By: Eric Klein, MD
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Before prostate-specific antigen (PSA) tests came along in the late 1980s, most men newly diagnosed with prostate cancer were incurable. Within a few years of using PSA, however, we saw an amazing shift: By the mid-1990s, most men newly diagnosed with prostate cancer were curable.
Since then, studies have shown that while PSA screening reduces a man’s likelihood of dying from prostate cancer, it does not reduce overall mortality. The problem has been with how we use PSA tests.
In the last two decades, we’ve learned that following traditional screening guidelines — screening all men annually beginning at age 50, or age 45 if higher risk — frequently results in the detection of non-life-threatening cancers (called overdiagnosis) that don’t need to be treated. Overdiagnosis often leads to overtreatment, where men not destined to die of their cancer get treated anyway and suffer the downtime, recovery issues and side effects of therapy.
To avoid overdiagnosis and overtreatment, we need to be smarter about how we use PSA testing. Recommendations for screening have already begun to change.
Here are two ways to screen smarter for prostate cancer:
1. Men should have a baseline PSA test at age 50
Knowing your baseline PSA level can help predict your lifetime risk of prostate cancer and indicate how frequently you need to have future PSA tests.For example, if your baseline PSA is below 0.7 ng/mL (the average for men at age 50), your lifetime risk of developing prostate cancer is less than 10 percent. It’s probably safe to be screened less often than previously recommended. I recommend a PSA only every five years.
On the other hand, if your baseline PSA level is above 0.7 ng/mL, evidence suggests your lifetime risk of developing prostate cancer is greater than 10 percent. More frequent screening makes sense, and I recommend a PSA test every two years. If you have high-risk factors, such as having a family history of prostate cancer or being African American, I still recommend screening yearly.
Furthermore, data shows that men age 60 and older who have PSA levels 2.0 ng/mL and lower have a very low risk of prostate cancer. I recommend stopping PSA screening for them or doing them less frequently. If we do screenings this way, it’s likely that we’ll reduce the risk of overdiagnosis as well as the overtreatment of non-lethal prostate cancer.
2. PSA screening should be supplemented with new, more specific, screening tools
Prostate cancer antigen 3 or “PCA3” (a urine test), OPKO 4Kscore™ (a blood test) and Prostate Health Index (a blood test) are three tools that provide accurate results than a PSA test — which can’t distinguish between prostate cancer, noncancerous prostate enlargement and prostate inflammation due to another condition.
These new diagnostic tools can help us detect more biologically significant prostate cancers, the ones that need to be treated. MRI-guided biopsy (also known as fusion or targeted biopsy using a combination of MRI, ultrasound and needle biopsy) is another tool that helps us identify aggressive prostate cancer tumors that need to be treated, versus low-grade tumors that can be managed with active surveillance.
Genomics and genetics soon will play a more significant role in detecting prostate cancer risk, much like mutations in BRCA genes indicate risk of breast cancer. We’re not there yet, but we’re getting closer. New genomic tests already on the market can tell if a newly diagnosed cancer can be safely watched or needs treatment.
Most urologists are aware of the limitations of screening patients yearly. But we need to get the word out to patients and primary care physicians, who are on the front lines of PSA screening.
While traditional standards haven’t been perfect, PSA tests still play an important role. Talk to your doctor about when and how frequently you should have one.