Department of Surgery Chair Peter Scardino on Smarter Screening for Prostate Cancer

Pictured: Peter Scardino

Department of Surgery Chair Peter Scardino

Update: Recent news headlines have raised questions about the value of the PSA test, a blood test used to screen for prostate cancer. The debate over PSA and its usefulness can leave men who are at risk for the disease wondering who to listen to and what course of action to take. Does the PSA test lead to overdiagnosis, or does it help detect cancer at an early stage? 

At Memorial Sloan Kettering, we’re always in pursuit of the most accurate information and latest treatment updates. Our doctors and researchers continue to be at the forefront of research into PSA screening, utilizing the most precise data and information available. Below is a blog post that addresses the debate over PSA and MSK’s balanced approach when incorporating these test results into the whole picture of a patient’s health. Stay tuned to our blog for the latest news on prostate cancer screening and treatment.  The long-standing controversy about the value of the prostate-specific antigen (PSA) blood test for the detection of prostate cancer intensified last year when the US Preventive Services Task Force (USPSTF) recommended against it, despite evidence that PSA screening saves lives.

Memorial Sloan Kettering urologist Peter T. Scardino, Chair of the Department of Surgery, recently coauthored an article with research methodologist Andrew Vickers for the American Urological Association’s AUANews, which suggests taking a balanced approach to prostate-cancer screening and treatment.

We spoke with Dr. Scardino to learn more.

What is the prostate-specific antigen?

PSA is a protein made by cells of the prostate gland. Although it’s normal for men to have low levels of PSA in their blood, prostate cancer can increase a man’s PSA levels. Doctors may recommend a biopsy – the removal of cells or tissue from the prostate gland for examination by a pathologist – for men with an elevated PSA level (greater than or equal to 3 ng/mL) or a rising value over time.

However, an elevated or rising PSA level alone does not always mean that a man has prostate cancer. In fact, most of the time an elevated PSA level also comes with age, and with the onset of other, noncancerous conditions such as benign prostatic hyperplasia, in which the prostate is enlarged, or prostatitis, an inflammation of the prostate gland.

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Why has PSA screening been criticized?

The problem is that an elevated PSA test may trigger a biopsy that incidentally finds a low-risk cancer that poses little danger to a man’s health and is very unlikely to become life threatening. Most men with such cancers are treated, even though their cancer is not aggressive and might not cause symptoms during the course of their natural lives. These treatments can lead to long-term health issues that impact quality of life. False-positive test results can also result in an unnecessary biopsy that has its own side effects, such as bleeding or infection.

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What are the advantages of using PSA testing to detect prostate cancer?

A number of clinical trials have demonstrated that PSA screening can reduce the risk of prostate cancer death by 20 to 44 percent over ten to 14 years when compared with not screening. If testing substantially decreases, deaths from the disease are likely to rise to the high levels seen prior to the widespread use of PSA screening.

Instead of abandoning PSA testing altogether, we should consider better, smarter ways to use the tool to continue to give patients the benefit of early detection and effective treatment for dangerous prostate cancers, while reducing the risk of harm from overdiagnosis and overtreatment.

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How can we strike a balance between the harms and benefits of PSA screening?

We can achieve this balance by using a more-selective and targeted approach to screening. Screening efforts should be focused on men who are at the highest risk of developing a life-threatening prostate cancer. This includes men with a family history of the disease, men with a genetic predisposition to prostate cancer, and African American men.

Older men stand to benefit the least from PSA testing. Research has shown that screening men over age 70 is not likely to be beneficial, but they continue to be screened at high rates.

Memorial Sloan Kettering’s prostate cancer screening guidelines recommend that men have an initial PSA test at age 45. Based on the results of that test, men at low risk for developing prostate cancer can be tested every five years, but men at an intermediate to high risk should receive more frequent evaluations every two years.

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How can doctors further reduce the risk of harm from overtreatment of low-risk prostate cancers?

A diagnosis of prostate cancer requires a biopsy, and men should not have a biopsy without a good reason. In fact, most men with an elevated PSA level do not have prostate cancer. PSA levels vary considerably and should be confirmed with a repeat test in six to 12 weeks before a doctor recommends a biopsy.

In the future, new blood markers now in development such as free-to-total PSA ratios, the 4K score,* and the Prostate Health Index may be able to increase the accuracy of PSA testing in predicting the presence of cancer, especially aggressive disease.

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When should prostate cancer be treated?

Prostate cancer treatments such as surgery and radiation therapy can lead to long-term problems with urinary, bowel, and sexual function. At Memorial Sloan Kettering, we don’t recommend treating prostate cancer unless it is aggressive.

Many cancers detected with PSA screening are at low risk for progressing and do not need immediate treatment. Men found to have a low-risk cancer should consider active surveillance, or watchful waiting, which involves regular monitoring of the cancer for any signs of progression or aggressiveness.

Active surveillance would also be an appropriate option for elderly men with intermediate-risk cancer, as it has been shown that surgery and radiation are usually of little benefit for men over 70, unless a man is unusually fit and otherwise healthy. Such patients should be carefully evaluated, given a repeat biopsy to rule out more-aggressive cancer, and then followed regularly with periodic biopsies.

If treatment for prostate cancer is indicated, studies show that outcomes are better when it is delivered by high-volume practitioners or at high-volume centers such as Memorial Sloan Kettering, in order to reduce the risk and severity of side effects that may adversely affect a man’s quality of life.

Urologists and primary care physicians who adopt this overall balanced approach and modify the way they counsel their patients about prostate cancer screening and treatment could help countless men in their care.

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*Disclosure: Drs. Scardino and Vickers are inventors of the 4K score and are involved in its commercial development. Dr. Scardino is a paid consultant to the company to which the 4K score is licensed.


Commenting is disabled for this blog post.

I was very skeptical of the recommendation to severely limit PSA screening when it was made last year. In my situation, I had a 3.9 PSA score from my 40th birthday physical. Over the next 10 years, I watched my PSA rise every year. I had several biopsies and was diagnosed just short of my 50th birthday. Dr Scardino did my surgery in 1999 after seeing an aggressive rise in the PSA score in just a few months.

Under the "new" guidelines, my cancer probably would not have been caught before it metastasized. Scardino's and Vicker's "smart" recommendation to the USPSTF standards seems like a much more intelligent approach that would reduce cost, avoid unneeded procedures yet use the PSA test in a a way to continue to save lives. Today, I'm prostate cancer free and living a normal life. Other men have that right as well.

I had yearly PSA screenings and 8 years ago my PSA went up from a normal 1.3 to a 3.9. My local Urologist suggested we wait and monitor but I insisted on a Biopsy which revealed Cancer. I went to SK and had surgery by Dr James Eastham and I am now cured. I recommend PSA test every year , especially for those men over 50 years old.

Dear Professor Scardino,
I am Urologist in Spain. What do you think is the right treatment for a high risk patient, diagnosed with PSA of 580 ng/ml but without imagen of metastasis? A local treatment is justified?
Thank you in advance

Hi Cesar, we are not able to answer individual medical questions on our blog. If your patient would like to get a second opinion from a Memorial Sloan-Kettering doctor, we recommend that he goes through our International Center. You can find more information at Thank you for your comment.

Dr. Scardino,
I have read that performing a 3 Tesla multiparametric MRI with spectroscopy
will pinpoint areas of concern for cancer in the prostate.
After the areas are identified a limited TARGETED biopsy
is performed instead of the usual 12 sample TRUSS biopsy.
Is the above suggested by and performed at Memorial Sloan.
If you have time to answer - your opinion would be appreciated.

John, we have forwarded your question to Dr. Scardino and will post a response if we receive one. Thank you for your comment.

John, Dr. Scardino provided this response to your question:

MRI is a valuable test to identify cancer within the prostate, but it is not perfect, and we generally do not use it before doing the first biopsy in a man with an elevated PSA, especially if the digital rectal exam is abnormal. I would suggest an MRI if you’ve already have one or more biopsies negative for cancer, but your PSA is persistently elevated. It is still a controversy whether to biopsy only the abnormal areas on MRI, i.e., targeted biopsies, or to do systematic biopsies as well. We generally do both to avoid missing an aggressive cancer.

i am 76 and recently my psa was 4.68 and 4.00 in 2012 i have bhp for a long time my free psa is 43. do you recommend a biopsy

When is "saturation biopsy" under anesthesia indicated and how do patients recover?

Allan, for more information about this procedure we recommend you call the National Cancer Institute’s Cancer Information Service at 800-4CANCER. If you’d like to speak to a doctor at Memorial Sloan Kettering, you can call 800-525-2225 or go to for more information on how to make an appointment. Thank you for your comment.

Is the 4k score available?

Allan, Memorial Sloan Kettering is not offering the 4k score test at this time. Thank you for your comment.

Dear Dr.Scardino, what about new test which save from,same times, unnecessary biopsy operation--PROLARIS TEST or DCA 3 ? Are they performing in Memorial Cancer Center? Thank You for Your answer.

Vladimir, we passed this question on to MSK prostate surgeon James Eastham (Chief of the Urology Service) who responds: The PCA3 test is used in the setting of a man with an elevated PSA with a prior negative biopsy to determine if a repeat biopsy is warranted; we do offer this test at MSK. Prolaris is a genetic test (not yet FDA approved) used in the setting of a prostate biopsy that shows low risk cancer to determine if the genetic profile is consistent with low-risk cancer. This is offered at our center.

Dear Dr. Scardino,
The PCA3 test has been criticized for detecting the level of likelihood of prostate cancer in men with negative biopsies because 1) the test does not differentiate between non aggressive cancer and aggressive cancer and 2) there are urologists who use PCA3 test results to encourage patients with a history of negative biopsies to have a saturation biopsy which may simply confirm non aggressive cancer but create a serious risk of infection from such a biopsy. How do you react to such criticism? Secondly, given the fact that the new 4Kscore Test is also a predictive test, do you recommend a saturation biopsy if a patient with prior negative biopsies, but an elevated PSA and a 4K score indicating a risk of aggressive cancer has a fusion biopsy using the guidance of a multriparametric MRI where the biopsy is again negative? In summary then, is there not a risk that the 4Kscore test could actually lead to needless biopsies, especially a saturation biopsy, which prove negative and do not confirm what is essentially a predictive algorithm? Thank you very much for your time and consideration.

Dear Peter, we forwarded your inquiry to Dr. Scardino and he responded:

“Dear Mr. Levine:

Thank you very much for your comment regarding the PCA3 test. I agree that the PCA3 test distinguishes between the presence and absence of cancer, but is not very good at characterizing the seriousness of the cancer. It should be taken in context of all the other data, including the PSA changes over time, the free PSA, the physical examination, and MRI results. We rarely recommend a saturation biopsy today.

The 4K score, I believe, is quite different. It has been shown to be much more predictive of the presence of a high-grade (Gleason 7 or higher) cancer than the presence of any cancer, and can actually help distinguish between the two. When one sets a threshold for the presence of a high-grade cancer, such as 10%, one can reduce the number of biopsies indicated by an elevated PSA alone by about 50%. I would not recommend a saturation biopsy in someone with an abnormal 4K score and an elevated PSA who had prior negative biopsies, but I would recommend an MRI of the prostate with guided biopsies of any suspicious abnormal areas. A saturation biopsy is rarely indicated.

Consequently, I think the 4K score would not lead to more saturation biopsies with consequent risk of bleeding or infection, but to fewer biopsies overall.

I hope this information is helpful

Peter Scardino, MD”

Thank you for your comment.

Does Sloan Kettering use the 4K score test?

Dear Stuart, we checked with Dr. Scardino and he said that the 4k score test is still in development and not being used clinically at this time. Thank you for your comment.

what are your most recent findings on protontherapy?

thank you

Hi Jerry, thanks so much for your question. We reached out to Dr. Oren Cahlon to learn more. He said: “At this time, proton therapy is considered to be a type of conformal external beam radiation therapy (similar to intensity-modulated radiation therapy, or IMRT) and is a good option for men with localized prostate cancer who wish to pursue external beam radiation. It is not known whether there are benefits to proton therapy compared with other types of radiation therapy — there are several ongoing clinical trials investigating this. MSK is participating in a national randomized trial comparing IMRT and proton therapy.”

recent nodule found during dre7, psa of 2.1. 70 yrs. only thing offered was traditional biopsy, looking for alternative testing. Thanx, Rich

Dear Rich, if you would like to make an appointment to discuss what options may be appropriate for you, please call our Physician Referral Service at 800-525-2225. To learn more about our approach to diagnosis and treatment of prostate cancer, please visit Thank you for reaching out to us.

Dear Dr. Scardino,

If a man with a benign enlarged prostate has no problem urinating by taking Tamsulosin/Flomax on a daily basis, should he also take Avodart or a comparable drug in this same category as Avodart? My concern, of course, is with relatively recent studies that indicate there is evidence that Avodart and drugs in this same category can actually increase the risk of developing small but aggressive prostate cancer cells. Given the fact that there are reputable medical experts on prostate cancer who favor the use of Avodart as well as reputable medical experts who do not favor its use, would caution dictate that the use of Avodart and any drug in this classification be avoided for the time being if a man with BPH has no difficulty urinating using Tamsulosin/Flomax or another drug in the same category as Tamsulosin/Flomax? I also understand that a 4K Score test is only reliable if the man has been off Avodart or a similar drug in this category for at least six months. Thank you for your time and consideration.

Peter LeVine

Peter, thank you for reaching out. Unfortunately, we are unable to answer specific medical questions on our blog. If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to Thanks for your comment.

With all due respect, my question is not a specific medical question or a question unique to any one individual. Rather, I have brought up the well known controversy over the use of Avodart and other drugs in this same category. I have simply asked Dr. Scardino when, if at all, he recommends the use of Avodart or any drug in this same drug category for treating BPH given the controversy over whether Avodart and other drugs in this category cause small but high grade prostate cancer cells. There are many readers of this public forum who would appreciate Dr. Scardino's thoughts on this medical controversy. Very importantly, Dr. Scardino may agree with other physicians who do not believe the 4K Score test is of any value if the patient is taking Avodart or a similar class of drugs. Thank you for your time and consideration.

I'm not sure if the above message went through. I apologized for any duplication.

Peter, our apologies for the delay. We have now been able to reach Dr. Scardino and here is his response to your query:

“A man who has no trouble urinating while taking an alpha-blocking drug such as Rapaflo or Flomax does not need to take a drug such as Avodart (dutasteride) or finasteride unless his urinary symptoms become worse and his prostate is enlarged (greater than 30 grams). The FDA did not approve dutasteride or finasteride to prevent prostate cancer, but does approve their use as safe for relief of symptoms from benign prostatic hyperplasia.

It is true that the 4K score is not accurate for men taking dutasteride or finasteride.”

What should I do if my surgeon failed to disclose negative findings on my MRI prior to surgery? I do not pose this as a legal question, but as an ethical one.

If you are an MSK patient, you can contact our Office of Patient Representatives to discuss this. They can be reached at 212-639-7202. You can also go to… to find out about requesting an ethics consultation.

If you’re a patient at another hospital, we recommend that you reach out to their patient representatives or their ethics committee. Thank you for your comment.

Dr. Scardino,

It has been recommended that I have an MRI of my prostate and I am clausterfobic. Can an Open MRI be done on the prostrate and if so do you or the hospital recommend a location? I have been unable to find such a facility? Thanks in advance for your thoughts.

William, thank you for reaching out. Memorial Sloan Kettering does not have an open MRI machine, but we do have multiple wide-bore MRI systems which have a much larger region inside and can be used for larger patients, or those with claustrophobia. Our physicians may also prescribe an anti-anxiety medication to help patients during the exam.

We are not able to make recommendations about open MRIs at other institutions, although open MRIS are not typically used for prostate imaging. We suggest you ask your treating physician or imaging radiologist for recommendations. If you are being treated elsewhere, you also can ask your physician for a prescription for a mild sedative prior to your scheduled examination.

Dear Dr. Scardino: I am 57 years old and in pretty good physical shape. I have been having PSA blood tests for the last 7-10 years and they have always been "normal" meaning always under 2, sometime under 1. I have also been having DREs for that same period of time, always normal. I had a PSA about 6-8 weeks ago and the result was 4.3 which was a concern to me and my regular doctor. He did another PSA last week and it was 2.8. I have an appointment with my urologist Dec. 4. Do you think these scores, regardless of the next DRE, warrant a biopsy? If so, is it recommended to have it done at MSKCC or can my urologist perform it? Many thanks.

Dear Dr. Scardino,

I hope you can shed some light on this issue since you are familiar with the 4K test.
If, aside from an elevated PSA, a variety of tests (eg., free PSA, PCA 3, MRI 3, biopsy) indicate a benign prostate condition and the 4K score indicates aggressive cancer, is there any way to resolve that inconsistency other than a biopsy?
Further, can a biopsy be safely performed on an inflamed or infected prostate?
Thanks so much for your time,

What is the latest status on the 4K Score Test.
Is there a percentage of accuracy.

Dear Bob, we sent your question to Dr. Scardino and he responded,

“The 4K test is commercially available through OPKO Laboratories. It involves a simple blood draw and reports back the PSA level, the Free PSA, and the 4K score, which predicts the probability that the patient has a high grade (Gleason 3+4 or more) cancer in the prostate. It is highly accurate and has been tested on over 15,000 men in Europe and the US.”

Thank you for your interest.

I have been trying to get a Prostate Health Index Test, here in central NJ with no success. Is it available at Memorial Sloan Kettering? It is my understanding it more accurate then the present PSA and 4K PSA tests.

Dear John, we do not offer prostate health index (PHI) or the 4K Score, PHI along with the 4K score are second line screening tests done in men with an elevated PSA to determine the likelihood cancer is present and help a man decide if he will undergo a biopsy. Thank you for reaching out to us.

Dear Dr. Scarpino

With the apparent vastly superior accuracy in prostate cancer detection of the multi parametric MRI scan and guided biopsy, which apparently has only a 10% error rate vs. up to a 40% error rate with trusss biopsies, why should random blind truss biopsies be done at all?

Dear Jeremiah, we forwarded your inquiry to Dr. Scardino and he responded:

“If a suspicious area is seen on MRI, targeting those areas on an ultrasound-guided biopsy (or a “fusion” biopsy) is more accurate than simply doing ultrasound - guided systematic biopsies alone. However, the MRI may not show any suspicious findings, or the patient may not be able to have an MRI (because of severe claustrophobia, or a medical implant such as a pacemaker), or high quality MRI may not be available in the geographic region or the cost may be too high. In that case, systematic ultrasound guided biopsies are 80-90% as accurate as MRI targeted biopsies. If an initial biopsy is negative, it can be repeated with more biopsies taken from the anterior transition zone, which will find the vast majority of clinically important cancers without MRI. All in all, we prefer to have an MRI before doing a biopsy, but it is not mandatory and has never been fully tested in a properly done trial to prove its superiority.”

We hope this is helpful. Thank you for reaching out to us.

Dear Dr. Scardino,
Several medical studies have indicated that men who suffer unwanted day time fatigue from a daily night time dose of tamsulosin or other alpha 1 blocker drug may experience less unwanted day time fatigue by reducing the frequency of use to every other day or every two or three days. The benefit of reduced unwanted daytime fatigue must, of course, be balanced against a potential worsening of BPH symptoms of frequent urination or difficulty passing urine. There are also medical studies that show a correlation between urinary retention and an increased total PSA.

My question is whether both unrelated studies would indicate the possibility, not the likelihood, but the possibility of a correlation between reduced usage of an alpha blocker drug/ increased urinary retention and and an increase in total PSA.

Your consideration of answering my question will be most appreciated. Thank you.


Peter LeVine

Dear Peter, we sent your inquiry to Dr. Scardino and he responded:

“Urinary obstruction and retention have been associated with an increased PSA but PSA levels are a poor indicator of the degree of obstruction.”

Thank you for reaching out to us.

Dear Dr. Scardino,

Many of your readers who value your experience and expertise would appreciate knowing the percentage likelihood of an MRI targeted biopsy actually finding high grade cancer (Gleason 7 or higher) following a 4K Score prediction of high grade cancer. In other words, what is the risk of what could, perhaps, be described as a false positive result from a 4K Score test where the blood test predicts high grade cancer that is sampled in an MRI guided biopsy? Conversely, what is the risk of a 4K Score test providing a false negative result - where an MRI guided biopsy finds the presence of high grade cancer (Gleason 7 or higher) which the the 4K Score failed to predict? These questions are, I believe, important. While no man wants an unnecessary MRI guided biopsy, is there a risk the 4K Score test could be removing the "gold standard" MRI guided biopsy from consideration when PSA test results would indicate the need for such a biopsy? Thank you very much for your time and consideration. Peter LeVine

Dear Peter, we sent your question to Dr. Scardino and he answered:


Thank you for your interest.

What is the predictive formula for the 4KScore test? The PHI score is described in various papers, but I can't find a paper that shows the predictive model for the 4KScore test. Also, is an anonymized copy of the data set (by which I mean the raw data) on which the test is based publicly available? In fact, are any raw data on the kallikrein markers publicly available? Thank you.

Is 4k testing available?

Dear Richard, we do not perform the test in MSK’s hospital lab, but we often refer patients to outside labs that do collect and process specimens for the test and send us the results. Thank you for your comment.

I have two 4K scores of 13 and 15%. I have also been self-catheterizing for over 25 years (neurogenic bladder). As the threshold for 4K screening is 7% (per my urologist), was is the impact of self-catheterizing 5 times per day on the 4K score)?
Note: just had a prostate MRI done and will be seeing my urologist on the results on 12/5/17 - trying to be better prepared with right questions.
Thank you in advance.
Jeffrey Davis