As rates of advanced prostate cancer continue to rise worryingly, the American Cancer Society recommends that most men ages 50 to 69 get screened every two years. People most at risk, including black men and others with a close family history of the disease, should have a prostate-specific antigen blood test annually.
Men ages 70 to 74 should talk with health care providers about whether PSA testing makes sense for them, based on their health and life expectancy, according to the ACS.
The new guidelines, published Thursday in CA: A Cancer Journal for Clinicians, are the latest pendulum swing in screening standards for prostate cancer, which is the second leading cause of cancer death in men, behind lung cancer.
Dr. William L. Dahut, ACS chief scientific officer, said he hoped the new guidelines would “increase screening in men at average risk and ultimately lead to fewer men developing or dying from metastatic disease, while mitigating harm.”
In previous ACS guidelines, men aged 40 to 50 were advised to participate with their doctor in “shared decision-making” regarding PSA testing, provided they had at least a decade of life expectancy. Repeat testing was based on a PSA level threshold.
Now, the ACS recommends much more emphatically that men get the PSA test every two years after they turn 50.
Annual screening from age 45 is recommended for two higher risk groups:
- Black men, who have higher rates of prostate cancer and are more likely to die from it.
- Men whose father or brothers were diagnosed younger than 65 years old or who have multiple relatives diagnosed at any age.
The PSA blood test can help detect signs of prostate cancer earlier, when it is usually more sensitive to treatment. There have long been concerns about the PSA test because it can trigger unnecessary treatment with devastating side effects, and historically there has been a lack of research showing that it actually improves men’s chances of survival.
Increase in cases of advanced prostate cancer
The new guidelines were influenced in particular by a major randomized study of PSA testing in Europe, which now has more than two decades of follow-up and found that screening middle-aged men actually reduced deaths from prostate cancer. Given these and other more recent, encouraging research findings, the authors of the updated ACS guidelines felt they could recommend testing as beneficial with greater confidence and be more specific about which groups should be tested and at what intervals.
Although the prostate cancer death rate has halved over the past three decades, the decline has slowed overall and has stabilized among men aged 55 to 69.
The Food and Drug Administration approved the PSA test for cancer surveillance in 1986. Following widespread use of the test for prostate cancer screening, diagnoses of advanced prostate cancer fell by more than half and the mortality rate fell 7 percent by the mid-1990s.
But in the 2000s, various national health authorities became more concerned about overdiagnosis. They therefore restricted the categories of men for whom they recommended screening. In 2012, the influential U.S. Preventive Services Task Force categorically recommended against PSA testing in men of any age.
Diagnoses of advanced disease then began to increase, leading to concerns that decreased testing was a factor and, ultimately, to campaigns to expand testing again.
An ACS study last year found that prostate cancer diagnoses increased about 3% annually between 2014 and 2021. Dahut, co-author of the study, said that trend has continued in recent years. The study also found that over a decade of data, cases of metastatic prostate cancer increased by about 6% per year among men aged 55 and older.
At best, the PSA test can identify prostate cancer early and lead to treatment (surgery and radiation are the standard of care) that stops it from spreading, thereby improving men’s survival.
Among men diagnosed with advanced prostate cancer, only about a third live another five years.
However, the PSA test often identifies cancers that will not cause serious illness or death, at least not in the short term.
In these cases, it would often be better for men to benefit from continued monitoring rather than treatment. Many elderly men die with prostate cancer, but not because of he.
This is one of the main reasons why the ACS and other health authorities do not recommend the test for older men or others who are unlikely to live 10 more years.
PSA tests can also produce false positives that lead to unnecessary treatment and anxiety. And the biopsy needed to diagnose prostate cancer carries health risks.
Importantly, prostate cancer surgery and treatment can have serious consequences, including sexual dysfunction, urinary incontinence, and bowel problems.
According to Dahut, recent improvements in medical practices have helped mitigate these effects.
Previous ACS guidelines, released in 2010, advised doctors to talk with middle-aged and younger senior men about whether they want to have the PSA test. This more flexible dynamic has left too many men forgoing screening, ACS experts said. The new guidelines prompt doctors to more strongly recommend the test to this age group.
It’s promising that doctors are better able to differentiate between cases of prostate cancer serious enough to require immediate treatment and those that are better monitored over time.
“Cancer still causes a negative visceral reaction in most people, which is mostly unwarranted in many circumstances,” said Dr. Daniel George, a medical oncologist at Duke Health who specializes in urologic cancers. George was not involved in the new guidelines.
“There are more cancer survivors in the United States than ever before in history,” he said. “It’s only going to increase. And it’s not because of overdiagnosis; it’s because of more effective therapies for these patients.”
The change in guidelines could, in theory, have led to former President Joe Biden’s cancer being detected earlier. Biden, 83, announced last year that he had aggressive metastatic prostate cancer that had spread to his bones. Biden had followed federal guidelines recommending against PSA tests after age 70.
Dahut said the revised ACS guidelines indicate the likelihood that many men in their 60s can expect to live more than a decade longer, so prostate cancer treatment could help extend their lives.
Biden said on social media this week that his “doctors continue to be encouraged by how I have responded to treatment” and that cancer “has not stopped me.” But he said that “sometimes it slows me down.” As a result, he said, he will limit his efforts to promote his upcoming memoir, which will be released Tuesday.
In the book, Biden defiantly responds to accusations that he slowed down cancer screenings or hid his diagnosis, calling such suggestions “absurd.”
“There is no person in this world with stage 4 cancer who would not wish it were detected earlier,” Biden wrote.
Gn Health
