A medical professional talks to a paitent about a prostate cancer screening.
Targeted guidelines can help men determine when to undergo prostate cancer screening. (For Spectrum Health Beat)

If you’re a man over age 40, you might want to give prostate cancer screening another look.

Although many men and their primary care physicians have turned their backs on the prostate-specific antigen, or PSA, test in the past decade, a new Northwestern University study calls for a return to screening as a means of early detection.

PSA levels in the blood are often elevated in men who have prostate cancer.

Brian Lane, MD, PhD, urology division chief for Spectrum Health Medical Group and a key member of the Spectrum Health Cancer Center team, agrees with the study’s authors.

“I don’t understand how you could look at this (study) and say that it doesn’t favor screening,” Dr. Lane said.

Detection saves lives

The study, released in a prostate cancer journal from the publishers of Nature, says that advanced prostate cancer is on the rise in the United States, and it places the blame, at least in part, on a lack of screening and early detection.

“Since screening guidelines have become more lax, when men do get diagnosed, it’s at a more advanced stage of disease,” the study’s senior author, Edward Schaeffer, MD, Ph.D., said in a Northwestern University article.

The study looked at all men in the National Cancer Database who were diagnosed with prostate cancer at nearly 1,100 U.S. health care centers between 2004 and 2013.

The researchers found an increase in metastatic prostate cancer—prostate cancer that has spread to other parts of the body—in all age groups. The largest increase was in men ages 55 to 69, which had a 92 percent increase.

Dr. Schaeffer and his co-authors called for improvements in prostate cancer screening and treatment nationwide because “PSA screening and rectal exams save lives.”

Why did screening decline?

Prostate cancer screening has been on the decline ever since a U.S. government-sponsored task force recommended in 2008 and 2012 that doctors stop using the PSA test to check for prostate cancer.

The risks of testing outweighed the benefits, the task force argued.

The problem with this recommendation, according to Dr. Lane, is that it was based on flawed research. The control group used in one of the research studies wasn’t truly controlled, he said, so the results were skewed.

Is it that the cancer’s getting worse or that we’re not looking? I think it’s that we’re not looking.

Dr. Brian Lane
Urology division chief for Spectrum Health Medical Group

The Northwestern study underscores what he has believed for a long time—that prostate cancer screening has clear benefits for early detection.

“This (study) shows that when you stop screening there’s an increase in metastatic prostate cancer,” Dr. Lane said.

“Now we really can say to our patients, ‘Look, there’s harm that’s happening (as a result of not screening),” he said. “It’s not just our opinion; there’s more objective evidence of harm that’s accumulating.”

The Northwestern study also raised the question of whether the increase in metastatic prostate cancer could be, in part, the result of the disease getting more aggressive. While Dr. Lane thinks this is possible, he believes the lack of screening is the more likely explanation.

“Is it that the cancer’s getting worse or that we’re not looking? I think it’s that we’re not looking,” he said.

The implications are far reaching.

“This study highlights the grave concerns of many cancer professionals,” said Judy Smith, MD, chief of the Spectrum Health Cancer Center. “Our concern is that similar changes in mammography or other screenings could lead to problems with cancers being detected later in the disease progression.”

New screening guidelines

Even before this study came out, Dr. Lane and his Spectrum Health urology colleagues, including Christopher Brede, MD, and Richard Kahnoski, MD, were at work developing a new set of prostate cancer screening guidelines for primary care doctors and their patients.

The urology group plans to widely distribute the guidelines this fall.

“We need to do PSA screening better,” Dr. Lane said. “We need to be smarter about it.”

The new recommendations avoid the errors of the past, which included over-screening and over-treating. Organized by age group, the guidelines recognize that it’s normal for a man’s PSA level to go up with age.

Here’s a summary of the new Spectrum Health PSA screening guidelines:

  • High-risk individuals: Consider getting tested earlier and more frequently if you have a family history of prostate cancer or if you are African-American, which puts you at higher risk.
  • Ages 40–49: If your PSA is 1.0 or less, get tested every five years. If it’s 1.1 to 1.9, get tested every three years. If it’s 2.1 to 2.9, get tested yearly. See a urologist if it’s 3.0 or higher.
  • Ages 50–59: If your PSA is lower than 1.5, get tested every five years. If it’s 1.5 to 2.9, get tested every three years. If it’s 3.0 to 3.9, get tested yearly. See a urologist if it’s 4.0 or higher.
  • Ages 60–75: If your PSA is lower than 2.0, get tested every five years. If it’s 2.1 to 3.9, get tested every three years. See a urologist if it’s 4.0 or higher.
  • Older than 75 or with a life expectancy of less than 10 years: If your PSA was 4.0 or lower when last checked, don’t get tested unless you develop urinary symptoms indicating prostate problems. If it was 4.1 to 9.9, continue to get tested yearly. See a urologist if it’s 10 or higher.

These targeted guidelines should dramatically reduce the number of PSA tests performed, Dr. Lane said.

For example, under this plan, between 70 and 80 percent of men in their 40s and 50s would need to be tested only once in five years.

Dr. Lane hopes doctors and patients will use guidelines like these as the basis for informed conversations and decisions about prostate cancer screening.