The November, 2024 issue of American Family Physician, the scientific publication of the American Academy of Family Physicians, has an article on prostate cancer screening that puts to rest most, if not all, of the controversies doctors face and patients query regarding the detection of prostate cancer. Screening for prostate cancer has been one of the most cussed and discussed medical topics over the last 2 or 3 decades. Finally, a consensus of opinion has been reached and physicians from Wayne State University in Detroit and Oakland University in Rochester, Michigan present it in a 7-page article. I will avoid a lot of explanation, unless necessary, and stick to the questions and answers.
Prostate Cancer (PCA) is “the most diagnosed non-cutaneous (non-skin) malignancy and the second most common cause of cancer death among men in the United States.” It occurs more often in older men, men with a family history of PCA, and in Black men. Blacks are affected by it more than Whites, Asians, or Hispanics. Screening for PCA is recommended every 2-4 years in men 55-69 years old who are at average risk. Prostate-Specific Antigen, PSA, is the screening method of choice for men up to 70 years of age. Family doctors and urologists are equally qualified to conduct and monitor screening.
Disagreement and confusion about screening and treatment are the norm. The United States Preventive Services Task Force (USPSTF), the American Urological Association (AUA), and the American Cancer Society (ACS) have all published guidelines and recommendations for screening that reach differing conclusions. Finally, however, this article gives straightforward, practical answers to the pertinent questions posed by physicians and patients. I will share these answers now.
WHICH PATIENTS HAVE A HIGHER RISK OF PCA AND HOW DOES THAT AFFECT SCREENING RECOMMENDATIONS? Older age, family history of PCA, and Black race are major risk factors for PCA. Screening men over age 70 provides no benefit death-wise and is not recommended. Men with a positive family history should begin screening at an age earlier than 55.
DOES PSA-BASED SCREENING REDUCE PROSTATE CANCER MORTALITY OR MORBIDITY? NO. PSA-based screening leads only to a small reduction in prostate cancer deaths and metastatic disease, and no reduction in deaths from any cause.
WHAT ARE THE HARMS ASSOCIATED WITH PSA-BASED SCREENING? False positive PSA results cause “psychological harm” such as worry and anxiety. Complications (pain, infection, hospitalization) after a prostate biopsy done for an elevated PSA are an additional risk. Other harms related to unnecessary treatment are incontinence (urinary, bowel), erectile dysfunction. Plus the costs of screening and treatment.
DOES DIGITAL RECTAL EXAMINATION (DRE) IMPROVE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER? NO. There is no evidence it is helpful in PCA screening.
WHAT ARE THE BENEFITS OF USING DECISION AIDS IN SHARED DECISION-MAKING FOR PCA SCREENING? A better-informed patient will make better decisions regarding screening.
HOW OFTEN SHOULD PSA TESTING BE DONE IN PATIENTS WHO DECIDE TO BE SCREENED? For men with average risk, PSA should be done every 2-4 years. Interval may be shortened if the PSA is elevated. For high risk patients, start earlier and retest yearly.
WHAT ARE THE INITIAL STEPS (PROCEDURES) AFTER A POSITIVE PSA RESULT? If the PSA is above 4mcg/L, the first step is to repeat it. If it’s still elevated, an MRI of the prostate is done plus a urinalysis and urology referral.
WHAT IS THE ROLE OF PROSTATE MRI IN EVALUATION? Prostate MRI in men with elevated PSA can identify men who need prostate biopsy and “map” biopsy sites. High quality MRI equipment and radiologic expertise are essential for accurate interpretation.
HAS ACTIVE SURVEILLANCE REDUCED THE HARMS OF OVER-TREATMENT OF PCA?
YES. It allows many patients to avoid surgery and radiation without increasing the risk of death. Regular PSA testing, digital rectal exams, and MRI are recommended practice guidelines that prevent unnecessary biopsies and surgeries.
CONCLUSION: This was a very well-organized and informative article. It clarifies for me just who does and does not need screening and evaluation. The advent of MRI technology has helped to greatly reduce the number of unnecessary prostate biopsies and surgeries. The accuracy and utility of MRI will only improve over time. However, none of these questions addresses the anxiety caused by PCA. Men worry about it so a lot of unnecessary PSA’s are done. I don’t have concern about over-testing. I do have concern about over-evaluating and over-treating. If doctors follow guidelines and do MRI’s for elevated PSA’s, I think anxiety will be quieted.
Reference: Xu J, McPharlin S, Mulhem E. Prostate Cancer Screening: Common Questions and Answers. Am Fam Phys 2024 November;110(5):493-499.
