, there are many new and innovative medications and treatments for prostate cancer — including metastatic disease — that help to significantly improve quality of life.
“Our toolkit for fighting prostate cancer is getting better and better, but the best treatments come when we catch it early — which starts with screening,” said Dr. Bhanvadia.
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