An Individualized Approach to Prostate Cancer Screening

December 01, 2020

It has become clear that screening for prostate cancer prevents men from dying of the disease. The question is how to screen.

Physicians are now able to do better, more personalized screening that goes beyond simply checking levels of prostate-specific antigen (PSA) in the blood, says urologic oncologist Jonathan Shoag, MD.

“It used to be you’d go to your primary care doctor, you’d have your PSA checked every year, and once it hit a certain level, it would trigger a biopsy,” Dr. Shoag says. “We now know that’s not the best way to screen."

Adapting screening to an individual patient’s risk is much more powerful. Dr. Shoag says. “The foundation of this strategy is obtaining a baseline PSA level in a man’s late 40s or early 50s and tailoring screening accordingly," he says.

The PSA Test

PSA is a protein produced by cancerous and noncancerous tissue in the prostate, a small gland that sits below the bladder in men.

The test has limitations, however. While high levels of PSA may indicate prostate cancer, many other noncancerous conditions, such as an enlarged or inflamed prostate, also can increase PSA levels. Also, around 30 percent of men with prostate cancer detected by PSA tests have tumors that neither cause symptoms nor present a threat to health or life.

While PSA screening is good at finding cancers, many prostate cancers are indolent -- meaning it does not cause symptoms or put a man’s health at risk, Dr. Shoag says.

“The question is how do we find the cancers that are going to put people at risk, and not find those that will not,” Dr. Shoag says.

Newer approaches to screening can provide a more targeted method to detect those cancers that pose the most health- or life-threatening disease, and avoid detecting those that will not.

A More Nuanced Approach

A more nuanced approach to prostate cancer screening is adaptive screening. In addition to PSA levels, the approach takes an individual’s risk factors into account, Dr. Shoag says, such as family history and race (African American men are at substantially higher risk of dying of prostate cancer). Newer strategies consider whether PSA levels change over time, and often incorporates other biomarkers such as prostate magnetic resonance imaging (MRI) and other tests.

With adaptive screening, men who have a higher risk of developing prostate cancer have more frequent screenings while men who are at lower risk have them less frequently.

Deciding whether a man has a low or high risk for developing prostate cancer starts with a baseline PSA test, taken when a man is in his late 40s or 50s.

If your PSA level is very high compared to others your age, or then becomes higher when you’re in your 50s, you are at a greater risk of developing prostate cancer, and of developing life-threatening prostate cancer.

Screening Is Important

“This is the aspect of PSA screening I feel most strongly about: All healthy men, particularly those at higher than average risk based on family history or race, in their late 40s or 50s should have a PSA test to give you a sense of your risk relative to the rest of the population,” Dr. Shoag says.

If that PSA level is very low, you have a very low risk of dying of prostate cancer over your lifetime. If that PSA level is on the higher end, you have a higher risk and should be a candidate for more screening, he says.

“I think adaptive prostate cancer screening should be performed in all healthy men," Dr. Shoag says. "And the reason for that is if you look over the course of a man’s lifetime, the benefits of prostate cancer screening are really substantial. If we find the cancer early, which means it’s localized in the prostate, where it hasn’t spread, our cure rates exceptional.”