A blood test called prostate-specific antigen (PSA) is commonly used as a screening test to detect the possibility of prostate cancer. In 2018, the United States Preventive Services Task Force, a group of primary care clinicians who develop screening guidelines based on systematic evidence, recommended that men ages 55 to 69 should talk with their doctor about the potential benefits and harms of checking a PSA level.
There are tradeoffs for screening or not screening, including the risks of further testing such as a biopsy, and the benefits of identifying a cancer early. Because of this, the decision to check a PSA level should be an individualized conversation between each patient and their doctor.
Has checking a PSA always been recommended?
Previously, in 2012, the task force recommended that men of all ages should not be routinely screened with PSA levels. This was updated in 2018 with the recommendation for individualized decision-making for men ages 55-69.
The task force considered two important factors in the change. “The first was new information about the number of cases of metastatic disease avoided by screening,” said Dr. David Penson. “They found that for every 100 men screened, three cases of metastatic disease would be avoided.”
“Second, they noted a greatly increased use of active surveillance in men with low-risk disease,” Penson said. “This reduced the harm of over-diagnosis and overtreatment and changed the balance.”
Questions to ask yourself and your doctor about screening
1. Do you want to know if you have even the slightest risk of death from prostate cancer?
An advantage of PSA screening is earlier prostate cancer detection — in other words, checking a PSA level can help identifying an early-stage prostate cancer. Prostate cancer is relatively slow-growing and can often be monitored without immediate treatment in the early stages. While prostate cancer is the second most common cancer in American men, most of the men who are diagnosed will not die from the disease.
2. Are you more tolerant of the uncertainty that may follow the news of an elevated PSA level?
Screening isn’t perfect. Sometimes it misses cancer, and sometimes it finds something suspicious that turns out to be harmless. It can be stressful to wait for a referral to a urologist, or to undergo additional testing. Even if early prostate cancer is found, often a urologist’s recommendations are to monitor without immediate treatment, which can cause anxiety for some patients.
3. Are you willing to undergo additional evaluation for prostate cancer if your PSA level is elevated?
The next step after an elevated PSA level is often a prostate biopsy or a prostate MRI scan to image the prostate – two interventions that are very useful in identifying a prostate cancer, but have their own risks as well. MRI scans take time and money, and can identify “incidental” findings which can require additional evaluation, even though they may never have caused you a problem. Prostate biopsies have risks including discomfort, infection, and bleeding. Some men require multiple prostate biopsies during the course of their evaluation and treatment.
4. Are you at greater risk for getting prostate cancer?
Risk factors include:
- Being Black or African American;
- Having a father, brother or son who had prostate cancer, especially at a young age;
- Your age, because the older you are, the greater your risk.
5. What is a normal PSA Level?
There is no specific PSA level that points to the possibility of cancer. Most doctors consider anything over 4.0 ng/mL, or 4 nanograms per milliliter of blood, as above the typical range. “At Vanderbilt, we flag anything over 3.0 ng/mL as elevated for review by your primary care physician,” Penson said.
If your PSA is elevated, you may want to ask for a second test if you have recently had prostatitis or a urinary tract infection, as these conditions may temporarily elevate PSA levels. In general, a higher PSA level points to a greater likelihood of prostate cancer. Rising PSA levels over time are also a warning sign of possible prostate cancer. If you have elevated PSA levels, talk to your doctor about a referral to a urologist to discuss next steps.
6. Are there alternatives to PSA?
New tests, called “biomarkers,” have recently been developed to try to identify patients at risk of prostate cancer even more accurately than PSA. These biomarker tests can be run on blood, urine and sometimes even tissue samples from a prostate biopsy. While these biomarkers have exciting implications, the American Urological Association still recommends that PSA should be the first screening test for prostate cancer.
Don’t Delay
Some things in life can be put off. A cancer screening shouldn’t be one of them. Cancer checks save lives.
