Originally published June 5, 2023
As noted 3 years ago in the blog below, a New York Times writer laid out the PSA controversy as identified by the American Urological Association, the U.S. Preventive Services Task Force, and the American College of Physicians.
Thankfully, “the National Comprehensive Cancer Network® (NCCN®)—an alliance of leading cancer centers—has published a new book explaining the latest evidence and expert recommendations around prostate cancer screening.”[i]
PSA screening has evolved toward a noninvasive yet accurate process that resolves the long-standing problem of a blood test that often led to over-detection, over-biopsy and over-treatment. Today, a suspicious PSA test result does not trigger an immediate biopsy. Instead, imaging using multiparametric MRI can determine which patients actually need a biopsy and which don’t.
Instead of a blanket one-size-fits-all approach, the NCCN’s new book offers clear and easy to understand age-based screening guidelines. Unlike the issues described below, NCCN offers a simple premise: “Screening for prostate cancer significantly reduces the likelihood of death from prostate cancer, but it’s important to start early, before any symptoms occur.”
This has been our longtime position at the Sperling Prostate Center. We invite you to download their free book, and we continue to recommend that all men begin annual screening per NCCN’s age guidelines.
The New York Times has been called a storied U.S. media outlet. It has been awarded 137 Pulitzer Prizes since the annual prize began in 1917. Regardless of whether or not you agree with founder Adolph Ochs’ famous slogan, “All the news that’s fit to print,” it would be hard to argue with the caliber of its dogged journalists who contributed stories like the exposé of wealthy, powerful sexual predators—and whose writing is truly high quality.
On May 8, 2023 NYT staff writer Paula Span published “Too Many Older Men Are Still Screened for Prostate Cancer.” She clearly did her homework regarding the problem of overtreating low-risk prostate cancer (PCa), and the resultant growing trend toward Active Surveillance (AS). Kudos to her for that.
On the other hand, she turned to the “usual suspects” for guidelines on PSA screening and PCa treatment: the American Urological Association, the U.S. Preventive Services Task Force, and the American College of Physicians. Their current screening guidelines for men 70 and older recommend individual physician-patient discussion on the merits and consequences of PSA screening. We have reason to question that recommendation, and recently posted our own blog in response to a JAMA article suggesting that men in that age bracket are being overscreened. We do believe PSA screening as it has historically been conducted for the past three decades has indeed led to harm, but rather than toss Baby PSA out with the bath, multiparametric MRI (mpMRI) offers a better way out of the dilemma. In fact, if a man’s PSA is abnormally high or rising, a noninvasive mpMRI scan can rule need for a biopsy in or out. Estimates range, but over 25% of patients can be spared biopsy, thanks to mpMRI. For men whose scan suggests presence of significant PCa (needs treatment), mpMRI can be used to guide a real-time, MRI-targeted biopsy. This method employs the least number of needles, yet gives the most accurate results.
Then there’s the rush to whole-gland treatment after a high PSA and TRUS biopsy. Ms. Span cites sobering published statistics on the incidence of urinary, sexual and bowel side effects of radical treatment vs. AS. Regarding the spending of healthcare dollars, she rightly quotes health economist David Kim (University of Chicago) on the costly cascade of tests and treatments that follow a suspicious PSA blood test outcome. We agree with the data showing way too many needless biopsies and way too much clobbering of insignificant PCa that may never require treatment. As she notes, because of such evidence more doctors and their low-risk patients are embarking on a strategy of AS to monitor their disease. We don’t dispute any of this.
What we do take issue with, however, is the absence of a middle ground option between radical treatment and AS. Here’s where the NYT article went amiss. The hole in Ms. Span’s research is failure to address focal therapy for properly qualified, selected patients, a happy medium between all or nothing. Focal therapy, a targeted tumor destruction, is a minimally invasive, outpatient approach to managing PCa. Depending on the patient’s anatomy, and the location and extent of the tumor, there are minimal-to-zero risks of urinary and sexual side effects.
If a biopsy has diagnosed PCa, appropriate patients may choose a focal therapy because they don’t want to risk urinary or sexual after effects, and they don’t want to live with the uncomfortable idea of cancer growing in their bodies. There are also patients who are good AS candidates, and who are not made anxious at the notion of PCa in their bodies, who see focal treatment as a way to extend AS in hopes of never needing a radical treatment.
We are not claiming that this approach is for everyone—far from it, since physically, psychologically, and lifestyle-wise each patient’s PCa has unique characteristics that must be identified. But it must be acknowledged that in the hands of an experienced practitioner of mpMRI detection, diagnosis, and image-guided tumor destruction, focal therapy is increasingly seen as a proper standard of care for the right patients. It is our hope that in the near future, Ms. Span (or a colleague of hers) would devote their investigative reporting to present all sides of focal treatment. At the Sperling Prostate Center, we offer three methods of focal therapy. For us, that’s all the news that’s fit to print.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] National Comprehensive Cancer Network. “The Benefits of Prostate Cancer Screening Outweigh the Harms, According to New Patient Guidelines From NCCN.” April 28, 2026. https://www.nccn.org/home/news/newsdetails?NewsId=5510
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
