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Disclaimer
If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
As we age, we begin to think a lot more about our health and any preventative measures we can—or should—take to ward off potentially serious illnesses or injuries. One of those preventative measures is undergoing various cancer screenings. But, when it comes to prostate cancer prevention and undergoing a prostate cancer screening, the medical community has different opinions on if and when you should receive one.
So, the answer of whether it’s recommended isn’t a simple “yes” or “no.” It depends on a few factors and is ultimately a decision you need to make with your healthcare provider. Let’s look at what a prostate cancer screening entails, who may benefit from one, and, on the flip side, who may not.
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Prostate cancer screening tests
Currently, there are two methods for prostate cancer screening (Jain, 2021):
- A digital rectal exam (DRE): when the healthcare provider feels the prostate with their finger and inspects it for lumps or areas that are harder or softer than normal
- PSA test: A blood test that measures PSA level (prostate specific antigen), a protein produced by prostate cells that increases in people with prostate cancer. A “positive” test result would show a high PSA level in the blood.
These tests can also be used together, but the PSA test is the most commonly used prostate cancer screening test. Both tests can potentially detect prostate cancer in men without symptoms, but they have significant drawbacks, too.
Pros and cons of prostate cancer screening
The potential benefits of screening for prostate cancer are, of course, preventing death from prostate cancer and decreasing the incidence of metastatic prostate cancer, which screening has been shown to do. But, there are also some drawbacks.
Accuracy
One of the drawbacks is the tests’ accuracy. The DRE has been shown not to be very sensitive or specific (Naji, 2018). This means many people who test negative still have the disease, and many people who test positive do not have the disease.
PSA screening is more sensitive and specific, but there are still potential drawbacks. One of the major drawbacks is that prostate cancer screening with PSA has not been found to decrease mortality (death), even though more people are diagnosed with prostate cancer if they are screened (Jain, 2021; Fenton, 2018).
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Overdiagnosis
Another one of the potential harms of screening is that about 20–50% of PSA screen-detected prostate cancer represents overdiagnosis due to overdetection (Fenton, 2018).
Overdetection basically means that the test found some kind of abnormality that, if left alone, would either not cause harm, not progress, or progress too slowly to cause symptoms during your lifetime (Brodersen, 2018). This means that people receive a diagnosis of prostate cancer, but they have a disease that would have never caused them problems.
Overtreatment
Overdiagnosis is likely to result in overtreatment. Simply put, overtreatment refers to treating a disease that would have never caused problems in a person’s lifetime.
Overtreatment comes with the risks of causing treatment-related side effects in people who didn’t need treatment in the first place. These risks include infections, bleeding, and urinary problems due to biopsies, erectile dysfunction (ED), urinary incontinence, and fecal incontinence from a range of treatments. In some cases, the cure or treatment can be worse than the disease (Brodersen, 2018).
Prostate cancer screening for high-risk men
In addition to weighing out the pros and cons, there are outstanding questions in the medical community about prostate cancer screening. One crucial risk-benefit question is whether the risk–benefit ratio is different in men with a higher risk of prostate cancer. This includes African Americans and men with a family history of prostate cancer (Jain, 2021).
Another question is whether there is a lower risk of harm today since more men and their healthcare providers are opting for active surveillance/active monitoring rather than surgery or other treatment options. Active surveillance/active monitoring is often used in stage I or stage II, the earlier stages of the disease (Jain 2021).
Over time patients undergoing active surveillance/active monitoring undergo physical exams, PSA testing, and often prostate ultrasounds and/or biopsies. Healthcare providers only begin treatment if there is evidence that the cancer is progressing. This approach may improve the risk-benefit ratio as well.
Lastly, is there a way to predict more accurately which men have high-risk disease (who should receive cancer treatment) versus men with low-risk disease (who can be monitored)? This may also reduce the adverse effects of overtreatment (Jain, 2021).
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Prostate cancer screening recommendations
Due to the many factors above at play, prostate cancer screening is far from being a no-brainer, and different specialty organizations have changed their recommendations over the years.
The American Urological Association (AUA)
The AUA recommends that men ages 55–69 should engage in shared decision-making with their healthcare providers when deciding whether to screen for prostate cancer (AUA, 2018).
Shared-decision making is a process by which healthcare providers share the best available evidence, weighing the risks and benefits, so that a man can make an informed decision with his healthcare provider’s support.
The AUA also recommends that decisions about screening men aged 40–54 be individualized, with risk factors for prostate cancer (e.g., family history, African American men) taken into consideration. The AUA does not recommend routine screening before age 40 or after age 70. Screening is performed by measuring prostate specific antigen (PSA) levels, sometimes with a digital prostate exam.
The United States Preventive Services Task Force (USPSTF)
The USPSTF has recommendations that are very similar to the AUA. It does not recommend a digital prostate exam for screenings due to the limited evidence that it provides any benefits (USPSTF, 2018).
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The American Academy of Family Practice (AAFP)
The AAFP recommends against routine screening for prostate cancer based on the small benefits and larger risks of screening. The AAFP is unclear about whether healthcare providers should start a conversation with men about screening or should only screen if someone asks for it specifically (AAFP, 2018).
So, should you undergo prostate cancer screening?
As you can see, the decision of whether you should undergo a prostate cancer screening is not so cut and dry. But, while different organizations’ prostate cancer screening guidelines differ in certain respects, all make it clear that screening decisions should be individualized for each man. Risk factors and personal values are important factors when choosing what to do, as is a trusting relationship with your healthcare provider.
References
- American Academy of Family Physicians (AAFP). (2018). Prostate Cancer Screening. Retrieved Nov. 16, 2021 from https://www.aafp.org/pubs/afp/issues/2018/1015/od1.html
- American Urological Association (AUA). (2018). Detection of Prostate Cancer Guidelines Panel of the American Urological Association Education and Research, Inc. Retrieved Nov. 16, 2021 from https://www.auanet.org//guidelines-and-quality/guidelines/prostate-cancer-early-detection-guideline
- Brodersen, J., Schwartz, L. K., Heneghan, C., O’Sullivan, J., Aronson, J. K., & Woloshin, S. (2018). Overdiagnosis: what it is and what it isn’t. BMJ Evidence-Based Medicine, 23(1), 1–3. Retrieved from https://ebm.bmj.com/content/23/1/1
- Fenton, J., Weyrich, M., Durbin, S., Liu, Y., Bang, H., & Melnikow, J. (2018). Prostate-Specific Antigen–Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 319(18), 1914–1931. doi: 10.1001/jama.2018.3712. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29801018/
- Jain, M., & Spra, A. (2021). Prostate cancer screening. [Updated Oct 9, 2021]. In: StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK556081/
- Mistry, K., & Cable, G. (2003). Meta-Analysis of Prostate-Specific Antigen and Digital Rectal Examination as Screening Tests for Prostate Carcinoma. The Journal of the American Board of Family Practice, 16(2), 95–101. doi: 10.3122/jabfm.16.2.95. Retrieved from https://pubmed.ncbi.nlm.nih.gov/12665174/
- Naji, L., Randhawa, H., Sohani, Z., Dennis, B., Lautenbach, D., Kavanagh, O., et al. (2018). Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis. Annals of Family Medicine, 16(2), 149–154. doi: 10.1370/afm.2205. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29531107/
- U.S. Preventive Services Task Force (USPSTF). (2018). Final Recommendation Statement: Prostate Cancer: Screening. Retrieved Nov. 16, 2021 from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.
