Are you confused about whether annual PSA screening is right for you? One can hardly be blamed, as guidelines have been zigzagging since 2012. Currently, shared decision-making between men and their medical caregivers is a compromise recommendation. Still, ongoing debate shows up in published literature backed up by data. Those in favor of annual testing point to the merits of early diagnosis, which gives the best odds for preserving life and lifestyle. On the other hand, naysayers attest to the potential harms and side effects of over-biopsy, over-detection, and over-treatment. Each side uses statistics to justify their position, but as the saying goes, “Statistics can prove anything,” meaning you can always find numbers to prove a point right or wrong.

These days, there is particular debate over annual screening for men age 70 and above. On average, it’s a fact that men are living longer. According to U.S. data, the average life expectancy for a male baby has steadily risen from 46.6 years in 1900 to 76.4 years as of 2017. More importantly, as men live longer, the number of years from age 65 to until death has also gradually lengthened; in 1950, a healthy man who reached 65 could expect to live an average of 12.8 more years, while in 2017 it had grown to 18.1 years!

Historically, prostate cancer (PCa) was viewed as a disease of old age—but it was also viewed as slow growing and not likely to kill a patient. Doctors were fond of saying that a man was more likely to die WITH it, not OF it.

However, in the words of Bob Dylan?, “the times they are a-changin’.” Or at least, the danger of PCa may be a-changin’ for older and elderly men. On one hand, reports a journal article by Shah, et al. (2022),

There are approximately 24 million US men age 70 years and older. Men in the age group 70–80 years have a higher incidence of prostate cancer, more aggressive cancer, more metastasis, and more deaths due to prostate cancer. …In our previous studies, we showed that after the 2012 USPSTF recommendations against prostate cancer screening, the number of prostate cancer diagnoses, and especially high-grade prostate cancer, increased.^[i]

The authors all but state that the rapid decline in annual PSA screening after the 2012 downgrade of the blood test has led to this situation. It raises the question, is PCa may morphing into a dangerous aging related threat for those approaching age 70 who discontinue the annual blood draw?

On the other hand, a 2024 data analysis published in JAMA connects the 10-year life expectancy of men who reach age 70 with the question of PSA risks vs. benefits in their situation. The authors, a team out of Weill Cornell Medicine (New York) apparently rely on the pre-2012 belief that PCa in elderly men is slow-growing, pointing out that many 70-year olds have a 10-year or less “high risk” of dying from other causes. They write, “Given the long natural history [emphasis mine] of prostate cancer and lead time associated with PSA-based screening, these males have a low likelihood of receiving any mortality benefit from continued screening yet face the potential harms of overdiagnosis, such as complications after prostate biopsy for a false-positive screening and psychological stress associated with a cancer diagnosis.”^[ii] At the same time, they observe that rates of PSA screening are actually increasing in this population and suggest that better shared decision-making for such men is in order.

Ask yourself, when you reach age 70—or maybe you’re already there—will you want a clinically based, honest estimate of how many more years you have in you? And given that number, will you choose to be annually screened? If not, is it because you fear the potential cascade of unpleasant biopsy and invasive treatments that could impair sexual, urinary and bowel function?

To put your mind at ease and urge you to keep up annual PSA tests, the PCa diagnostic pathway is a changin’ for the better! Thanks to multiparametric MRI (mpMRI) in the hands of an experienced team, here are the reasons to continue getting a simple Medicare-covered PSA blood test:

• If the results are abnormal, don’t rush to biopsy. A noninvasive mpMRI can reveal the location, size, and clinical significance of any suspicious area that might be there—or show if there’s nothing to worry about.
• If there’s an area of concern, a real-time in bore MRI targeted biopsy uses a minimum of needles for maximum accuracy of diagnosis, with greatly reduced chances of side effects.
• If there’s a tumor that is within the range of very low-to-low risk, it may qualify for Active Surveillance.
• If there’s a tumor that should be treated, it may be a candidate for a focal treatment that controls the cancer with very little risk of side effects.

For patients who are candidates for Active Surveillance but don’t want to take any chances, the Sperling Prostate Center offers three FDA-approved methods for focal therapy: Focal Laser Ablation (FLA), TULSA, and Exablate (MRI-guided Focused Ultrasound). Per American Cancer Society age recommendations, we encourage continuing annual PSA testing as long as you are healthy, active, and expect to live at least 10 more years. And of course, continue your annual physical or wellness exam so your medical caregiver is familiar with you and your lifestyle choices to maintain your health. He or she can share decision-making about when is the right time to get serious about life expectancy—and the right time to safely discontinue annual PSA tests.

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] Shah N, Ioffe V, Chang JC. Increasing aggressive prostate cancer. Can J Urol. 2022 Dec;29(6):11384-11390.
[ii] Kensler KH, Mao J, Davuluri M. Frequency of Guideline-Discordant Prostate Cancer Screening Among Older Males. JAMA Netw Open. 2024;7(4):e248487.