Prostate Cancer Screenings Have Changed — For the Better

You wouldn’t be alone if you had an image of a prostate exam formed by a punchline in a raunchy movie or a standup comedy routine. Think: a patient bending over an exam table while a doctor puts on a rubber glove. 

You may have also heard that prostate specific antigen tests can result in the overdiagnosis of cancer, leading to unnecessary invasive procedures and treatments.  

But it turns out prostate screenings have changed a lot in recent years, and if you’ve been avoiding getting one, you might have an outdated idea of what it will entail and what the results will mean. 

Here is what prostate cancer screenings look like now and why staying on top of them is so important. 

What is prostate cancer? 

The prostate is a gland that sits right below the bladder. Its function is to make fluid for semen and provide nutrition for sperm.  

About 1 in every 8 men will be diagnosed with prostate cancer in their lifetime — for the vast majority, after 65. It is the most common non-skin cancer for men to get.   

“The typical phrase you hear is that if a man lives long enough, he’s going to get prostate cancer, which is probably true,” says Dr. Daniel Lin, a urologist at the Urology Clinic at UW Medical Center and Fred Hutch Cancer Center, and the Chief of UW Medicine Urologic Oncology. “But a lot of prostate cancers that men get, particularly as they age, are the type of cancers that might never harm them, even if they’re never diagnosed.”

Most prostate cancers grow slowly and won’t cause problems during your lifetime. Others, however, can be much more aggressive and require immediate treatment.  

What do prostate cancer screenings entail? 

Screening for and diagnosing prostate cancer encompasses multiple procedures and tests. If, when and how you get screened comes down to a conversation with your primary care doctor, which ideally will happen beginning at 45, depending on your risk factors (more on that below). 

“The core principle that surrounds prostate cancer screening right now is shared decision-making,” says Lin. “So we have a discussion with our patients on the pros and cons of screening before we start the screening itself.” 

Here are the most common tools used to screen and diagnose prostate cancer, plus their benefits and risks: 

The PSA test 

The prostate-specific antigen is a protein made by the prostate. A simple blood test can tell your PSA level, which can aid in the detection of prostate cancer. If your PSA levels are elevated, it could indicate cancer and warrant further diagnostic steps. 

But it could also be caused by other issues like an enlarged or inflamed prostate. 

In fact, the PSA test has been the subject of some skepticism because of how it’s led to overdiagnosis or overtreatment of prostate cancer. This can happen in two ways:  

• The results are misinterpreted, and the elevated PSA levels are not caused by cancer.  
• The results lead to the diagnosis of cancer that doesn’t need to be treated. If someone is old enough or if the cancer is slow-growing enough, it could cause unnecessary anxiety or a biopsy that carries the risk of bleeding or infection. 

On the other hand, the PSA test is crucial in the early diagnosis of aggressive cancers, which can save lives.  

“I think that we’ve learned more about who to do PSA screening on — for example, we don’t necessarily need to do it on older patients with less life expectancy,” says Lin. “There are tools that we use that combine age plus family history that help to identify if a patient needs a biopsy.” 

What about the dreaded digital rectal exam? 

The digital rectal exam — that’s “digital” as in using a gloved finger, not a digital device — was once a standard part of a routine physical exam for older men. In 2023, the American Urological Association’s new guidelines, which Lin co-chaired, walked that back.

“A digital rectal examination by itself has a poor association with a diagnosis of prostate cancer,” says Lin. “But if the PSA is elevated, then a digital rectal examination actually does lend us some information.” 

Now, the AUA’s guidelines only recommend that doctors perform a digital exam on patients with elevated PSAs to help them evaluate their cancer risk. 

The promise of imaging 

One last tool being used more and more by urologists is imaging. Your doctor may now use an MRI with a PSA test to determine if a biopsy is needed and which specific part of the prostate to take the biopsy from.  

“I think imaging is certainly taking on a new role,” says Lin. “There is a lot of promise in using MRI for prostate cancer evaluation.” 

While an MRI scan can be a bit claustrophobic, it’s much less invasive than a digital rectal exam or an unnecessary biopsy.  

What happens after a prostate cancer screening 

If your PSA levels are normal, you now have a baseline that your doctor can reference if your levels change in the future. If the PSA test is elevated, your doctor may recommend an MRI or a digital rectal exam to determine if a biopsy is necessary.  

Once the biopsy is completed, your medical team will find out if you have cancer and how aggressive it is. Treatments for aggressive cancers can include surgery, hormone therapy, radiation or chemotherapy.  

For less aggressive cancers, your doctor might suggest “active surveillance” with regular follow-up tests to monitor if the cancer spreads. While it can be scary to know you have cancer, active surveillance can allow patients to avoid the risk of side effects from surgery or radiation, such as loss of sexual function and incontinence. 

And active surveillance has been proven to be an effective strategy for many prostate cancers. Lin is the principal investigator for the Canary Prostate Active Surveillance Study, which found that 10 years after diagnosis, less than 2% of patients in the study who opted for active surveillance developed metastatic cancer. Only 0.1% died from prostate cancer.

When should you start getting prostate cancer screenings 

So when should you start thinking about getting screened? The American Urological Association’s guidelines recommend getting a baseline PSA test between 45 and 50. Your primary care doctor can order it as part of a regular blood draw.  

If your PSA levels are normal, the guidelines say to keep getting PSA tests every two to four years.  

“We feel like that’s a reasonable ask,” says Lin. “It’s a rather low-intensity recommendation that we feel can catch cancer earlier.” 

If you have a family history of prostate cancer or a mutation like BRCA2, Lin suggests starting screening earlier, between 40 and 45 years old.  

Black men also have a higher risk of getting prostate cancer. A recent study led by UW Medicine urologist Dr. Yaw Nyame found that prostate cancer develops three to nine years earlier in Black men, so they should also get a baseline PSA test in their early 40s.

If you’re approaching your 50s and have been avoiding your primary care doctor, rest assured that a prostate cancer screening will likely be much less invasive than before — and it might just save your life.