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 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 when deciding whether to undergo screening 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 be tested, 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
Recommendations: Ages 50 to 75 | Over age 75
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 the organizational guidelines you and your health care provider follow. It is important to consider your own tolerances for risk and uncertainty and 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, 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. The organization recommends that men 50 years of age and older, with average risk and a life expectancy of at least 10 years be offered both a PSA test and DRE each year. The ACS recommends earlier testing for higher-risk groups. If you are in one of these groups, you may want to consider ongoing testing or starting it now.
- If you are African American or have a father or brother who was diagnosed before they were 65, you should begin testing now if you didn't start at the recommended age of 45.
- If more than one relative had prostate cancer at an early age, the ACS recommends testing begin at 40; then, depending on the results, retest 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, and advises testing for those 40 and older who are at increased or high risk. If you don't have a baseline PSA, you may consider testing now. The AUA 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 you age.
- 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. If you haven't yet had a baseline test, you may consider getting tested now. The NCCN advises using the DRE and the PSA test, in combination, for the broadest detection of cancer in its early stages. 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.
Recommendations: Over age 75 | Ages 50 to 75
- The USPSTF recommends that men older than 75 not be screened for prostate cancer. It found that potential harms from prostate screening outweigh the benefits for men at an age where prostate cancer is not likely to cause death.
- The American Cancer Society and the American Urological Association emphasize that overall health, not just age, is an important consideration for older men when deciding to be tested. They recommend that men with a life expectancy less than 10 years not be tested.
- The National Comprehensive Cancer Network emphasizes that men over 75 should receive individual consideration for their overall health, previous PSA results, family history and risk factors before deciding to screen for prostate cancer, and how frequently.
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
(2011 October 11) United States Preventive Services Task Force. Screening for Prostate Cancer Draft Recommendations Statement. Available online at http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm through http://www.uspreventiveservicestaskforce.org/. Accessed January 2012.
(2010 December 1) American Cancer Society. Prostate Cancer: Early Detection. Available online through http://www.cancer.org. Accessed January 2012.
(2012 February 27) American Cancer Society. American Cancer Society recommendations for prostate cancer early detection. Available online at http://www.cancer.org/Cancer/ProstateCancer/MoreInformation/ProstateCancerEarlyDetection/prostate-cancer-early-detection-acs-recommendations through http://www.cancer.org. Accessed June 2012.
(2011 October 7) National Cancer Institute, National Institutes of Health. Prostate cancer (PDQ®): screening (summary of evidence). Available online at http://www.cancer.gov/cancertopics/pdq/screening/prostate/HealthProfessional/page2 through http://www.cancer.org. Accessed January 2012.
(Updated 2011 June 1) The National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prostate Cancer Early Detection. PDF available for download at http://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf through http://www.nccn.org. Accessed January 2012.
(2009 April) American Urological Association Foundation. Patient Series Guide: What You Should Know About Prostate Cancer Screening. Available online at http://www.auanet.org/resources.cfm?ID=517 through http://www.auanet.org. Accessed January 2012.
(2009 March 18) National Cancer Institute. Factsheet: Prostate-specific antigen test. Available online at http://www.cancer.gov/cancertopics/factsheet/detection/PSA through http://www.cancer.gov. Accessed January 2012.
(2012 January 9) National Comprehensive Cancer Network. PSA screening doesn't prevent cancer deaths: study (Reuters Health). Available online at http://www.nccn.com/news/1557-psa-screening-doesn%27t-prevent-cancer-deaths--study.html through http://www.nccn.com. Accessed January 2012.
American Cancer Society. Prostate Cancer Early Detection: Update 2010. PDF available for download at http://www.cancer.org/acs/groups/content/documents/document/acspc-026003.pdf through http://www.cancer.org. Accessed January 2012.
(2009 March 10). National Cancer Institute. Dr. Len’s Cancer Blog. The Overdiagnosis of Prostate Cancer: Is it news? Available online at http://www.cancer.org/AboutUs/DrLensBlog/post/2009/03/10/The-Overdiagnosis-of-Prostate-Cancer-Is-It-News.aspx through http://www.cancer.org. Accessed January 2012.
(2009 October) American Urological Association. Prostate Specific Antigen Best Practices Statement: 2009 Update. PDF available for download at http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf through http://www.auanet.org. Accessed January 2012.
American Urological Association Education and Research, Inc. American Urological Association Best Practices Statement: 2009 update. Available on at http://www.auanet.org/resources.cfm?ID=515 through http://www.auanet.org. Accessed January 2012.