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Prostate cancer screening helps to detect the presence of this disease when signs and symptoms aren’t present. The early stages of prostate cancer are often symptomless. Many individuals in the early stages of prostate cancer don’t have noticeable indications that a problem is present.
Symptoms such as urinary problems or blood in urine or semen tend to arise as prostate cancer advances, the American Cancer Society explains.
The United States Preventative Services Task Force (USPSTF) sets recommendations for clinical preventative services. That includes the USPSTF prostate cancer screening guidelines.
Currently, the USPSTF recommends that men aged 55-69 make an individual decision about undergoing periodic prostate-specific antigen (PSA) testing to screen for prostate cancer. The task force also recommends against PSA-based screening for men aged 70 and older.
We have a more nuanced view than these current recommendations. We will explain why in this article.
First, we will take a closer look at the current recommendations.
Understanding Prostate Cancer Screening: The USPSTF, its Guidelines & Traditional Screening Procedures
The USPSTF is a part of the US Department of Health and Human Services. This federal department selects a volunteer panel of healthcare professionals who have experience related to methodology in population health and related fields.
The task force’s main goal is to develop population-level recommendations for preventative health services. That includes, among many other types of preventative services, recommendations related to prostate cancer screening.
PSA Screening Guidelines from USPSTF: Men Aged 55-69
The current recommendations (as of 2018) for prostate cancer screening are separated by age group. For men age 55-69, the USPSTF guidelines for prostate cancer screening are as follows:
“For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms based on family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.”
The overarching guidance is that a man aged 55-69 should consult with his physician about the benefits and drawbacks of prostate cancer screening. Then, he should decide whether to engage in periodic screening after weighing the potential benefits and drawbacks.
PSA Screening Guidelines from USPSTF: Men Aged 70 and Older
For men aged 70 and older, the USPSTF prostate cancer screening recommendation is more succinct:
“The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.”
The task force believes the potential harms of screening and treatment stemming from it outweigh the potential benefits.
This is in part due to the slow progression of some low risk prostate cancers. The potential complications of treatment, such as urinary incontinence, are also considered in this recommendation. The possibility that an older man could pass away due to other health issues unrelated to prostate cancer is another factor in the recommendation.
Traditional Screening for Prostate Cancer
Generally, screening for prostate cancer starts with two tests, as the Centers for Disease Control and Prevention (CDC) explains.
PSA testing measures the level of a specific protein in the blood. This protein, PSA, is secreted by the prostate gland and prostate cancer cells. Measuring PSA levels can help to identify the potential presence of prostate cancer.
However, there are many potential causes of an elevated PSA level. Additionally, a test result showing “normal” PSA levels doesn’t preclude the possibility of prostate cancer being present.
Yet, several tests showing rising PSA levels over time can be a useful indicator of the possibility of prostate cancer. Establishing a baseline level for an individual makes it easier to detect increases that could indicate prostate issues, such as prostate cancer.
A digital rectal exam (DRE) is a physical examination of the prostate. A physician uses their finger to check the back of the prostate for abnormalities. The finger cannot reach the front or even the middle of the prostate. This test cannot confirm the presence of prostate cancer, but can detect some potential issues related to the prostate.
The overall efficacy of a DRE has been strongly questioned. A 2018 peer-reviewed systematic review and meta-analysis of research related to the procedure, published in the Annals of Family Medicine, found a “considerable lack of evidence supporting its efficacy.”
Traditional Next Steps for Detecting Prostate Cancer
If the results of a DRE and PSA testing indicate the potential for prostate cancer, the traditional next step is a transrectal ultrasound-guided (TRUS) biopsy. This procedure uses ultrasound imaging to guide the selection of 12 scattered areas of the prostate.
However, a TRUS biopsy does not target any specific masses or abnormalities in the prostate. It is a random sample.
A peer-reviewed study published in the medical journal The Lancet established the sensitivity of TRUS biopsy for clinically significant prostate cancer at 48%. This means TRUS biopsies can be expected to detect maybe half of all clinically significant prostate cancers.
TRUS biopsies also have certain risks. These include the potential for pain, urinary retention, infection, and sepsis, among other concerns.
Why Question the USPSTF Prostate Cancer Screening Recommendations?
As specialists in diagnosing and treating prostate issues including prostate cancer, we believe that otherwise healthy men (those who aren’t expected to pass away in 10 or fewer years due to unrelated health issues) should consider using PSA testing starting at age 45, especially if they have a family history of prostate cancer.
Why do we expand the scope of screening compared to the USPSTF prostate cancer screening guidelines? There are several reasons to consider.
Population Health vs. Individual Health
The USPSTF makes population-level health recommendations, which take many factors into account. It’s true that the USPSTF PSA guidelines ultimately recommend an individual decision. However, this recommendation was still reached from a public health viewpoint.
From a cost-effectiveness perspective, which is a valid consideration in terms of public health, it may not make financial sense to screen all men beyond a certain age. Additionally, third-party carriers such as Medicare and private health insurers may not be trying to optimize the system to get the best results for every individual.
It’s crucial for individual men (and all other individuals, for that matter) to advocate for themselves and their health. Population-health recommendations can be valuable for guiding priorities, policy, and many similar considerations among large groups. However, they do not prioritize every individual’s health.
The Importance of Building an Individual Baseline in PSA Testing
As previously mentioned, PSA testing offers the most value when it can be used to establish a baseline. Routine PSA screening gives healthcare professionals several data points to work with. Relatively frequent testing, starting early, makes it easier to identify trends and abnormalities. An increasing PSA trend may be worrisome even if the PSA is “normal.”
PSA levels increase over time due to the normal growth of the prostate as men age. The baseline, age-adjusted level for a man aged 50-59 is 0-3.5 nanograms per milliliter (ng/mL). A test result significantly above this threshold is a sign that additional testing may be needed.
A single test can only provide so much context, however. With a history of past testing, physicians can identify not only a single elevated result, but change over time as well. Tests that indicate a consistently increasing PSA level over a few years are more suspicious than an elevated but stable level over a long period of time, for example.
Routine screening provides data points to physicians that make it possible to recognize potentially significant changes. That provides a patient with valuable context as well. It’s easier for him to make an informed decision about treatment with a longer-term understanding of their PSA levels.
Additional Approaches to Screening for Prostate Cancer
Traditional screening methods for prostate cancer start with a PSA test and a digital rectal exam. However, the progression of testing does not need to be limited to a PSA and DRE that suggests whether or not to then perform a TRUS biopsy.
There are new additional screening procedures that can be used between traditional first-line testing and a TRUS biopsy. These tests provide additional context to help determine if more invasive testing is appropriate. Effective alternatives to TRUS biopsies are available as well.
The USPSTF PSA screening guidelines were developed before many of these newer screening methods became available. It’s important to re-evaluate existing guidelines as effective screening and treatment options emerge.
A high-quality multiparametric MRI (mpMRI) is one example. This non-invasive imaging procedure provides physicians with valuable data that helps to identify or rule out prostate cancer. If a PSA test returns elevated results, or recent tests show significant increases over time, mpMRI delivers more context without the invasive nature or potential side effects of a TRUS biopsy.
Select mdx is another non-invasive test designed to identify mRNA biomarkers related to cancer. This urine test is performed in tandem with a DRE and produces a binary result. Physicians then use that result in the context of a patient’s individual context, like clinical risk factors, to help guide next steps.
With additional testing, more effective risk stratification is achievable. On a practical level, that means reducing unnecessary biopsies and their associated risks — a key factor in the USPSTF prostate cancer screening recommendations.
Improved risk stratification also helps to steer appropriate patients toward effective treatments, including those with lower risks of side effects as compared to traditional treatment options like surgery and radiation.
Additional Options for Treating Prostate Cancer
Identification of clinically significant prostate cancer requires treatment. The USPSTF cites the potential for overtreatment and complications from treatment as reasons for recommending an individual decision related to prostate cancer screening.
Potentially effective, less-invasive options for treating prostate cancer can reduce the risk associated with treatment complications. More aggressive options, like surgery and radiation, will still be appropriate in some cases. However, lower-risk treatment options help to further stratify risk.
Laser focal therapy (LFT), guided by MRI, is one such less-invasive option. In cases where prostate cancer is localized, of low-to-intermediate risk, and has well-defined lesions, LFT may be an effective treatment.
Transurethral ultrasound ablation (TULSA-PRO), also guided by MRI, is another less-invasive treatment option. It can cover a larger area than LFT, making TULSA-PRO a potentially effective option for patients with larger or more diffuse cancer within the prostate.
LFT and TULSA-PRO compare favorably to surgery and radiation therapy in terms of two key side effects: urinary incontinence risk and erectile dysfunction risk. Learn about the specific rates of incidence and review the studies that provide these statistics in our prostate cancer treatment comparison.
Effective Alternatives to the Traditional TRUS Biopsy
If a biopsy is determined to be necessary, a patient is not limited to only a TRUS biopsy. Instead, he can opt for effective alternatives, such as a targeted biopsy utilizing MRI imaging following an initial mpMRI scan to identify areas of concern.
With the additional context provided by imaging, the radiologist does not have to limit themselves to 12 random samples. Instead, they can target suspicious areas to improve the accuracy of subsequent analysis.
A peer-reviewed study published in the New England Journal of Medicine found that the use of MRI-guided biopsy reduced the risk of overdiagnosis by 50% as compared to a TRUS biopsy.
A separate study, also published in the New England Journal of Medicine, found a higher rate of detection for clinically significant cancer (38%) in the subgroup of study participants receiving an MRI-guided biopsy. That’s as compared to a 26% detection rate for the subgroup of participants who received a standard biopsy. In other words, MRI-guided biopsies offer improved detection of clinically significant cancer while reducing detection of clinically insignificant cancer.
Contaminated Study Results
The USPSTF used results from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published in 2009, to inform the since-suspended development of a recommendation that would have discouraged PSA testing in all men.
The findings of that study appeared to indicate no significant difference between men receiving usual care and men receiving annual prostate cancer screening in terms of a primary outcome of prostate cancer mortality, according to a letter to the editor published in the New England Journal of Medicine.
That same letter goes on to explain that more than 80% of men in the control group — those not receiving annual prostate cancer screening — had one or more PSA tests during the time the trial was active, even though they weren’t supposed to according to the trial! They must have gotten the screening elsewhere.
This brings the study results into question. A substantial number of men in the study who were thought to have not received a PSA test actually did. This testing informed decisions about healthcare related to prostate cancer, contaminating the study results.
Health recommendations need to be based on accurate data. In cases where inaccuracies are found, re-evaluation of recommendations is appropriate.
Considerations for Men Aged 70 and Older
PSA testing, and subsequent testing and treatment, need to take a patient’s current and projected future health into account. It’s especially important to avoid overtreatment for older patients, who are more likely to have health concerns that could make them more vulnerable to the side effects of testing and treatment.
That said, PSA testing for a man aged 70 and older who are otherwise in good health is a reasonable approach. It must be paired with appropriate screening measures, such as the newer options for prostate cancer screening detailed previously. In those cases, he can and should consider PSA testing and other appropriate screening measures for prostate cancer.
Making the Decision to Screen for Prostate Cancer
The USPSTF prostate cancer screening guidelines currently state that screening should be an individual decision for men aged 55-69 and discourage screening for men aged 70 and older.
In light of the information above and our experience in treating patients, that otherwise healthy men should consider annual screening starting at age 45.
Our staff consistently compare the results of MRI imaging to MRI guided, targeted, in-bore biopsy results in the course of treating patients. Over time, this process, called radiology pathology correlation, can help improve a physician’s ability to more accurately interpret these MRIs.
Prostate Laser Center has taken a proactive approach to prostate cancer by offering MRI guided, minimally invase treatment approaches which can help decrease the risk of side effects of treatment, making screening for prostate cancer more reasonable for more men.
Seeking treatment for prostate cancer? Request a consultation today.
NOTE: The information provided on this website is general medical information and does not establish a physician-patient relationship. Please discuss your particular situation with a qualified medical professional.
