New prostate cancer guidelines call for routine PSA screening in middle-aged men

Prostate cancer screening should be routine for all men ages 50 to 69, according to new American Cancer Society guidelines released Thursday. Earlier screening is recommended for high-risk groups such as Black men.

The recommendation marks a major shift from the organization’s previous emphasis on patients and doctors deciding together whether to screen — and its first update to the guidelines since 2010.

Concerns about overdiagnosis and overtreatment had driven a shift away from routine screening using a prostate-specific antigen (PSA) blood test. But advances in clinical trials and diagnostic tools over the last decade have prompted a reassessment in its favor.

“Prostate cancer screening has just gone through this roller coaster,” said Richard Wender, chair of family medicine and community health at the University of Pennsylvania and former chief cancer control officer for the American Cancer Society.

Prostate cancer, one of the most common cancers, affects roughly one in eight men during their lifetime. The Georgia-headquartered nonprofit American Cancer Society estimates 333,830 men in the U.S. will be diagnosed with the disease this year, and 36,320 men will die from it.

Since prostate cancer usually doesn’t cause symptoms until late stages, screening has become an important tool for early detection. The PSA test is the primary screening tool, measuring a protein in the blood that can be elevated in men with the disease.

Under its new guidelines, ACS now calls for average-risk men to get screened every two years from ages 50 to 69.

Those at high risk, including men who are Black or have a strong family history, should start annual testing at age 45.

However, after age 75, screening is not recommended because prostate cancer often grows slowly, and the harms of treatment may outweigh the benefits.

The U.S. Preventive Services Task Force — the federal government’s panel of independent experts on preventive care — currently recommends shared decision-making between clinicians and patients for prostate cancer screening.

“We’re going to have a big job getting the word out to primary care clinicians about this change,” Wender said.

The last few decades of screening guidelines have been marked by dramatic shifts.

When the American Cancer Society first released prostate cancer guidelines in the 1990s, it recommended annual screening to all men over 50. That led to a decrease in death rates from the cancer, which had previously been going up.

But there was a problem: everyone who got diagnosed with prostate cancer was treated aggressively, Wender said. Most men were treated with prostate removal surgery, which at the time carried a higher risk of incontinence and impotence.

Today, doctors know that many men who get prostate cancer are not actually destined to die from it.

“It wouldn’t have mattered if you’d found the prostate cancer at all, because they never would have known they had it,” Wender said.

These concerns over unnecessary biopsies and treatments led to a “pretty serious reconsideration” of the recommendation, he said.

Wender still remembers when the U.S. Preventive Services Task Force issued a recommendation against PSA testing for the general population in 2012.

A task force member had told him about the change in advance at a conference.

Wender recalled replying: “Don’t do it. It’s a mistake.”

He worried the pendulum would swing too far away from screening, and that doctors would stop prioritizing it for patients.

In 2018, the task force updated its stance to advise that patients and their doctors approach routine screening as an individual, shared decision.

“But in a way, the harm had been done,” Wender said. “Primary care docs had stopped prioritizing [it].”

In the years since opinion shifted away from routine screening, research and medical options have advanced.

A 2014 follow-up report from a European clinical trial found that PSA screening reduced the prostate cancer death rate by roughly 20%, “which is really a massive reduction for screening,” said Alexander Kutikov, the chair of urology at Temple’s Fox Chase Cancer Center. It included 162,388 men across European countries.

Diagnostic tools have also improved. Now, when a patient’s PSA test shows elevated levels, they can undergo an advanced form of MRI to check for other signs of cancer, like high-risk lesions.

Patients can then avoid unnecessary biopsies if, for example, they have a high PSA level simply due to having a large prostate or inflammation. Conversely, if they need a biopsy, it could be targeted to the high-risk region.

Discoveries of biomarkers, a measurable substance or process in the body, have also enabled doctors to more precisely diagnose patients and determine what treatment, if any, they need.

“There are existing mechanisms to mitigate the harms of screening by sort of reducing rates of overdiagnosis and also reducing rates of overtreatment,” Kutikov said.

Some patients with low-risk prostate cancer can elect active surveillance, which involves regular monitoring rather than immediate treatment.

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Under the new guidelines, men who are Black, have a strong family history of prostate cancer, or have BRCA genetic mutations that increase their risk, should be screened annually from ages 45 to 69.

Black men have a roughly 70% higher incidence of prostate cancer than white men, and are twice as likely to die from it when diagnosed.

For men ages 70 to 74, screening is a personal decision to discuss with their doctor, based largely on their overall health.

After 75, screening is not recommended.

“It’s just more likely that you’re going to be subjected to harms of treatment and really never get the benefit,” Kutikov said.

But the risk analysis for a 75-year-old with multiple medical problems could look very different from a superactive 76-year-old who has a life expectancy over 20 years, he emphasized.

“Everybody’s a bit different,” he said. “That’s why these decisions have to be very much individualized.”

Wender, who left his position at ACS in 2020, was not involved in the development of the new guidelines. However, toward the end of the process, he reviewed and provided feedback on a draft.

He urged the development of easy-to-read, concise points for busy doctors.

Wender said he was reluctant to predict whether the U.S. Preventive Services Task Force would also adopt the changes.

The Affordable Care Act requires most health insurance plans to cover screenings that receive a strong recommendation from the task force. In the absence of that, coverage for routine prostate cancer screening varies and depends heavily on state laws and plans.