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PSA testing for Prostate Cancer Screening

Turn your head and cough, but also keep your pants on

In the ever-changing world of prostate cancer screening, there's been a recent new development I just did a talk on that I thought was interesting.  As recently as last week, there was a New York Times article Debating the Value of PSA Prostate Screening so just a few salient points:

- The PSA test, initially developed to monitor for prostate cancer RECURRENCE, was then used to screen for prostate cancer before we really understood how to use it, which led to many years of procedures and treatments that we now think were likely not helpful in keeping people from dying from prostate cancer.

- NOW, there is no real right answer.  Prostate cancer screening MAY save lives for some very high risk people (African-Americans and men with BRCA 1 or 2 mutations), but having a family history of it is less understood, mainly because of how many people were over-diagnosed and over-treated.  If your dad had prostate cancer that went elsewhere in his body, that's important as that's an advanced stage cancer, but for a lot of the other types, it's not clear how much of a genetic risk there is.

- The US Preventative Services Task Force and the American Urological Association agree that men should think about screening between ages 55-69, and most health insurances generally go with the USPSTF.  Any society that has the word "cancer" in it, recommends earlier screening for basically every cancer there is, though most people agree its really trying to identify people at the highest risk, which is still tough to do with our current knowledge.

- An addition to our knowledge was a recent article saying that if your first PSA is 2 or higher at age 55, and especially if it's over 4, your risk of significant prostate cancer down the road is higher.  On the other hand, if the PSA is under 1 when first checked, your risks of getting prostate cancer are very low.  Of note, the PSA test ain't perfect either as you can have high levels and no disease and normal levels and major cancer, though those are usually the exceptions and not the rule.  They are still working on better ways of testing and sometimes they are doing MRI's instead of biopsies after a PSA is elevated so it's an ever-evolving field.

- The changes in guideline recommendations over the last decade have led to a slight increase in the incidence of advanced stage prostate cancer, possibly due to reduced earlier screening, but they are still at their lowest level in decades.  Importantly, African-American men now have their lowest incidence of prostate cancer deaths ever, but still much higher than everyone else.

- Most people now agree a digital rectal exam is pretty worthless for screening prostate cancer as it usually ends up being a coin flip as to how helpful it is in finding cancer (meaning half the time when we find something, it's not cancer, and half the time we don't find something, people can have cancer) and if that's the case, you might as well just flip the coin and save the glove.

My current leaning is to more strongly recommend at least a one-time check to men, especially those who haven't had it before, and that's been a shift in my philosophy over the last few years.
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