Is Prostate Cancer Screening Right for You?

When the prostate specific antigen (PSA) blood test became available in the 1990s, it revolutionized the ability to detect prostate cancer. Urologists such as Simon Kimm, M.D., of the Palo Alto Medical Foundation, could finally spot a disease that affected one in seven men at an earlier stage where treatment might be simpler and more effective. Along with the test came new advances in surgery and radiation therapy that let doctors target prostate cancers with increasing precision.

“This lead to a period of widespread and aggressive treatment of prostate cancer,” Dr. Kimm says. “Studies show this approach saved lives, but it also subjected many men to the side-effects of treatment.”

After skin cancer, prostate cancer is the most common cancer among men. Although it is a serious disease, it can often be treated successfully. More than 3.1 million men in the United States are prostate cancer survivors, according to the American Cancer Society.

“With a simple blood test to screen for prostate cancer and better methods for removing cancers, the conventional wisdom was that it was safest to assume every prostate cancer detected could be an aggressive, fast growing, deadly cancer and should be treated,” Dr. Kimm explains. “However, as the PSA test came into widespread use, data began to show that aggressive treatment for every prostate cancer might not be best for all men. Over the past ten years, we have learned from studies that a smaller number of prostate cancers behave very aggressively. Some pose more intermediate risk, and many are low risk and unlikely to be life-threatening. We also have learned that PSA alone is not always a good test for discriminating between these types of prostate cancers.”

Personalizing Prostate Cancer Care

Just like people, cancers are not all the same. Many prostate cancers are slow growing and may never cause a problem in a man’s lifetime. Treating these cancers could do more harm than good as some potential side effects, like incontinence and impotence, are quite serious.

“Today, doctors take a much more individualized approach,” Dr. Kimm says. “We look at the whole patient to assess whether the PSA screening test is appropriate. If it is and a cancer is detected, we also may recommend active surveillance rather than removing the cancer immediately.”

Active surveillance typically involves redoing the PSA blood test and having a digital rectal exam (DRE) twice a year to see if your cancer is growing. You may also need a prostate biopsy, where a small sample of the cancer is withdrawn through a needle and studied by a pathologist, once a year.

“This follow-up testing schedule is still evolving,” Dr. Kimm explains. “Your doctor may have you tested either more or less frequently depending on your individual risk.”

If the risk that the prostate cancer is very low, watchful waiting might even be appropriate. Here men are taught symptoms to look out for and asked to call the doctor if they notice any such changes in their bodies.

Is the PSA Test Right for You?

Currently there is much controversy surrounding the PSA test and its use. The U.S. Preventive Services Task Force has even advocated abandoning screening for prostate cancer altogether. This recommendation is based on an analysis of older data that questioned whether the benefits of treatment outweighed its potential harms, Dr. Kimm says.

“The solution to the problem of overtreatment does not lie in abandoning the screening test that has been clearly shown to save lives,” he says. “Our focus should be on improving how we use this information to guide biopsy and treatment in a more informed way. By working closely and being judicious in screening and treatment of this disease, doctors and patients can together find a balance between the benefits and potential harms of PSA screening for each man.”

Dr. Kimm uses a statistical model called the PSA risk calculator to help clarify each patient’s individual risk of prostate cancer after getting a PSA test. The tool can also help predict if a cancer is a low risk cancer that can undergo active surveillance versus a high risk cancer that requires treatment.

“I use this calculator in discussions with my patient to help come to a consensus on how to move forward after being screened,” he says.

In addition to a more individualized approach using risk models, newer more accurate tests have come to the market that can help to improve doctors’ ability to detect these cancers. The Opko 4K Test and the Prostate Health Index (PHI) are useful adjuncts to the PSA test when it is unclear whether an elevated PSA is due to prostate cancer or not, Dr. Kimm explains.

“Rather than returning to an era prior to PSA testing, when men with life-threatening cancers went undiagnosed, we should refine our approach to offer more personalized assessments of risk for a disease that is still a leading cause of death in men,” he says.

Based on the best available evidence to date, the American Urological Association has released guidelines for PSA screening for prostate cancer. However, these guidelines continue to evolve and should be individualized to each patient, Dr. Kimm says.