Prostate cancer is the most frequently diagnosed cancer in men and the second leading cause of cancer death, after lung cancer. As many as 1 in 6 American men will develop it during their lifetime, with most cases diagnosed in men 65 years of age or older. Some prostate cancers progress quickly and cause death within months or a few years, but most grow slowly and never pose a threat. Screening tests for prostate cancer are important for men to discuss with their health care providers, especially because expert panels have reached different conclusions about prostate screening.
Since the introduction of blood tests for prostate-specific antigen (PSA), more prostate cancers are being caught before they spread to other organs and become difficult to cure. However, PSA tests have not been linked to declining prostate cancer deaths in a cause-and-effect relationship. Deciding if and when to be screened for prostate cancer is especially challenging because of conflicting expert opinion. Research on how PSA testing improves prostate cancer survival rates has been inconclusive.
Many complicated issues are involved:
- Current technology cannot tell a slow-growing cancer from a fast one, and the cancer may never affect a man's health or life expectancy.
- PSA tests do not detect all cases, and many positive results do not prove to be cancer. According to the American Cancer Society, of 100 men with a PSA level greater than what is considered normal (4.0 ng/mL), a biopsy will find prostate cancer in 30 of them.
- Side effects of treatment (impotence and incontinence) and diagnosis through biopsy (infection and bleeding) can be more harmful than the cancer itself. Most prostate cancers are slow-growing and may not cause any trouble.
- Results from long-term trials have not resolved ambiguity about whether screening is useful in improving prostate cancer survival rates.
In spite of the controversy surrounding prostate cancer screening, many scientific and medical organizations recommend prostate cancer screening in average-risk men. This includes men with no known risk factors who are 40 or older and have a life expectancy greater than 10 years. Experts agree that older and middle-aged men should receive balanced information about prostate cancer screening. You need to know the risks, uncertainties, benefits and limits of prostate cancer testing and treatment and should work with your health care provider to understand your options and decide what is best for you.
One important factor to consider is your personal risk of developing prostate cancer:
- Average risk: Healthy men with no known risk factors
- Increased risk: African American men or men who have a father or brother who was diagnosed before they were 65
- High risk: Men with more than one relative who was affected at an early age
If you choose to undergo screening, one or both of the following tests may be recommended:
- Prostate specific antigen (PSA)—this is a blood test that measures the level of PSA in the blood.
- Digital rectal exam (DRE)—part of a physical exam the doctor performs to examine the prostate gland
Medical organizations have different recommendations for prostate screening. The earliest age at which you should be offered screening and how often you should be tested varies depends on which organization's guidelines you and your health care provider follow. It is important to consider your own tolerances for risk and uncertainty and to consult with your doctor about which recommendations are best for you, and how you will use the test results.
- The U.S. Preventive Services Task Force (USPSTF) advises against PSA screening in healthy men of any age, concluding that screening does not improve survival rates for prostate cancer for healthy men. The decision is based on the harm that can come from diagnoses that lead to false-positive test results or harm from the treatment of cases that are slow-growing and non-lethal. However, the USPSTF recommendation is at odds with many other major health organizations. Such inconsistencies make it important for men to consider their age, overall health, individual prostate cancer risks, and what they would do if they received a positive prostate screening result.
The American Cancer Society, the American Urological Association and the National Comprehensive Cancer Network do recommend that healthy men be offered prostate screening so that they can decide what is right for them. Recommendations for how often you choose to be screened also vary among organizations, depending on your risk factors and the results of your initial screening:
- The American Cancer Society (ACS) emphasizes that men should not be screened until they have been informed about the uncertainties, risks and benefits of prostate screening. For healthy men with average risk, the organization recommends that you consider waiting to get tested until age 50. The ACS recommends considering earlier testing for higher-risk groups.
- If you are African American or have a father or brother who was diagnosed before they were 65, the ACS recommends considering starting testing at 45 years of age.
- If more than one relative was affected at an early age, you could begin testing at 40 years; then, depending on the results, get tested again at age 45 or earlier as results warrant.
The ACS recommends rescreening every two years if your PSA level is less than 2.5 ng/mL and annual screening if it is 2.5 ng/mL or higher.
- The American Urological Association recommends a baseline PSA and DRE at age 40, for men who wish to be screened. For those at increased or high risk, the group advises testing at 40. It recommends regular PSA and DRE testing regardless of whether your PSA was high or low or if the DRE was abnormal. It emphasizes having baseline PSA values to monitor as a man ages.
- The National Comprehensive Cancer Network recommends a baseline test at age 40 for men who want screening, which will determine when and how often to have future tests. It advises using the DRE and the PSA test, in combination, for the broadest detection of cancer in its early stages. If the initial PSA test result is 1.0 ng/mL, they recommend repeating screening at 45. If the result is greater than 1.0 ng/mL, or the man is higher risk, it recommends an annual DRE and PSA test.
Before choosing prostate screening, it is important that you have a discussion with your health care provider that will help you weigh the pros and cons based on your age, life expectancy, family history, race, overall health, previous test results, and individual risk tolerance.
National Cancer Institute: Prostate Specific Antigen Test Fact Sheet
National Cancer Institute: Screening and Testing to Detect Prostate Cancer
American Cancer Society: Prostate Cancer
National Comprehensive Cancer Network
Ottawa Health Research Institute: Decision Aids
Sources Used in Current Review
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