This Isn’t Your Dad’s Prostate Test

IF GETTING A screening test for prostate cancer isn’t on your radar, it’s probably because the government guidelines essentially told you not to bother back in 2012. But prostate cancer rates have continued to rise. It’s now the second leading cause of cancer deaths in men, and it’s particularly lethal for Black men, who are more than twice as likely to die from it as white men. The guidelines have evolved.

The reason to consider the prostate-specific antigen (PSA) test now isn’t any big, headline-grabbing news that there’s a whole new way to test for it (there isn’t yet). It’s not even that PSA testing is now associated with about a 13 percent reduction in deaths from cancer and a 35 percent reduction in metastatic cancer diagnoses. It’s that the entire landscape of what happens after a troublesome result has shifted.

A high PSA number used to fast-track you to an uncomfortable or potentially infection-causing biopsy and hustle you to radiation or surgery. “A lot of men were being exposed to treatments and side effects without necessarily extending their lives,” says Kelvin Moses, MD, PhD, a professor at Vanderbilt University Medical Center who just helped revise the prostate-screening guidelines for the American Urological Association (AUA) and the Society of Urologic Oncology (SUO). Because many prostate cancers grow slowly—which is why doctors say men are more likely to die with prostate cancer than from it—lots of guys underwent procedures that they wouldn’t have really needed.

But now, MRIs and high-tech monitoring can help ID which prostate cancers need to be acted on and which can be left safely alone. “We really need to change the narrative on PSA,” says Yaw Nyame, MD, of the Fred Hutchinson Cancer Center at the University of Washington Medical Center. “It’s not whether it works or not. It’s how we can use it as part of a smart screening pathway.”

Why the Test Was Canceled—and Uncanceled

THE PSA TEST, which measures a protein produced by the prostate, has never been straightforward. High levels indicate something’s off in that walnut-size gland, but they don’t tell you if it’s cancer; it might just be an enlarged prostate or a urinary tract infection.

When the FDA approved the test for cancer screening more than 30 years ago, the message was clear: Get the test! Then in 2012, the U.S. Preventive Services Task Force didn’t recommend it on grounds that there wasn’t enough evidence that the benefits outweighed the harms. Now, the tide is turning back to “get it.” Start at age 40 to 45 if you’re Black, have a family history of prostate cancer (father, brothers, uncles), or if breast or ovarian cancer runs in your family. Start around age 50 if you don’t have a family history or other risk factors. (When to get it again? If your PSA is in a healthy range, then screen every two to four years after that.)

And there’s one test you don’t have to take. If fear of the digital rectal exam (DRE) is keeping you from getting tested, relax. The new guidelines reinforce what people have been hoping for all along: It’s an inefficient way to screen for cancer.

The New Prostate Care Path

NOW, PSA TEST results are only a starting point. If your PSA is high, you’ll want another test in a few months to confirm that it’s not due to something else—inflammation, irritation, or recent ejaculation can drive up the numbers. In 25 to 40 percent of cases, the second PSA test will be normal. About that “normal”: It shifts with age. “A PSA of 4 has always been a cutoff. If your PSA is 4 and you’re 53 years old, that’s very high. But if you’re 75 or 80, that’s pretty reasonable,” says Dr. Moses.

If the follow-up confirms a high number, doctors dig deeper. You may—depending on your doctor and how clear your case is—be eligible for one of what Dr. Nyame calls a “whole entourage” of urinary and blood biomarkers with names like the Prostate Health Index (PHI), 4K, IsoPSA, and MyProstateScore 2.0 that can help clarify if you’re pointing down a biopsy path.

Even then, the next move should be imaging before anybody comes at your prostate with a biopsy needle. “A prostate MRI can reduce the need for a prostate biopsy by about 20 to 30 percent,” says Dr. Nyame. Yet “only 30 to 40 percent of patients with an elevated PSA are getting an MRI before biopsy,” he says. Part of the issue is access to MRIs, combined with the fact that it’s a relatively new recommendation that some physicians aren’t yet accustomed to following.

If all these checkpoints suggest you do need a biopsy, ask your doc which technique they’re comfortable with and good at doing. Traditionally, these have been done through the wall of the rectum, which leaves up to 7 percent of guys with infections that can land them in the hospital. Research on a procedure that goes through the perineum suggests it may cut the risk of infection. It also requires specific equipment and training, so not every doctor offers it yet. Don’t go off a cliff trying to find this; the AUA/SUO guidelines say that either way is still okay.

When Tracking Beats the Knife

ONE OF THE biggest shifts in the new rules of prostate care is what to do if cancer is detected. Often, “keep an eye on it” is the ultimate strategy. “We think that something like 50 percent of cancers don’t need treatment,” says Dr. Nyame. Wait, what?!

“The C-word short-circuits people. There’s this rush to get scheduled for treatment,” says Heather Goltz, PhD, professor of social work at the University of Houston-Downtown and health educator for people with cancer. Skipping right to surgery or radiation carries risks, including urinary incontinence and erectile dysfunction, issues you can avoid when the cancer was never likely to harm you.

Enter active surveillance, a treatment strategy of closely monitoring the prostate with, yes, more PSA tests, as well as with MRIs and biopsies. A multicenter study published in JAMA found that 10 years after guys chose active surveillance, less than 1 percent died of their disease; less than 2 percent developed metastatic cancer; and nearly half saw no progression in their disease at all. “The adoption of active surveillance has increased in the U.S. and has really reduced the harm of PSA-based screening,” says Dr. Nyame.

Is PSA Really All We’ve Got?

IF THE WHOLE PSA test thing feels antiquated in this age of cancer blood tests (like Galleri) and whole-body MRIs (like Prenuvo), it’s because these new technologies are still the “someone’s texting you” dots in the screening conversation. They’re a signal, but it’s not clear yet what they’re saying.

Cancer blood tests look for tumor DNA floating around in your circulatory system. “Not every cancer shows up very well in the bloodstream, and prostate is one of them,” says Dr. Moses. That’s because prostate cancer, at early stages, doesn’t shed a lot of DNA into the bloodstream.

But what about MRIs? If you’re going to need one anyway when your PSA is high, why not just start there? Studies are looking at that very thing right now, but even if they are found to be useful, cost and access will still keep them from the front lines, at least for a while.

That means the new tests won’t take over yet, but they don’t have to. The PSA might not have changed, but the protocols around it have made screening easier to opt into, giving the test a better chance to save lives.