Prostate Cancer And The PSA Controversy

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. 

This week we're focusing on an important topic for Men’s Health Month—prostate cancer screening and the controversy surrounding PSA testing. There’s been a lot of confusion and unnecessary worry about the PSA (prostate-specific antigen) test, and I want to help clear some of that up. Prostate cancer is the second leading cause of cancer deaths in men in the U.S., right behind lung cancer, so it’s something men—and their doctors—need to understand well. Recent news, including the missed advanced cancer in President Joe Biden, highlights flaws in our healthcare system and the danger of sticking too closely to age-based guidelines rather than individual health status. Screening recommendations vary, but most experts agree that men need to be advocates for their own prostate health.

PSA testing is not a simple “yes or no” indicator. Interpreting a PSA score involves looking at factors like your age, family history, race, changes in PSA over time (velocity), and even prostate volume. The PSA alone isn’t enough to make a diagnosis or rush into a biopsy, and many additional tools—like free PSA percentage and prostate MRI—are available to help get a clearer picture. The key is not to panic if your numbers rise, but to look at the whole picture with the right medical guidance. 

PODCAST NOTES 

• Navigating PSA Screening Controversy - There’s a lot of confusion and debate around when and how to use the PSA (prostate-specific antigen) test for prostate cancer screening. While it remains the second leading cause of cancer death in men, inconsistent guidelines and outdated practices can lead to needless anxiety and missed diagnoses. Even the doctors can be unclear about the proper approach, so it’s important for men to understand the basics and take an active role in their prostate health decisions.

• Who Should Start Screening, and When - Most major organizations recommend that average-risk men begin PSA testing at age 50, but those at higher risk—such as African American men and those with a strong family history—should start earlier, at 45 or even 40. The American Urologic Association suggests getting a baseline PSA at 40, along with a digital rectal exam (DRE), to establish a personal reference point moving forward.

• Digital Rectal Exam Debate - The DRE is no longer recommended by the USPSTF or CDC as a standard screening measure, but in my experience it is still valuable. The simple, low-tech exam can detect changes in prostate size, nodules, or rectal cancer that could be missed otherwise. Not every provider is proficient at it, but it remains an important tool for those who know how to use it effectively.

• Getting the Most Accurate PSA Test - Several factors can artificially increase PSA levels, leading to false alarms. To get the most reliable result, men should avoid sexual activity and strenuous exercise for 48 hours prior to the test, steer clear of prostate stimulation (including recent rectal exams) for a week, and delay testing if they’re currently dealing with a urinary infection or prostatitis. Additionally, medications like finasteride (Proscar) or Avodart can falsely lower the PSA value, potentially masking a problem.

• Interpreting PSA Values Is More Than a Number -  A single elevated PSA doesn’t automatically mean cancer. It’s important to watch how fast the value changes—if your PSA rises by more than 0.5 ng/mL per year (PSA velocity), it’s a red flag and warrants further investigation. Prostate cancer is usually slow-growing, so this trend over time gives valuable information and allows for a more nuanced approach rather than rushing to biopsy.

• Considering PSA Density in Enlarged Prostates - Many men have enlarged prostates as they age, which naturally increases PSA output. PSA density is calculated by dividing the PSA level by the actual prostate size (measured by MRI or ultrasound). This helps distinguish between benign enlargement and worrisome increases due to cancer, allowing for more individualized and accurate assessment.

• Free PSA Percentage as a Valuable Tool - PSA in the blood can be in "bound" or "free" form. A higher proportion of free PSA tends to signal benign conditions, while a lower percentage may indicate a higher risk for cancer. The free PSA test is especially helpful when total PSA is in a borderline range (such as 5–10), making it easier to decide if further testing (like MRI or biopsy) is necessary.

• Not All Elevated PSAs or Detected Cancers Are the Same - Historically, any PSA above 4 would prompt a biopsy, but we now know this leads to many unnecessary procedures. A high PSA isn’t always cancer, and a low PSA doesn’t mean you're in the clear. Additionally, not all prostate cancers are aggressive—many are slow-growing (Gleason 6) and may require only careful observation ("watchful waiting"), while higher scores indicate more urgent treatment needs.

Prostate cancer screening is not a “one-size-fits-all” matter. The key is knowledge—understanding your personal risk, getting quality information, and working with a physician who’s up-to-date and open to nuanced decision-making. Don’t let confusion or outdated advice keep you from getting the right screening, but also don’t panic with every blip in the numbers. 

Be your own advocate, take control of your health, and empower yourself to make informed choices. If you have concerns or questions about PSA or prostate cancer screening, schedule a thoughtful conversation with your doctor. 

Stay educated. Stay healthy. 

Till next week.