From the Guidelines
Prostate cancer screening should be individualized based on personal risk factors, age, overall health status, and personal preferences after discussing the potential benefits and limitations with a healthcare provider. Men should begin discussing prostate cancer screening with their doctor at age 50, or earlier at age 45 if they have risk factors such as African American race or family history of prostate cancer 1. The PSA test measures the level of PSA in the blood, with levels above 4 ng/mL generally considered elevated and potentially warranting further investigation. However, PSA levels can be elevated for reasons other than cancer, including benign prostatic hyperplasia, prostatitis, or recent ejaculation. If PSA levels are elevated or the DRE reveals abnormalities, additional testing such as an MRI or prostate biopsy may be recommended. Regular screening is important because prostate cancer often has no symptoms in early stages when it's most treatable.
Some key points to consider when discussing prostate cancer screening with a healthcare provider include:
- The potential benefits of screening, including the possibility of detecting cancer at an earlier stage when it is more treatable
- The potential risks of screening, including the possibility of false-positive results, overdiagnosis, and overtreatment
- The importance of individualizing the decision to undergo screening based on personal risk factors, age, and overall health status
- The need for ongoing discussion and risk assessment if biopsy is performed, as biopsy results can be complex and may require further testing or treatment 1.
It's also important to note that the use of PSA testing for the early detection of prostate cancer remains controversial due to strong evidence for overdiagnosis and overtreatment, and that the decision to undergo screening should be made after careful consideration of the potential benefits and limitations 1.
From the Research
Prostate Cancer Screening Methods
- Prostate-specific antigen (PSA) testing is a common method for screening prostate cancer, and its effectiveness has been compared to digital rectal examination (DRE) in various studies 2, 3, 4.
- A study published in 1993 found that PSA testing is as effective as or more effective than DRE for detecting prostate cancer, and the combined use of both methods provides a more complete evaluation of the prostate gland for malignant involvement 2.
- Another study published in 2017 compared the efficacy of DRE and PSA in the early detection of prostate cancer and found that PSA detected significantly more tumors than DRE, with a cancer detection rate of 4.6% for PSA and 3.2% for DRE 3.
Digital Rectal Examination (DRE) in Prostate Cancer Screening
- A systematic review and meta-analysis published in 2024 found that DRE has a low diagnostic value for prostate cancer detection, with a pooled positive predictive value of 0.21, similar to that of PSA, and a significantly lower cancer detection rate than PSA 4.
- However, a study published in 2020 found that DRE can still be useful in predicting the presence of clinically significant prostate cancer, particularly in men with low PSA values, and a suspicious DRE can prompt further assessment 5.
Prostate-Specific Antigen (PSA) Testing
- A study published in 2024 found that PSA testing may lead to a small reduction in prostate cancer-specific mortality, but it can also cause significant harms related to false-positive test results, unnecessary biopsies, overdiagnosis, and overtreatment 6.
- The same study recommended shared decision-making before initiating screening and suggested screening every 2 to 4 years in men 55 to 69 years of age at average risk 6.
Combination of Screening Methods
- A study published in 1993 found that transrectal ultrasonography (TRUS) is more costly and does not add appreciable detectability when results of both DRE and PSA determination are normal, and it is best reserved for patients who have abnormal results of DRE or increased PSA values 2.
- Another study published in 2017 found that the use of PSA in conjunction with DRE enhances early prostate cancer detection, and prostatic biopsy should be considered if either the PSA level is greater than 4 μg./l. or DRE is suspicious for cancer, even in the absence of abnormal TRUS findings 3.