PSA Screening

What is the PSA test?

The most common screening tool for prostate cancer is the prostate-specific antigen (PSA) test. This is a simple blood test that measures the presence of PSA circulating in your bloodstream. This test is usually the first step in any prostate cancer diagnosis. However, the PSA screening by itself cannot tell you if cancer is present.

The PSA test is also used to track the effects of prostate cancer treatment such as surgery, radiation, hormone therapy and chemotherapy. When a man has treatment for prostate cancer, his PSA level will drop significantly. Regular screening with PSA is one of the tools the physician will use to measure if the cancer has returned.

When PSA levels rise to a certain threshold after prostate cancer treatment, this is known as biochemical recurrence. This means that some cancer cells have survived and are producing PSA. If this happens, the doctor will order additional tests and make recommendations for additional treatment.

What is Prostate-Specific Antigen?

PSA is a protein produced by prostate cells, which keeps semen in liquid form so that sperm can swim. A simple blood test can measure how much PSA is present in a man’s bloodstream. When a man has prostate cancer, his PSA level increases, which is why the PSA test is used as a screening tool.

However, the levels of PSA can rise due to a number of reasons, including cancer. When PSA is elevated it is a warning sign that you should follow up on with your doctor.

What is the controversy surrounding PSA screening?

In recent years, there has been some controversy surrounding the PSA test. In 2012, the U.S. Preventive Services Task Force (USPSTF) assigned the PSA test a “D” rating. This meant that the USPSTF concluded the harms that resulted from PSA testing, such as unnecessary biopsies and negative treatment side effects, outweighed the benefits of finding and managing the disease early. This recommendation did not include exceptions for men at increased risk of developing the disease, such as African American men, those with a family history of the disease, and those with BRCA gene mutations. The USPSTF recommendation is important as it guides primary care physicians in preventive care and can impact insurance coverage and reimbursement for screening. Prior to its “D” rating, the PSA test had an “I” rating, meaning the USPSTF concluded there was insufficient evidence to assess the pros and cons of testing.

 

In May 2018, the USPSTF updated their recommendation on PSA screening. In response to new research demonstrating the benefits of PSA screening (such as the European Randomized Study of Screening for Prostate Cancer), an increase in the number of men choosing active surveillance, and advocacy efforts, the USPSTF released a draft recommendation in April 2017 that assigns the PSA test a “C” rating for men ages 55to 69 (the test still has a “D” rating for men ages 70+). This rating has now been certified official by the task force.

This means that the USPSTF recognizes a small potential benefit of PSA testing and recommends that men make individual decisions about whether or not to get tested after discussing the risks and benefits with their doctors. Like the 2012 recommendation, this update does not include specific language for men at increased risk.

This 2016 article by Dr. Stacy Loeb provides a thorough overview of the evidence for and against the PSA test, and how we can interpret this evidence with nuance in order to prevent suffering and death.

When should I get a PSA test?

The guidelines below are adapted from the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Prostate Cancer Early Detection. Please use these guidelines to have a discussion with your physician about your personal risk and make a plan for screening.

  • If you are between ages 45 and 75:
    • Discuss the risks and benefits of prostate cancer screening with your doctor, have a baseline PSA, and consider a baseline DRE
    • If your PSA is below 1 ng/mL and your DRE is normal, repeat testing every 2-4 years
    • If your PSA is between 1 and 3 ng/mL and your DRE is normal, repeat testing every 1-2 years
    • If your PSA is greater than 3 ng/ML or your DRE is very suspicious, your doctor may suggest additional testing or a biopsy
  • If you are over 75:
    • Decide together with your doctor if PSA/DRE testing is right for you
    • If you continue testing and your psA is less than 3 ng/mL and your DRE is normal, repeat testing every 1-4 years
    • If your PSA is greater than 3 ng/ML or your DRE is very suspicious, your doctor may suggest additional testing or a biopsy