Prostate cancer screening: pros and cons

Created date

September 13th, 2018
A blue ribbon represents prostate cancer

Did you know? 

Most men diagnosed with prostate cancer do not die from it. About 98.2% are still alive after five years.

With many cancers, regular screening, detection, and prompt treatment can extend your life. For some men, especially older men, this may not be necessarily the rule for prostate cancer, the most common cancer in men. That’s because prostate cancer is so slow-growing, you may be more likely to die from something else before the cancer would become a problem.

PSA: the major screening advancement

Along with a thorough history, doctors can measure your prostate-specific antigen (PSA) to determine if cancer could be present. PSA is a protein produced by cells of the prostate gland. “When the PSA test first became available for prostate cancer screening, it was a great tool for detecting the disease,” says Brian J. Miles, a urologist and prostate cancer specialist at Houston Methodist Hospital in Houston, Tex.

As a result of the PSA, more prostate cancer was being found, but treating it may not have been in the best interest of every patient. “At first we were finding disease that didn’t necessarily warrant further diagnostic evaluation or treatment, but standard of care at the time was to treat most of the cases,” Miles says. “Then as the years went by, more research was conducted and we learned much more about this disease.”

Research-based recommendations

In 2012, the U.S. Preventive Services Task Force (USPSTF), an independent volunteer group of national experts in prevention and evidence-based medicine, reviewed the available scientific evidence on PSA screening and made a recommendation. “The task force gave PSA screening a ‘D’ recommendation for most men,” Miles says.

A “D” rating meant that the USPSTF discouraged the use of PSA, because they believed there was sufficient evidence that the harms of screening and early treatment outweighed the benefits for a statistically significant number of men. Specifically, they cited studies showing that these measures prevented 0 to 1 prostate cancer deaths per 1,000 men screened.

This recommendation did not apply to men with a high risk of disease. “African-Americans and people with a family history of prostate cancer are at a high risk,” Miles says.

The task force contended that up to 80% of PSAs produced a false positive, which could cause psychological distress and lead to further diagnostic testing, mainly a biopsy. A biopsy is a surgical procedure that can have complications (although rare) such as bleeding and infection.

Controversial decision

Not everyone thought the USPSTF’s decision was best for patients. “At the time of that recommendation, there were no urologists or oncologists on the panel,” Miles says. “Specialists disagreed with the task force. We believe that PSA can be a valuable tool in a complete examination for certain patients who are at high risk, even if they are over 70 years old.”

Results of the recommendation

Many primary care physicians who used to order PSAs as part of physical exams for men stopped doing so. After several years, Miles and his colleagues were not surprised by the effects. “We began to notice more patients coming in to our offices with advanced prostate cancer,” he says.

In 2018, the task force revised their statement somewhat, by changing from a D-grade recommendation to a C, which means that PSA should be used for selected patients ages 55 to 69 depending on their individual health and circumstances. But the task force has remained steadfast on a ‘D’ grade for men 70 years of age and up.

Observe and monitor

In part because of the original 2012 USPSTF statement, watchful waiting, sometimes called active surveillance, protocols were developed for patients who were at low risk for complications or death from prostate cancer. Active surveillance involves seeing your doctor every six months for an examination, PSA, or biopsy if indicated. “We can also order genomic tests to determine what kind of cancer you have,” Miles adds. “MRI exams are being used more often as well.”

According to the American Cancer Society, the terms active surveillance and watchful waiting are actually different levels of monitoring, depending on the doctor and patient’s definitions and decisions. Watchful waiting might involve fewer tests and monitoring for any signs of the disease before further diagnostic measures are taken.

Understanding what you should do

“Whether or not to have a PSA blood test should be based upon a careful discussion with your medical provider and then ultimately your own understanding of the risks and benefits of testing,” says Matt Narrett, M.D., chief medical officer of Erickson Living. “You want to be confident that undergoing testing and procedures will benefit you in the long run.”

“At Erickson Health Medical Group, we utilize ‘shared decision making’ in working with our residents,” says John Marcelis, M.D., regional medical director at Erickson Living. “This includes a discussion and understanding on the risk and benefits of PSA testing and a determination based on evidenced-based geriatric principles and the resident’s preferences.”