MEN'S HEALTH
PROSTATE CANCER SCREENING IN THE
MODERN PSA ERA
AUTHOR Ganesh K. Kartha, MD
O
ver the last decade, there have
been conflicting recommenda-
tions from varying governing so-
cieties on whether routine pros-
tate cancer screening should be
performed. Primary care provid-
ers have been left wondering how
to properly manage and council
their patients. Prostate specific antigen (PSA) and digital rectal
exam (DRE) have been the mainstay of prostate cancer screening
for years, but recently that mainstay has been brought into question.
Urologists often get asked by providers in the community wheth-
er they should continue PSA/DRE testing on their patients. Though
it is not straightforward, the answer nonetheless remains “YES” to
prostate cancer screening in the adult male after proper selection
and counseling. To understand why prostate cancer screening should
be performed, an understanding of prostate cancer epidemiology
must first be reviewed. In addition, the underlying risks and ben-
efits should be considered before supporting a recommendation
for prostate cancer screening. Lastly, it is worthwhile to discuss
the tools and management strategies that have been developed by
the urological community to mitigate the risks surrounding broad
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prostate cancer screening. Overall, prostate cancer screening is a
valuable tool for preventing cancer-related deaths.
Despite the uncertainty surrounding screening, prostate can-
cer is a real threat to the male population. Prostate cancer is the
second leading cause of cancer death in men in the United States,
and according to the National Cancer Institute, the lifetime risk
of developing prostate cancer is roughly 16%. Based on this data
alone, it would be easy to justify screening. However, the prevalence
of so-called “insignificant” prostate cancer (low risk disease that is
unlikely to metastasize and/or cause death) is what has put routine
prostate cancer screening into question. Though 16% of the male
population is at risk of developing prostate cancer, only 2-3% of
males in the United States are at risk of dying from prostate cancer.
Autopsy studies have concluded that clinically insignificant prostate
cancer is quite common: 60% of all males by age 80 have evidence
of prostate cancer pathology on their post-mortem specimens
(1). Furthermore, there have been large randomized trials that
have concluded that PSA screening had little effect on mortality
rates. The European Randomized Study of Screening for Prostate
Cancer (ERSPC) and the United States Prostate, Lung, Colorectal
and Ovarian Cancer Screening Trial (PLCO) were two such studies
that may have influenced the United States Preventive Services Task