New Prostate Cancer Screening Guidelines Don't Go Far Enough (Op-Ed)

Dr. David Samadi is the chairman of urology and chief of robotic surgery at Lenox Hill Hospital in New York City and is a board-certified urologist and oncologist specializing in the diagnosis and treatment of urologic diseases, kidney cancer, bladder cancer and prostate cancer. He contributed this article to Live Science's Expert Voices: Op-Ed & Insights.

A disturbing trend has been emerging in my practice over recent years: More men are being diagnosed with aggressive prostate cancer, and in some cases the cancer has already metastasized to the bones and become incurable. It's a direct result, in my opinion, of 2012 guidelines by an influential government panel recommending against routine prostate cancer screening in men of all ages.    

So it's encouraging to hear that now, upgraded recommendations from the U.S. Preventive Services Task Force (USPSTF) say men between ages 55 and 69 should speak with their doctors to decide whether to undergo PSA (prostate-specific antigen) testing. But the new guidelines – which are not finalized yet, and are open for public comment until May 8 – don't go far enough, since I believe scientific evidence strongly suggests the benefits of this routine testing in younger men outweigh the potential harms. 

Prostate-cancer screening requires a simple blood test measuring a man's level of PSA, a substance made by the prostate gland. Most men without prostate cancer have PSA levels under 4 nanograms per milliliter of blood, and the odds of prostate cancer being present rise as PSA levels rise. [Macho Man: 10 Wild Facts About the Male Body]

Prostate cancer is the most common cancer in American men after skin cancer, affecting 1 in 7 males, according to the American Cancer Society (ACS). More than 161,000 men are expected to be diagnosed with the disease this year and nearly 27,000 will die, according to the ACS. By the numbers, prostate cancer and breast cancer are quite similar in diagnosis and death rates. But women are far more proactive about obtaining mammogram screenings – regardless of evolving USPSTF guidelines – than men are about PSA screening. This needs to change – men need to become just as proactive.

Why? Research I published with colleagues in the journal Urologic Oncology in August 2016 showed that among men with prostate cancer, those under age 50 had rates of advanced-stage prostate cancer similar to those of older men, and that the PSA levels before surgery in the younger group were comparable to those in the older group. The study drove home the point that screening as early as age 50 – and even as young as 40, depending on a man's family history and ethnicity – can result in fewer late diagnoses in up to 11 percent of men with the disease. More than 10 percent of the men who had prostate cancer by age 46 were found to have advanced cases of prostate cancer.

Given this insight, we recognize that many men with moderate to aggressive cases of prostate cancer wouldn't survive to age 55, when the upgraded USPSTF guideline says the conversation with their doctors about PSA testing should just be beginning. In the United States, deaths from prostate cancer dropped more than 40 percent in the last two decades, coinciding with more widespread PSA testing.

It's true that prostate cancer screening – like any screening test – poses potential pitfalls. A small number of men will experience false-positive results, and will consequently undergo invasive biopsies for what will turn out to be benign lesions. Others may have slow-growing cases of prostate cancer that will never pose a health threat, but these men may still pursue treatment – such as surgery or radiation – that can lead to negative side effects such as incontinence or impotence. [5 Things You Should Know About Prostate Cancer]

However, these outcomes are far less likely now with advanced technologies, including MRI fusion biopsies, which allow urologists to better target the tissue they biopsy, improving the test's sensitivity to detecting prostate cancer. Seeking out urologists with much experience in treating prostate cancer also pays off, since there's an art to reading the PSA test that, in expert hands, makes the diagnostic process much more precise.

I worry that health insurers will use the revised PSA screening guideline as fuel to deny coverage for these simple but telling blood tests in men of any age. The recommendation to merely have  individualized doctor-patient conversations does not offer the blanket of protection a more generalized recommendation in favor of screening would. I urge men to be proactive about their prostate health, and ask their doctors specifically to order testing on their behalf and justify the testing accordingly. Women have successfully accomplished this with routine mammograms despite fluctuating USPSTF recommendations over the years for who should undergo breast-cancer screening.      

I'm glad to see the USPSTF update its recommendations, but the panel needs to go further. I believe all men should undergo baseline PSA screening at age 50 along with the standard digital rectal exam. African-Americans and those with a family history of prostate cancer – who face increased risks of the disease – should seek baseline a PSA reading at age 40. Those whose PSA at that time is less than 1.5 ng/mL– the level signifying a high risk of developing moderate-to-aggressive prostate cancer – can wait to be re-tested at 45 or 50.

Here's what the USPSTF got right: Talk with your doctor about your individual risks and concerns. Just don't wait until you're 55 to get started – by then, it may be far too late.  

Originally published on Live Science.