MSK Expert Explains New Prostate Cancer Screening Guideline

By Andrew J. Roth,

James Eastham, Chief of the Urology Service at Memorial Sloan Kettering
Summary

An MSK expert comments on a new US Preventive Services Task Force (USPSTF) guideline regarding a type of prostate cancer screening.

The USPSTF has issued an updated guideline for prostate-specific-antigen-based screening for prostate cancer. The new guideline states that prostate-specific antigen (PSA) testing for men between age 55 and 69 should be preceded by a conversation between doctor and patient about the risks and benefits of the test. PSA is a protein produced by the prostate gland and is commonly elevated in men with prostate cancer. For men who report prostate problems, a PSA test can help find the cause.

James Eastham, Chief of the Urology Service at Memorial Sloan Kettering, explains the pros and cons of PSA testing and what patients need to know about the new guideline.

What makes the new guideline different?

The previous guideline, which was only a few years old, recommended against PSA testing in all age groups. The USPSTF gave PSA testing a grade of D, meaning that it was likely to do more harm than good.

The new USPSTF guideline gives PSA testing a grade of C, which essentially means that there are risks and benefits and a doctor should have a discussion with a patient to help reach a decision regarding whether or not the PSA should be checked. This is the strategy that the American Urological Association advocates: It’s called shared decision-making. The new guideline says that for men between age 55 and 69, PSA testing can take place after the shared decision making conversation about pros and cons.

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What’s the downside of PSA testing? Why shouldn’t it be done sometimes?

In prostate cancer, most men do not develop lethal disease. If you treated everyone who was diagnosed with prostate cancer, which is what used to be done, most men would not benefit. They would be undergoing procedures or treatments that would not improve their quantity of life but would affect their quality of life. All treatments have side effects, from sexual function to urinary function, bowel function, and more.

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Even further, most men who have an elevated PSA level don’t have prostate cancer. They just have a high PSA level. These men would have psychological side effects: They’d worry about having prostate cancer when most wouldn’t. Having every man undergo a PSA test without shared decision-making can open the floodgates in terms of procedures, the diagnosis of nonlethal prostate cancer, treatments, and side effects.

Having every man undergo a PSA test every year is not what should be done. That’s what was being done before, and that’s what the USPSTF was reacting to with its D recommendation. It’s also wrong to say that we should never do PSA testing because it has been shown to save lives. We want to test the right men at the right time, following an appropriate discussion about risks and benefits.

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What do we recommend here at MSK?

The USPSTF bases its recommendations largely on prospective trials, which the scientific community doesn’t have a lot of in the area of prostate cancer screening. We have a lot of retrospective data — where we look back on a population — but not prospective data.

Much of the retrospective data show that a PSA test done early — in a man aged 40 to 45 — will assess his risk of developing lethal prostate cancer. From that, you can put a man into one of three groups: a low-risk group (he doesn’t need PSA testing for another five years or so), an intermediate-risk group (he should get PSA testing in another year or two), and a high-risk group (he should be evaluated more closely right away). That’s how we approach the subject of screening at MSK. We want to do a PSA test early, establish risk, and then personalize future follow-up.

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Comments

I am a 69 year Caucasian male and have been getting routine PSA testing with DREs for the past 10 years or so. At the age of 67 my PCP noticed that my PSA had gone to 3.6 from the previous yearly value of 2.6. Although within normal limits she recommended a urology consult. The urologist said that all appeared and felt normal, but suggested a biopsy just to rule out a problem. The results were rather shocking: cancer in three of the cells with a Gleason of 9. I have since undergone a prostatectomy, and 39 treatments of radiation at JHH to cover a 4mm capsular breakout. My PSA has remained undetectable since then. If it weren't for routine PSA testing and an aggressive PCP I would probably be dead now or close to it.

Dear Phil, thank you for sharing your story. We're glad to hear you're doing well.

I'm 62 years old, and my PSA just came back at 4.10, which I understand is somewhat high, especially since 6 months ago it was 2.67. My father died from prostate cancer, so I have no doubt that my Urologist will suggest a biopsy. How invasive is this type of biopsy? Will I be able to perform physical activities (back to work) the next day? I will also be looking for a second opinion from someone who specializes in this at Sloan Kettering. Any suggestions?

Dear Harry, we're sorry to hear that you're going through this. We recommend you discuss the biopsy procedure and recovery time with your urologist. If you are interested in coming to MSK for a biopsy or for a second opinion after you get your results, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Our referral specialists at that number will be able to match you with the MSK specialist who is right for your situation. Thank you for your comment, and best wishes to you.

I have had regular PSA testing since age 45. All returned with a 2. At age 60, with a PSA test in conjunction with a yearly physical, the number rose over 3. After an antibiotic and a PSA re-test, it went back to 2. Each yearly test saw the number rise, always a bit higher, and then fall back.
At age 65 [May 2010] I saw my urologist when the number was over 6. He said something was going on, and suggested a biopsy. That revealed all four quadrants involved.
I had the prostate removed a month later by the urologist using a DaVinci. The pathology showed it was confined with a Gleason's score of 7.
A point I would like to make is that I had no symptoms other than the elevated PSA. Digital and ultra sound exams done prior to the biopsy returned nothing. I had no family history of any cancers, and no urinary problems at all. It was only that I had consistent PSA exams and a urologist that suspected something going on.
My yearly PSAs since have shown no traces.
I am very happy with my decision and the outcome.

Dear Richard, thank you for sharing your story. We're glad to hear that you were happy with your decision. Best wishes to you.

I am 72 years old. At the age of 50 I was diagnosed with prostate cancer- graded at a Gleason score of 5. I had opted for surgery. 1 year 6 months later my psa rose to 0.7. I underwent radiation treatment . My psa remained less than .1 for almost 20 years.
last month I had another psa as part of a physical . My psa has risen from .1 to .3 in a span of 2 years. Just how aggressive is this cancer? What is the likelihood of long term survival? beyond age 72.-provided I don't die of something elese.

the age range shouldn't be the deciding factor. i'm 22 and been suffering with my prostate since i was 16. and because medical studies only look at older men i've been neglected, and it has impacted my life and i'm still not being treated, because i'm young but i have the BPH since i was a teen, E-coli, Staphylocco, strepcolicous came up Bacilli came up in my semen culture, and the urologist dont know what to do because i'm young, this is not right,i'm disappointed in western medical and their one group studies, what about the rest of us thats not in that age group, we get overlooked, we all should be treated, and not based on our age,,

Dear Dominique, we're sorry to hear you've gone through this. Thank you for sharing your story, and best wishes to you.

my psa started out ,07 , 6 months ago,, and now its 48,, and my urine is very foamy has been for years and the prostate is enlarged it hurts when i sit down, and its painful to ejaculate so i do not engage in sexual relations ,at 22, and i'm always fatigued,, Help me

recently diagnosed with PC Gleason score 3+4
PSA jumps between 5-7. Prostate not enlarged and I have no symptoms of PC outside of a main in my pelvis Urologist recommended IMRT over cyberknife due to not enough historical data on CK... if we use what is available which procedure is tracking better for patients moderate PC?

Dear Dan, we're sorry to hear about your diagnosis. We are not able to offer medical advice on our blog, but if you are interested in making an appointment with a doctor at MSK for a consultation, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information. Thank you for your comment, and best wishes to you.

Very informative article about Prostate Cancer Screening Guidelines and importance of PSA test, Thanks for sharing!

I am coming up on 62nd birthday and have always taken excellent care of my health. A year ago, after fighting my primary doctor about getting a PSA test for 7 years, I insisted I get one. He asked whether I accepted the consequences, namely that there could be false positives, a possible biopsy, and possible unnecessary mental and physical anguish. I agreed to this risk due to having lost two friends to rapidly spreading cancers at that time, being vigilant about my health, and experiencing certain unexplained physical symptoms (non urological/sexual) at that time. Making a long story short, I had 3 consecutive PSAs and all scored in high 6s. A 4K Score which indicated a 53% chance (high) of having an aggressive cancer. An MRI using a 3 Skyra magnet detected one major lesion on the capsule and several smaller lesions. 19 cores were taken, using the MRI as a 3D map . MSK graded the worst of them as 3+4=7 Gleason. Due to the position on the capsule and the potential risk of spread outward, I chose to undergo a radical prostatectomy at MSK rather than other alternatives. This was only 3 months from my first PSA and a difficult time in my life. I went in for surgery on a Thursday morning and was home by 11AM the next morning. The hospital experience was first class all the way. I left with a catheter which was the bane of my existence for about a week, though I started walking immediately. The doctor, PAs, and nurses were able to preserve my nerve bundle and found nothing in the margins, thank God. No chemo or radiation was required. I was working from home 3 days after my surgery and took only Tylenol for about 2 days after surgery. I was back in the office after 4 weeks and gradually resumed exercising. My PSA has been undetectable since then. I have good sexual function and no incontinence. I am back to my regular exercise regimen, diet, etc. There are not enough good things I can say about the way I have been treated at MSKCC. Advice: be vigilant, be your own advocate, use trustworthy professionals, and be thankful for loved ones who help you through difficult times.

Dear Harry, thank you so much for sharing your experience. We're thrilled to hear you're doing well. Best wishes to you!

If a psa test is nothing more than a blood sample, what's the problem with having it done often.

Dear Ron, the problem with having PSA done too often is that it can lead to unnecessary biopsies and potentially to psychological distress. Thank you for your comment.

Why isn't there a mention of the reasons or causes for PSA false positives? Of all the patients' stories above not one response talks about false positive of PSA results.

I am after surgery Jan 2009 and psa was 0.19 gleason was 4+5
since than intermidiate Hormonal therapy
last year metastatics found at bone marrow by PET/CT PSMA and hormonal therapy hold the PSA at around 0.3 but have some bone pain (attach esrogen patch)
Should I add or change therapy ? thx Janek

Dear Jacob, we're very sorry to hear about your recurrence. Unfortunately we are not able to offer medical advice on our blog. If you would like to come to MSK for a consultation, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

I am 83 years of age . My PSA has risen to 8.3 and my Urologist has recommended a prostate ultrasound and biopsy I have no other prostate problems. Do you recommend that I proceed with the procedure? Many thanks

Dr. Eastham surgically removed my Prostrate almost 10 years ago. My PSA test have been <0.1 since then (just had one last month. I have been experiencing some abdominal pain and slight nausea feeling for the past few weeks. Will the PSA test detect possible colon or stomach cancer? I had a recent endoscopy performed and they put me on Rabeprazole for stop acid issues.

Dear Joe, we're sorry to hear that you're experiencing these problems. The PSA test detects a protein that is made by the prostate, so it would not be elevated for another type of cancer. We recommend you discuss your concerns with your primary care provider. Thank you for your comment, and best wishes to you.

I’ve noticed that Dr Vickers, Dr Scardino and Sloan Kettering in general have said if at age 60the psa level is under 1.0 it isn’t necessary to be screened anymore. My psa has stayed under 1 through age 66 but I still was screened annually. At age 67 it jumped to 1.4 and then 2.2 at age 68 which despite your guidelines has me a bit nervous. I have an appointment with my urologist but considering your research is it probably some type of inflamation causing the rise?

Dear Barry, you can find MSK's screening guidelines here: https://www.mskcc.org/cancer-care/types/prostate/screening/screening-gu…

We recommend that you discuss the specifics of your case with your doctor. If you are interested in coming to MSK for a consultation, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

I recently had a fusion biopsy, which shown that, one side of my prostate has cancer cells. My doctor called me and advised me to have the prostate remove. She also offered different types of other choices. The cancer is localized and hasn't been spread to any other parts of my body.
I would like to seek a second opinion before having surgery. I' m sure there are some better alternatives out there, other than surgery. I would like to make an appointment to see one of your Board certified Urologists for further assistance.

Dear JD, we're sorry to hear about your diagnosis. If you're interested in coming to MSK for treatment or a second opinion from one of our experts, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

I am fit and will be 77 years old in September.
I have BPH and have treated it with Flomax for 5+ years. I normally sleep until 5:00 am which is OK for me.
My brother , 78 years old has aggressive prostate cancer.
I have experienced a jump in PSA as follows:
3/15: 4.1 (March ,2015)
9/15: 4.2
2/16: 4.5
3/17: 6.4
6/17: 6.5
9/17: 6.4
5/18: 10.2

In 2014 MRI showed Prostate size of 58 mL with probability of tumor on lesion # 1 was 3 on a scale of 1-5. Lesion# 2 indicated probability of 2.

In 1999 I had emergency surgery for colon cancer with a partial removal of my colon. including ileum and appendix.

What are my next steps. I hope the PSA is up as a result of my enlarged prostate. I want to avoid over treatment. I think next step is an MRI. What do you suggest?

Dear Billy, unfortunately we are not able to offer medical advice on our blog. If you'd like to speak with someone about arranging a consultation with an expert at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment and best wishes to you.

Hi Folks. My dad died of aggressive prostate cancer. I'm 56, and my last PSA was in January of 2016. It came in at .71. Based on this number and Sloan-Kettering's guidelines, I should get tested again at age 60. However, given my family history, would it be prudent to get tested more often?

My psa has been low I am 65 it was first 2.2 and now it’s down to 1.2 do you think if I get tested once a year it would be sufficient enough

Dear Anthony, we are not able to offer medical advice on our blog. We recommend that you discuss this with your healthcare team, who have access to your records and are familiar with your medical history. Thank you for your comment, and best wishes to you.

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