Why the PSA Test and Prostate Cancer Biomarkers are Critical for Men’s Health

Take-home points

• The rate of advanced prostate cancer is rising, which is correlated with a decline in prostate cancer screenings.
• The PSA test is a simple, inexpensive blood test that can be highly valuable in detecting prostate cancer early while avoiding overtreatment when paired with non-invasive prostate cancer biomarker testing.
• Prostate cancer biomarkers can differentiate between prostate cancer and benign conditions, determine the aggressiveness of the cancer, and indicate which treatment options may be most effective.
• Men at average risk of prostate cancer should have PSA tests starting at age 50. Men at higher risk should start at 45, and African American men should consider screening at age 40.
• Most men may have to request PSA testing and proactively discuss the advancements in biomarker testing with their providers.  

Why are the rates of advanced prostate cancer on the rise?

One out of every 8 men in the US will be diagnosed with prostate cancer in his lifetime.¹ While prostate cancer is the second leading cause of cancer-related death for men, when diagnosed early, prostate cancer has a nearly 100 percent survival rate.² Yet, more men today are likely to be diagnosed with advanced prostate cancer than 10 years ago. Advanced prostate cancer means that the cancer has spread outside of the prostate to other parts of the body, which makes it more difficult to treat. Survival rates of men with advanced prostate cancer are 34 percent.³

The rate of prostate cancer deaths had been steadily decreasing for 20 years until, in 2008, the US Preventive Services Task Force (USPSTF) stopped recommending the routine use of the prostate-specific antigen (PSA) test for prostate cancer screening as the task force determined it was doing more harm than good. Prior to 2008, many men with elevated PSA levels and enlarged prostates were being referred for a prostate biopsy that turned out to be unnecessary. The USPSTF found that nearly 50 percent of men were overtreated with biopsies as an enlarged prostate and elevated PSA levels can be caused by non-cancerous conditions or slow-growing prostate cancer.⁴  

The USPSTF adjusted its recommendation in 2018, suggesting that men between the ages of 55-69 should make a personal decision about having a PSA test.⁵ As of October 6, 2023, the USPSTF is in a review process to update its prostate cancer screening recommendations again.⁶

To put this in simple terms: In the past decade, many healthcare providers shied away from recommending the PSA test for prostate cancer screening so fewer men have had the test and now prostate cancer is being found at more advanced stages.  

Is the PSA test still important to the early diagnosis of prostate cancer?

The PSA test is incredibly valuable when it comes to diagnosing prostate cancer early. The simple, inexpensive blood test can help healthcare providers determine if some patients with elevated PSA levels require additional testing. However, the PSA test can’t be used alone–it only tells part of the story.

Today, the PSA test can be coupled with prostate cancer biomarker tests for men with elevated PSA levels to identify prostate cancer early while ruling out cancer in men who might otherwise be referred for a biopsy. One study found that a biomarker test used with patients who had PSA levels of 4.0-10.0 ng/mL reduced the number of biopsies by 40%.⁷

Prostate cancer biomarker tests are non-invasive and require only a urine, blood, or tissue (from a previous biopsy) sample. These tests can provide more insight, including:

• If an elevated PSA means you have cancer or a benign condition, such as benign prostatic hyperplasia (BPH).
• If you undergo a biopsy, what your chances are of finding aggressive prostate cancer.
• If you have a negative biopsy, the chances that cancer was missed (false negative biopsy).
• If cancer is present, how receptive your cancer might be to different treatment options.
• If you have a genetic mutation that increases your risk of developing prostate cancer and should be more carefully monitored and/or screened.

How to get a PSA test and avoid over-treatment

Unfortunately, because of the changing guidelines from USPSTF and various medical organizations, many healthcare providers no longer routinely order PSA tests. However, the PSA test is still an incredibly valuable first step in detecting prostate cancer early. This is why many prostate cancer organizations and even the United States Congress are now recommending that men at average risk of prostate cancer get regular PSA testing starting at age 50.

In Europe, approximately 450,000 men are diagnosed with prostate cancer each year, making it the most frequently occuring male cancer.⁸ In December 2022, an updated Council of the EU recommendation on cancer screening was adopted. Prostate cancer was included as a suitable target disease for organized screening in the recommendation and countries were invited to proceed with pilot screening programs and additional research.⁹ In 2023, the EU4Health Programme funded the PRAISE-U project with the goal of reducing morbidity and mortality caused by prostate cancer in EU Member States through smart early detection. ¹⁰

While official medical association guidelines vary, men with a family history or genetic testing that shows mutations that put them at higher risk should start screening at 45. Black men, who have a historically higher rate of prostate cancer, should start PSA testing at age 40.  

Because PSA testing has been associated with over-treatment, you may need to proactively ask for the simple blood test. And you may need to keep asking. I’m an expert in prostate cancer and still have to ask my primary care provider for the test time and time again.

After you ask for and receive a PSA test, it’s important to remember that if you have an elevated PSA level, the next step shouldn’t be a biopsy. There are prostate cancer biomarkers that can provide more insights before undergoing an invasive procedure that may not be necessary.

5 steps to increase your chances of being diagnosed with prostate cancer early when it is curable

‍Step 1: Know Your Risk – Do you have a family history of breast, colon, ovarian, pancreatic or prostate cancer? If so, you may have a genetic mutation that could increase your risk of prostate cancer.  Age, race, and lifestyle factors also increase your risk.

Step 2: Ask for the PSA Test – If you are 50 or older and at average risk, request PSA testing at your annual physical. If you are considered higher risk, talk to your healthcare provider about starting screening at age 45 or younger. Or, if you are Black, discuss PSA testing as early as age 40.

Step 3: Advocate for Your Health – If you run into roadblocks when requesting PSA testing from your healthcare provider, ask them about biomarker testing that can provide more specific insights beyond the PSA test. Or ask them about a 4Kscore test instead of a PSA test. The 4Kscore is a simple test that can indicate the probability of finding aggressive prostate cancer by  assessing four prostate-specific biomarkers and clinical information.

Step 4: Know What’s Next – If you are like 80% of men, your PSA will be less than 1.5 ng/mL, and you and your healthcare provider will likely opt to have you re-tested in 5 years. If your PSA is 1.5 ng/mL or higher, the next step is that your healthcare provider will likely conduct a digital rectal exam (DRE) to assess the size of your prostate and any suspicious nodules. In addition, you and your healthcare provider should consider prostate biomarker tests for additional insights and to determine if your elevated PSA level may be due to cancer or a benign condition. You might also consider repeating the PSA test in 6 months.

Step 5: Use All Information to Inform a Biopsy Decision – You and your healthcare provider should evaluate all of your results, including your PSA results, DRE, and prostate biomarker tests to determine if a prostate biopsy is a necessary next step.

References

1. American Cancer Society: Key Statistics for Prostate Cancer [Accessed 2-NOV-2023]‍
2. American Society of Clinical Oncology Prostate Cancer Statistics [Accessed 2-NOV-2023]‍
3. National Institutes of Health: National Cancer Institute, Cancer Stat Facts: Prostate Cancer [Accessed 2-NOV-2023]‍
4. US Preventive Services Task Force Final Recommendation Statement: Prostate Cancer Screening, 2008. [Accessed 2-NOV-2023]‍
5. US Preventive Services Task Force Final Recommendation Statement: Prostate Cancer Screening, 2018. [Accessed 2-NOV-2023]
6. US Preventive Services Task Force Prostate Cancer: Screening An Update for This Topic is In Progress. 6 October 2023. [Accessed 2-NOV-2023]
7. White J, et al. Prostate Cancer and Prostatic Diseases 2018; 21, 78-84. ‍
8. Ferlay, J.et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018. European journal of cancer, 103, 356–387. 2018 [Accessed 9-Nov-2023]‍
9. Májek O, Babjuk M, Roobol MJ, et al. How to follow the new EU Council recommendation and improve prostate cancer early detection: the Prostaforum 2022 declaration. Eur Urol Open Sci. 2023;53:106-108. 8 June 2023 [Accessed 9-Nov-2023]^‍
10. European Commission: PRAISE-U [Accessed 9-Nov-2023]