How to talk to patients about prostate cancer screening
Key points include rationale for disease screening, current controversy, and guidelines
Not a clinic of mine goes by without at least one man, typically in his late 50s or early 60s, bringing in a recent newspaper clipping or magazine article on the “harms” of prostate-specific antigen (PSA) screening for prostate cancer. Although PSA screening has been the subject of controversy in primary care for a number of years, discourse about it in the lay press heightened following recommendations from the American Academy of Family Physicians (AAFP) and the United States Preventive Services Task Force (USPSTF) against its use in asymptomatic men regardless of age.1,2 After listening to the patient’s concerns, I tell him that my goal is to keep him healthy with care that is right for his needs, which may or may not involve PSA screening.
In this article, I further outline my patient discussion concerning prostate cancer screening, which includes defining what the PSA test is, why to screen or not to screen, the screening controversy, current guidelines, and decision aids.
What is the PSA test?
Many men have confusion about what PSA screening entails. To begin, I clarify that PSA is a protein produced by cells in the prostate gland, which has a role in reproduction. I explain that the PSA test is used to measure the level of PSA in the blood. The results (reported in nanograms of PSA per milliliter of blood) are known to be age dependent. Elevations can be seen with a number of benign conditions, including benign prostatic hyperplasia, prostatitis, and urinary tract infection. However, the blood level of PSA may also be high in men with prostate cancer.
While initially used to monitor for disease progression among men with known prostate cancer, the PSA test (when combined with findings from digital rectal examination) was approved by the FDA in the 1990s to screen for prostate cancer. It is important to differentiate between use of the PSA test for diagnostic and screening purposes. Diagnostic testing applies to men with lower urinary tract symptoms or other signs of underlying pathology, whereas screening applies to the use of the PSA test in asymptomatic men, the intent of which is to find prostate cancer early (in the preclinical phase) when it is usually easier to treat (figure 1).