What a urologist wants you to know about prostate screening

CNN

2 days ago

When I learned that former President Joe Biden had not undergone prostate-specific antigen (PSA) screening since 2014—and was later diagnosed with metastatic prostate cancer—I knew there would be renewed interest and debate about prostate cancer screening guidelines.
As a urologist, I regularly discuss the complexities surrounding PSA testing with my patients. The PSA test remains valuable for early detection, but it continues to generate controversy due to its limitations. Here's what you should know about PSA screening, why medical guidelines vary and why individualized approaches are essential.
Prostate-specific antigen, or PSA, is a protein produced by the prostate. The PSA blood test measures this protein to help screen for prostate cancer. Typically, a PSA level above 4 on lab results is flagged as 'abnormal,' prompting further evaluation. However, even PSA numbers below 4 can be concerning if they're rapidly increasing. That's why PSA tests are done annually: to monitor trends over time.
Elevated PSA levels don't always mean cancer. Noncancerous conditions like an enlarged prostate, prostatitis (inflammation), recent ejaculation, stress or even strenuous activity can temporarily raise PSA. Ultimately, the PSA level is just a starting point for a deeper investigation (or conversation).
Additionally, not all prostate cancers cause elevated PSA levels. Some aggressive cancers may produce normal PSA results. Ultimately, the PSA level is a starting point for further evaluation and deeper conversations with your doctor.
The controversy around PSA testing isn't really about the test itself, but about how its results are interpreted and acted upon. Before 2012, PSA screening was routinely recommended for all men over age 50. I completed my urology training that same year, witnessing firsthand how dramatically the screening landscape changed almost overnight.
In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA screening due to concerns of 'overdiagnosis.' The worry was that screening could detect slow-growing cancers that may never cause harm but still result in unnecessary biopsies, anxiety, and treatments—some of which caused more harm than good.
The recommendation led doctors to scale back, causing routine PSA testing to decline sharply. However, by 2018, new research and rising concerns about aggressive prostate cancers led the USPSTF to revise their recommendations again, advising men aged 55 to 69 to engage in shared decision-making with their providers.
This current stance emphasizes personalized discussions between patients and doctors, acknowledging that there's no one-size-fits-all approach to PSA testing. According to their website, the USPSTF is now working on another update, so we can expect further adjustments in the near future.
As someone who experienced this shift firsthand early in my career, I deeply appreciate how critical shared decision-making and patient involvement are in navigating these complex screening choices. These ongoing changes in recommendations have also reinforced the importance for me as a physician to stay informed, continuously adapting my practice as new research and technologies emerge.
Several organizations provide prostate cancer screening guidelines, including the USPSTF, the American Cancer Society and the American Urological Association (AUA). Each offers slightly different recommendations for both patients and health care providers. The USPSTF generally focuses on minimizing potential harm from overtreatment, while the AUA provides detailed, individualized recommendations based on clinical factors and risk profiles.
Even after practicing urology for more than a decade, I still sometimes find it challenging to navigate these subtle differences in guidelines. Although I primarily follow the AUA guidelines—my overarching professional body—I've established a balanced approach that feels comfortable for me and, I believe, best serves my patients' interests.
I start PSA testing at age 40 for men at higher risk, such as African Americans or those with a first-degree family member who has prostate cancer. For most patients, I typically initiate annual PSA screening at age 50.
It's important to know that primary care doctors perform most prostate cancer screenings. Depending on their training, clinical judgment and professional guidelines, their approach may differ slightly from my take as a urologist. This highlights the importance of clear communication among you the patient, your primary care provider and your specialists. Only through these conversations can we create personalized screening strategies that align with your health goals.
President Biden's case raises a question: Could earlier PSA screening have detected his cancer sooner, at a more treatable stage? We will never know for certain. According to current guidelines, stopping screening in one's 70s is considered appropriate. Perhaps there was a shared decision to stop testing. From a guideline perspective, nothing was necessarily done incorrectly. Still, Biden's diagnosis highlights the potential consequences of discontinuing prostate screening for an otherwise healthy older adult.
Men in the United States now have an average life expectancy of approximately 76 years, with many living healthy, active lives well into their 80s and beyond. Older guidelines based on shorter lifespans now need updating to reflect today's longer, healthier lives. I believe that decisions about prostate screening in older adults should thus focus more on individual health status rather than chronological age alone.
Changing guidelines based on longer life expectancy will require thorough research and evidence-based data. Consequently, updates to recommendations will take time. What you can do in the meantime is be proactive in your conversations with your doctors about not just prostate cancer screenings but all cancer screenings.
Prostate cancer isn't the only medical condition subject to evolving guidelines. Screening recommendations for colorectal and breast cancers have also changed recently. Colon cancer screening now generally starts at age 45 instead of 50 due to rising cases among younger adults.
Breast cancer guidelines continue to vary among organizations, but the USPSTF updated its recommendation last year to say that most women should start getting mammograms earlier. These frequent shifts reflect ongoing research and the importance of personalized, informed conversations between patients and health care providers.
Historically, an elevated PSA test led directly to a prostate biopsy, potentially causing unnecessary anxiety and sometimes overtreatment. Today, however, we have more advanced PSA-based tests that help better identify significant prostate cancers. Advanced imaging, like prostate MRI, allows us to pinpoint suspicious areas before performing a biopsy, increasing accuracy and decreasing unnecessary procedures.
Biopsy techniques have also improved, some shifting from traditional transrectal biopsies to transperineal methods, reducing infection risks. Treatments have similarly evolved, emphasizing active surveillance of low-risk cancers and minimally invasive focal therapies. These advancements have significantly reduced side effects and improved quality of life, even among older patients.
In my office, I frequently discuss PSA screening with patients who are over 70. If a patient remains active and healthy and we anticipate good life expectancy, I generally recommend that we continue regular PSA tests. However, the final decision always belongs to the patient, after we carefully weigh the pros and cons together.
If your doctor hasn't initiated this conversation yet, it's important for you to bring it up. And remember, regardless of age, promptly inform your health care provider about any new urinary symptoms or health concerns. Staying proactive gives you the best chance to maintain good health this year and next.