Q. I am 74 years old and unsure whether I want to continue with PSA screening for prostate cancer. Before deciding, I wanted to better understand my options since I probably would not want surgery or radiation therapy if I do have prostate cancer. What is your approach?
A. No matter what your age, men should ask themselves these types of questions before having a blood test for PSA (prostate-specific antigen) to look for hidden prostate cancer.
While some guidelines suggest stopping prostate cancer screening after age 70, the decision to continue depends on your general health and life expectancy. The reason: Most prostate cancers are low-grade and will not shorten a man's life or diminish his quality of life. On the other hand, diagnosing higher-grade cancer at an earlier stage could lead to treatment to keep the cancer from spreading.
In the past, a man with a high or rising PSA level would have to choose between having an immediate prostate biopsy (to locate any cancer and assess its severity) or living with some uncertainty. Today, other tests can help predict the presence of cancer, especially cancer that is more likely to spread. Examples include MRI (magnetic resonance imaging), specific subtypes of PSA blood tests, and urine testing for specific genetic markers. For men who do opt for prostate cancer screening but may not want immediate treatment even if cancer is likely, the two main strategies are watchful waiting or active surveillance.
Watchful waiting. Watchful waiting either before or after a biopsy means you don't get regular PSA tests or other monitoring. Only if symptoms occur would you have further diagnostic testing to determine whether and how to treat the symptoms.
Active surveillance. An active surveillance strategy requires a prostate biopsy first to identify the cancer's size and probability of spreading. High-grade and many intermediate-grade prostate cancers don't qualify for active surveillance because treatment usually begins right away. However, this strategy is an option for men who would be comfortable with close monitoring for low-grade cancer. Active surveillance involves more frequent PSA testing (to look for any rise in the level over time) and likely periodic prostate biopsies. Your doctor might order an MRI or a urine test for genetic markers to determine when a repeat biopsy is needed. If and when evidence arises that the cancer has become more active, then treatment would begin.
Studies comparing men with low-grade prostate cancer who choose active surveillance rather than immediate surgery or radiation show similar outcomes and life expectancy. By choosing active surveillance, a man can delay or even avoid treatment side effects, such as erectile dysfunction and incontinence. The downside is the small risk of delaying treatment of a cancer that grows faster than expected.
— Howard LeWine, M.D.
Editor in Chief, Harvard Men's Health Watch
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