Prostate cancer is the most common cancer affecting American men other than skin cancer and the second leading cause of male cancer deaths. The American Cancer Society estimates that about 313,780 men will be diagnosed with prostate cancer and more than 35,000 will succumb to the disease in 2025. The introduction of the prostate-specific antigen (PSA) blood test as a prostate cancer screening test (early detection) in the early 1990s led to a dramatic 50% decline in prostate cancer deaths.
Subsequent studies have shown, however, that many screen-detected prostate cancers are slow growing (indolent) and often can be managed conservatively via active surveillance with close monitoring for many years, thereby avoiding the risks of urinary incontinence and sexual dysfunction that sometimes are associated with surgery or radiation treatment.
Prostate cancer screening efforts have been hampered by the U.S. Preventive Services Task Force, which initially recommended against prostate-specific antigen screening for older men (75 years and older) in 2008, and in 2012 recommended against screening for all men concluding that the harms of screening, due to the overtreatment of low-risk prostate cancer patients outweighing the benefits.
However, a subsequent analysis of one of the studies impacting the task force’s decision was found to be flawed due to an inaccurately reported rate of prostate-specific antigen testing in the control arm of the study.
In 2018, the task force reversed its Grade D decision (no screening for all men) to a Grade C decision: “for men age 55-69, clinicians should inform men about the potential benefits and harms of screening.” There is no doubt that men who are screened have a lower risk of advanced disease and lower risk of death from prostate cancer. With the use of additional biomarkers and prostate MRI, the diagnosis of men with prostate cancer is more precise and avoids the detection of low-risk indolent prostate cancer and rather focuses on the early detection and effective treatment of more clinically risky prostate cancer.
Subsequent to the task force’s recommendations about screening, several studies revealed concerning findings including increased rates of advanced prostate cancer at presentation. Our local San Diego study, published in 2016 in the New England Journal of Medicine, revealed worrisome, more aggressive prostate cancer pathology at the time of prostate cancer diagnosis.
At that time, we opined that “should this trend continue, we may return to the pre-PSA era and miss the window of curability for many men.” Sadly, a recent study published in the Journal of the American Medical Association concluded that “among California residents, the incidence of distant stage prostate cancer increased throughout the state between 2011 and 2021 and mortality rates plateaued between 2012 and 2021, ending previous decades of decline. Implementation of more effective prostate cancer screening strategies are critically needed.”
Currently, prostate-specific antigen testing remains underutilized with only 42% of White men and 34% of Black men over the age of 50 getting tested. These observations warrant an urgent standard prostate cancer prostate-specific antigen screening approach to halt the rapid rise in advanced prostate cancer and prevent the likely subsequent increase in men dying from prostate cancer in the future.
One major challenge is the variation of different guideline recommendations. In general, a prudent approach should be to offer patients screening based on their individual risk for developing prostate cancer, if they have a 10-15 year life expectancy and are well-informed.
When to start screening, when to stop and how often to screen is quite controversial. The National Comprehensive Cancer Network suggest starting screening at age 40-45 and stopping at 75, with some exceptions.
Men with a family history of prostate cancer and Black men should start screening earlier in their 40s and should be tested more frequently. The incidence (new cases) and mortality (deaths) from prostate cancer is significantly higher amongst Black men.
Not all prostate cancer needs to be treated as many “low-grade” cancers are slow growing and can be carefully monitored. To avoid overtreatment of slow-growing prostate cancer, men diagnosed with low-risk disease should be managed with active surveillance that includes close monitoring with prostate-specific antigen (testing, periodic prostate biopsies and imaging), with the intention of treating and curing the prostate cancer if the disease worsens.
Educational programs are needed to help men understand the benefits and risks of prostate cancer screening. More widespread prostate-specific antigen testing will save lives. We now have the ability to more precisely diagnose and treat men with prostate cancer while avoiding the overdetection and overtreatment of indolent prostate cancer.
Gaylis, M.D., is executive medical director at Unio Health Partners and voluntary professor of urology at UCSD and lives in San Diego. Dato, M.D., is the medical director at Unio Health Partners and lives in Rancho Peñasquitos. Kane, M.D., is the senior assistant vice chancellor of clinical affairs and a professor of urology at UC San Diego Health Sciences and lives in Del Mar.
