Prostate Cancer Screening: Everything you need to know

Medically reviewed: 19, February 2024

Prostate Cancer Screening: Everything you need to know about prostate cancer tests

Prostate cancer is a significant concern for men’s health, being one of the most common types of cancer diagnosed among males. Regular screening plays a crucial role in early detection and intervention, potentially saving lives. In this article, we will provide a comprehensive overview of prostate cancer screening, discussing its importance, when it should be performed, and associated benefits and risks.

Key takeaways about Prostate Cancer Screening

Here are five easy-to-understand points about prostate cancer screening:

1. Doctor Visit: Have open talks with your doctor about starting prostate examinations when you turn 50, or sooner if there’s a family record of prostate difficulties.
2. Low Risk Early On: Younger guys, normally beneath 40 years old, usually don’t get tested because prostate cancer isn’t very common then.
3. Many Things Can Increase PSA Levels: Apart from cancer, several things like aging, inflammation, or bladder problems can raise PSA numbers. So, getting checked doesn’t always mean cancer.
4. Personal Decision Time: Around ages 55-69, you and your doctor will decide together if continued PSA tests are good for you based on your overall health and past outcomes.
5. Gentlemen, Take Care: Keep learning about the latest advancements in prostate health and stay connected with your doctor regularly to promote healthy living and quick response when needed.

What is Prostate Cancer Screening?

Prostate cancer screening refers to medical tests designed to identify signs of cancer before symptoms appear. It typically involves two main methods:

• Prostate Specific Antigen (PSA) Test: This blood test measures the level of PSA, a protein produced by both normal and cancerous cells within the prostate gland. Elevated levels may indicate potential malignancies, although benign conditions can also cause higher PSA values.
• Digital Rectal Examination (DRE): During this physical examination, a healthcare provider manually checks the prostate’s size, shape, and texture for any abnormalities by inserting a gloved, lubricated finger into the rectum. While DRE alone might miss small tumors, especially in the posterior part of the gland, it provides valuable information when combined with the PSA test.

Why is Prostate Cancer Screening Important?

Early detection and treatment significantly improve the chances of survival and decrease morbidity rates linked with advanced stages of prostate cancer. The American Urological Association recommends informed decision-making regarding regular prostate cancer screening after discussing the following factors with healthcare providers:

1. Age: Men aged 55 to 69 years benefit most from balanced discussions on pros and cons of screening since incidence increases with age.
2. Family History: Individuals with first-degree relatives (father, brother) affected by prostate cancer have a greater risk of developing the disease themselves.
3. Race: African Americans face a relatively high lifetime probability of prostate cancer diagnosis compared to other racial groups.

Benefits and Risks Associated with Prostate Cancer Screening

Understanding both advantages and disadvantages enables patients to participate actively in informed decisions regarding their healthcare:

Benefits:

• Early Diagnosis: Identifying malignancies at earlier stages allows for curative treatments, preserving quality of life and enhancing long-term survivability.
• Reduced Morbidity & Mortality: Lower metastasis risk reduces overall suffering and minimizes therapy side effects due to timely interventions.

Risks:

• Overdiagnosis: Given that some slow-growing cancers never progress to threaten lifespan, unnecessary treatments could result in unwarranted complications and psychological distress.
• False Positives: Misleading outcomes sometimes necessitate invasive diagnostic procedures causing stress, inconvenience, and additional costs without revealing actual illness.
• False Negatives: Missed diagnoses might lead to delayed therapies resulting in poorer prognostications.

Types of Prostate Cancer Screenings

Prostate cancer is a significant health concern for many men, especially those over the age of 50. Regular screening can help detect prostate cancer early, allowing for more effective treatment options.

There are two primary types of prostate cancer screenings:

• PSA tests
• and digital rectal examinations (DRE).

PSA Prostate Cancer Test

The Prostate Specific Antigen (PSA) test measures the level of PSA protein produced by cells within the prostate gland. An elevated PSA level might indicate the presence of prostate cancer, although additional conditions may also result in increased PSA levels. Therefore, interpreting PSA test results requires careful consideration and context.

Interpreting Results

PSA values alone cannot definitively diagnose prostate cancer. Instead, healthcare providers assess PSA levels alongside additional risk factors, medical history, physical examination findings, and sometimes biopsy results.

• Normal range: For most men, a normal PSA value falls below 4 nanograms per milliliter (ng/mL). However, some physicians may still regard slightly higher values as normal based on individual circumstances and trends over time.
• Elevated PSA: If a man has a PSA between 4 ng/mL and 10 ng/mL, he has approximately a 25% chance of having prostate cancer—a situation often referred to as a “gray zone.” Men with a PSA above 10 ng/mL have a considerably greater likelihood of harboring malignancy.
• Rising PSA levels: Even when initial PSA readings remain within the normal range, consistently rising PSA values could be indicative of emerging problems, warranting closer monitoring and possible retesting at shorter intervals.

Ultimately, urologists interpret PSA levels along with several variables, so consulting a physician remains crucial in determining whether any concerning trend warrants further investigation.

Advantages and Disadvantages

Advantages of the PSA test include:

• Relatively noninvasive procedure compared to DRE or tissue sampling (biopsy).
• Detectable changes in PSA concentration may signal the existence of treatable early-stage disease.
• Enables tracking alterations in PSA concentrations over time, potentially identifying problematic developments sooner rather than later.

However, there are notable downsides associated with the PSA test:

• Approximately 75% of men who undergo a biopsy due to abnormal PSA results don’t actually have prostate cancer.
• Many detected tumors prove indolent (slow growing) and never require intervention, causing unnecessary anxiety and potential side effects from unneeded treatments.
• Some aggressive cancers fail detection by routine PSA measurement techniques, offering a false sense of security.
• Routine annual PSA screening adds substantial financial burden without necessarily reducing mortality rates significantly.

Despite limitations, PSA tests serve an essential role in guiding clinicians toward appropriate management decisions regarding patients with suspected prostate cancer. By acknowledging inherent weaknesses and incorporating supplementary information, thoughtfully applied PSA measurements contribute valuable insights into diagnostic dilemmas surrounding prostate cancer identification.

Special PSA tests for prostate cancer

When considering prostate specific antigen (PSA) screening tests for possible indicators of prostate cancer, you might come across varying types of PSA measurements. While a standard PSA test calculates the entire quantity of PSA present in the body, distinct methods focus on alternative facets of PSA behavior to aid medical professionals in evaluating your risk for prostate cancer. Not every physician agrees on the utilization of these particular tests, however, thus engaging in open dialogue with yours following an abnormal primary PSA outcome is highly recommended.

Free PSA (fPSA)

Circulating PSA molecules appear in two main configurations: bound to other blood proteins or freely drifting. fPSA, also termed the free-to-total PSA ratio (f/t PSA), quantifies the proportion of freely moving PSA contrasted against complete PSA. Men diagnosed with prostate cancer generally exhibit lowered fPSA ratios compared to those devoid of the condition.

Should your PSA test yield results within the ambiguous spectrum (4-10 ng/mL), physicians might utilize fPSA percentages to help guide biopsy recommendations—lower fPSAs signify amplified odds of harboring prostate cancer, thereby warranting closer scrutiny. Typical thresholds entail recommending biopsies for fPSA ratios equal to or below 10%, whereas levels ranging from 10%-25% often spur careful deliberation of tissue sampling. Note that there remains debate around optimal cut-off points and potential fluctuations based on overall PSA concentration.

Bound PSA

Distinctively measuring the share of PSA linked to additional proteins presents an alternative approach equivalent to determining total and free PSA concentrations combined. Despite being accessible, wide-scale implementation remains infrequent owing to comparable informational value provided by total versus free PSA assessment.

Composite PSA assays

Recently developed tests encompass multiple PSA variants, generating scores reflective of the probability an individual hosts prostate cancer (especially cases necessitating intervention). Examples comprise:

• Prostate Health Index (phi): Merges outcomes from total PSA (-b2), free PSA ([-b2]), and p2PSA (-b2). Generally beneficial for assessing whether a biopsy is required amid mildly elevated PSA levels.
• 4Kscore Test: Combines free PSA, whole PSA, intact PSA, hK2 alongside other variables to forecast the likelihood of unfavorable prostate cancer outcomes. Utilful particularly in discerning the necessity for repeat biopsies post inconclusive initial attempts.
• IsoPSA Test: Investigates distinctive protein configurations derived from cancerous prostate cells. Primarily employed for individuals presenting modestly elevated PSA levels in order to ascertain the urgency of requisite biopsies.

While advantageous primarily for nuanced evaluation of suspicious PSA readings, these composite tests aren’t universally endorsed nor routinely implemented as definitive judgement criteria. Further discussion with your healthcare practitioner remains imperative once presented with any atypical PSA test results.

PSA Density (PSAD)

Large prostates inherently generate escalated PSA amounts irrespective of underlying pathology. PSAD compensates for voluminous glands by accounting for measured volumes on TRUS examinations coupled with respective PSA counts. Higher densities indicate elevated cancer susceptibilities. Though roughly commensurate in accuracy to fPSA percentage assessments, inherent requirement for imagery limits regular employment of PSAD measurement protocols.

Despite common belief, neither PSA Velocity nor Age-Specific PSA Thresholds serve prominent roles in contemporary prostate cancer screenings. Professional consensus discourages reliance on these parameters given inconsistencies in practical application and lackluster predictive abilities respectively. Consult your healthcare provider exclusively for personalized advice concerning each aspect of PSA measurement techniques mentioned above.

What can affect your PSA test?

PSA levels can vary for reasons other than cancer, which makes it hard to use a fixed cutoff point for the screening PSA test.

Some factors that can increase PSA levels are:

1. Age: As you age, your PSA levels tend to rise slowly, even if your prostate is healthy.
2. Prostate size: Having a larger prostate, which is common in older men, can make your PSA levels go up. This can be caused by BPH, a benign condition that enlarges the prostate.
3. Prostate infection or inflammation: This is called prostatitis, and it can also make your PSA levels go up.
4. Sexual activity: Your PSA levels can go up briefly after you ejaculate. That’s why some doctors recommend that you avoid ejaculation for a day or two before testing.
5. Cycling: Some research has suggested that riding a bike can temporarily raise your PSA levels (maybe because the seat presses on the prostate), but this is not confirmed by all studies.
6. Certain procedures that affect the prostate: These include prostate biopsy or cystoscopy, which are done in a doctor’s office. They can make your PSA levels go up for a short time. Some research has also suggested that a DRE might slightly raise your PSA levels, but this is not agreed by all studies. To be safe, some doctors suggest that you have your blood drawn for the PSA test before having the DRE, if you are having both.
7. Certain medications: Taking testosterone or other drugs that increase testosterone levels can make your PSA levels go up.

Some factors that can decrease PSA levels are:

• 5-alpha reductase inhibitors: These are drugs that treat BPH or urinary problems, such as finasteride (Proscar or Propecia) or dutasteride (Avodart). They can lower your PSA levels. They can also affect your risk of prostate cancer. You should tell your doctor if you are taking these drugs. Your doctor might need to adjust your PSA levels accordingly.
• Herbal supplements: Some supplements that are sold as natural remedies might hide a high PSA level. That’s why you should tell your doctor if you are taking any supplements, even if they are not for prostate health. Saw palmetto (an herb that some men use for BPH) does not seem to affect PSA.
• Certain other medications: Some studies have suggested that using certain drugs for a long time, such as aspirin, statins (drugs that lower cholesterol), and thiazide diuretics (such as hydrochlorothiazide) might lower your PSA levels. Further investigation is required to validate this claim.

If you are considering screening for prostate cancer, you should talk to your doctor about anything that might affect your PSA level, as it might change the accuracy of your test result.

Digital Rectal Examination (DRE) for Prostate Cancer

Digital rectal examinations provide an alternative means of evaluating potential signs of prostate enlargement, irregularities, or nodules suggesting underlying neoplastic growth directly within reach of gloved fingers inserted into the rectum. Although less quantifiable than PSA analysis, combining both methods offers complementary perspectives beneficial to comprehensive assessment strategies.

Process and Purpose

Performed by a trained healthcare professional, a digital rectal examination typically follows these steps:

• Patient preparation involves emptying bladder prior to the procedure.
• Physician dons gloves and applies lubricant before inserting a well-lubricated finger gently into the rectum, ensuring steady pressure against the posterior wall of the organ.
• With gentle exploration across different segments, practitioners seek palpable anomalies suggestive of structural variations requiring further evaluation.

While performing DRE, doctors aim to identify suspicious regions consistent with potential malignancies demanding subsequent scrutiny via imaging studies, advanced molecular assays, or invasive biopsies.

What are the limits of DRE?

• Incomplete visualization limits comprehension of overall architecture and morphology, possibly omitting focal lesions concealed from manual probing.
• Subjectivity introduces variability among operators, complicating interpretation reliability across diverse clinical settings.
• Potential discomfort experienced during the procedure may deter regular repetition required for longitudinal surveillance.
• Limited sensitivity precludes reliable exclusion of occult carcinomas obscured beneath surface irregularities.

Prostate Cancer Screening Guidelines and Recommendations

When it comes to prostate cancer screenings, numerous organizations offer varying suggestions depending on individuals’ ages, family histories, and personal preferences. Among them are three prominent entities whose opinions hold considerable sway:

• American Urological Association (AUA),
• American Cancer Society (ACS),
• United States Preventive Services Task Force (USPSTF).

Each organization brings forth evidence-based guidance aimed at optimizing benefits while minimizing risks linked to early prostate cancer detection.

American Urological Association (AUA) Guidelines

The AUA addresses asymptomatic males aged 40 years and older, advocating shared decision-making in conjunction with healthcare providers around prostate cancer screenings. Their recommendations hinge on a man’s life expectancy, comorbidities, ethnic background, and familial prostate cancer prevalence. Key takeaways include:

• Men younger than 40: No general recommendation exists for PSA screenings unless high-risk scenarios arise, e.g., inherited genetic mutations or extensive family histories.
• Men aged 40-54: Absent compelling influences, systematic PSA testing isn’t advised unless requested post detailed discussions centered around possible gains and drawbacks.
• Men aged 55-69: Consider regular PSA monitoring every few years after discussing pros and cons explicitly.
• Men aged ≥70: Clinicians should refrain from routinely recommending PSA screenings given diminishing returns owing to competing causes of mortality taking precedence.

Remember, conversations between patients and healthcare providers form the cornerstone of AUA guidelines, emphasizing shared responsibility and educated consent.

American Cancer Society (ACS) Recommendations

Similar to the AUA, the ACS underscores mutual deliberations when deciding upon prostate cancer screenings. Unlike the AUA, however, they concentrate primarily on African Americans and men bearing germline BRCA1/BRCA2 gene mutations – subsets particularly susceptible to developing lethal prostate malignancies. Principal points to remember entail:

• Beginnings at age 45, black men or those possessing BRCA1/BRCA2 genes should engage in open dialogues exploring pros and cons of yearly PSA screenings until reaching 70.
• Commencing at age 50, average-risk men ought to commence similar considerations annually for five years following thorough discourse. Afterward, shared judgment determines further action.

It’s worth noting that the ACS does not advocate mandatory baseline PSA measurements nor obligatory cutoff thresholds beyond which biopsies must occur.

US Preventive Services Task Force (USPSTF) Advice

Unlike both the AUA and the ACS, the USPSTF employs categorical ratings systems (“Grade A,” “B,” “C,” etc.) denoting strength of conviction behind proposed preventative actions. Grades incorporate balancing likely positive consequences versus expected harm plus quality of accessible scientific research. Regarding prostate cancer screenings, key directives encompass:

• Grade C: Men aged 55-69 seeking PSA screenings should embark on individualized risk-benefit analyses weighing potential advantages (reduced metastasis incidence) vs. plausible detriments (unnecessary procedures, distress). Shared decision-making becomes paramount here.
• Grade D: Evidence overwhelmingly supports avoiding routine PSA measurements for men over 70, citing minimal survival improvements contrasted against sizable risks provoked by excessive therapeutic interventions.

Prostate Cancer Screenings – False Positive and Negative Rates

Regular screenings can be crucial for early detection and improved survival rates. However, understanding certain key elements surrounding prostate cancer screenings is vital before making informed decisions regarding tests and potential treatments.

Like many medical tests, prostate cancer screenings may produce both false positives and false negatives. These results refer to instances where the test indicates either the presence or absence of cancer when no actual malignancy exists. Both scenarios pose challenges in clinical decision-making and should be carefully considered.

A false positive result occurs when the screening shows signs suggestive of cancer, prompting additional invasive diagnostic procedures such as biopsies. Although uncommon, benign conditions could lead to unnecessary stress, anxiety, and complications associated with subsequent examinations. Moreover, excessive healthcare costs might ensue due to redundant interventions resulting solely from misleading initial findings.

Conversely, a false negative outcome implies the failure to detect existing prostate cancer. Consequently, patients will continue without timely intervention or treatment opportunities, possibly enabling disease progression and worsened health consequences. In some cases, undetected tumors remain indolent, never causing significant harm throughout a man’s lifetime. However, identifying aggressive subtypes at earlier stages maximizes therapeutic options and increases cure chances significantly.

Ethnic Disparities in Screening Outcomes

Discrepancies observed across different racial groups highlight substantial inequity concerning prostate cancer incidence, mortality, and overall survival rates. African American males bear disproportionately higher risks than other populations, manifested through elevated morbidity statistics and inferior treatment responses.

Abnormal Prostate Cancer Screening Results

A high blood PSA level after a prostate cancer screening does not necessarily mean you have cancer. Many men with elevated PSA levels are cancer-free. However, you will need more tests to confirm your diagnosis. Your doctor may offer one of the following options:

• Taking another PSA test after some time
• Having a different type of test to see how likely you are to have cancer (and if you need a prostate biopsy)
• Having a prostate biopsy to check for cancer cells

You should talk to your doctor about your options and their advantages and disadvantages. This information will assist you in making a decision that aligns with your needs and preferences. Various factors can come into play and influence your choice:

• Your age and general health
• Your chances of having prostate cancer (based on the tests you have done)
• How you feel about waiting or having more tests

If your primary care provider ordered your first PSA test, you may be sent to a urologist (a doctor who specializes in the genital and urinary system, including prostate cancer) for more consultation or testing.

Discussing Screening Options With Your Doctor

If you are a man over 50, or have a family history of prostate cancer, you may be wondering if you should get screened for this disease. Screening means testing for a disease before you have any symptoms. The main screening test for prostate cancer is the prostate-specific antigen (PSA) test, which measures the level of a protein in your blood that is made by the prostate gland. A high PSA level can indicate that you have prostate cancer, but it can also be caused by other factors, such as age, infection, or enlargement of the prostate.

Screening for prostate cancer has both benefits and risks. The benefit is that it can help find prostate cancer early, when it may be easier to treat. The risk is that it can lead to overdiagnosis and overtreatment, which means finding and treating cancers that would not have caused any problems in your lifetime. Some treatments for prostate cancer can have serious side effects, such as impotence, incontinence, and bowel problems.

Therefore, it is important to talk to your doctor about whether screening is right for you, and what your options are. Here are some questions you can ask your doctor to help you make an informed decision.

Questions and answers about Prostate Cancer Screening

What is the PSA level for prostate cancer?

There is no specific PSA level that can diagnose prostate cancer. Different labs may have different normal ranges for PSA, but generally, a PSA level of 4 ng/mL or higher is considered abnormal. However, some men with prostate cancer may have lower PSA levels, and some men without prostate cancer may have higher PSA levels. Other factors, such as age, race, and medications, can also affect PSA levels. Therefore, your doctor will consider your PSA level along with other factors, such as your age, family history, and symptoms, to decide if you need further testing.

What is normal PSA by age?

PSA levels tend to increase as you get older, even if you do not have prostate cancer. This is because the prostate gland usually grows larger with age, and produces more PSA. The following table shows the average PSA levels by age group, according to the American Cancer Society:

Age group	Average PSA level (ng/mL)
40 to 49	0.7
50 to 59	1.0
60 to 69	1.4
70 to 79	2.0

However, these are only averages, and your PSA level may vary depending on your individual factors. Your doctor will compare your PSA level to the normal range for your age group, and also look at how fast your PSA level changes over time (called PSA velocity).

How can I lower my PSA level quickly?

There is no proven way to lower your PSA level quickly, unless you have a condition that causes a temporary rise in PSA, such as an infection, inflammation, or ejaculation. In these cases, your PSA level may go down after the condition is treated or resolved.

However, if your PSA level is high because of prostate cancer, lowering it artificially will not change the fact that you have cancer, and may delay your diagnosis and treatment.

Some studies have suggested that certain lifestyle changes, such as eating a healthy diet, exercising regularly, losing weight, and quitting smoking, may help lower your PSA level or reduce your risk of prostate cancer. However, further studies are required to validate these outcomes. Additional research is necessary to corroborate these effects.

Does PSA test always detect prostate cancer?

No, the PSA test is not a perfect test for prostate cancer. It can miss some cancers (called false negatives), or suggest that you have cancer when you do not (called false positives). According to the American Cancer Society, about 15% of men with a normal PSA level have prostate cancer, and about 75% of men with an elevated PSA level do not have prostate cancer. Therefore, the PSA test alone cannot diagnose prostate cancer, and needs to be followed by other tests, such as a digital rectal exam (DRE) or a prostate biopsy, to confirm the diagnosis.

The PSA test is also not very good at telling how aggressive or advanced your prostate cancer is, or how likely it is to spread or cause symptoms. Therefore, your doctor will use other tests, such as a Gleason score or a staging system, to assess the severity of your prostate cancer and plan your treatment.