August 29, 2008
US News and World Report

What 9 Types of Men Should Do About Prostate Cancer Screening

A public health group comes out against PSA screening in older men. How to decide for yourself

By Adam Voiland

Screening for early signs of cancer may seem like a no-brainer. Screening can catch tumors at an early stage, but research also shows that screening doesn't consistently extend life span, and it can lead to aggressive and unnecessary follow-up tests or treatments that can leave men incontinent and impotent. Some doctors even believe that for certain men the test causes more harm than good. In fact, new guidelines released Monday by the United States Preventive Services Task Force recommend that men 75 or older skip the test if they have no reason to suspect they're at high risk. For men younger than 75, the task force concluded there isn't enough good evidence to recommend either for or against screening.

Some medical groups, such as the American Cancer Society and the American Urological Association, encourage all healthy men to start PSA screening by age 50. Others, such as the American Academy of Family Physicians, are more skeptical of the test and encourage men to get it only if they've fully considered the risks. Given such conflicting advice, how do you know if it's right for you? Most doctors agree that risk factors—such as a man's age, race, overall health, and his family's medical history—play a key role in tipping the scales. Here is how eight different men might weigh those factors. Since your situation is unique, you should talk to your doctor and read up on PSA tests before making a decision.

1. You're an 85-year-old man with significant health problems.

Don't get screened, say most doctors who spoke with U.S. News. You're exactly the type of guy that the USPSTF intends, through its new guidelines, to discourage from getting PSA tests. In general, experts discourage men with a life expectancy of less than 10 years from getting tested, because a prostate tumor that develops that late in life isn't likely to become the cause of death. This is especially true for men with chronic health problems such as cardiovascular disease or diabetes.

2. You're a fit, healthy 85-year-old with many long-lived family members.

Most doctors would still say don't get it, but your longer life expectancy offers a tick in the other column. Be aware that some doctors, for fear of getting sued, order PSA tests for older patients even when doing so isn't apt to help them, says Doug Campos-Outcalt, a spokesperson for the American Academy of Family Physicians. One important study, for example, published in the Journal of the American Medical Association in 2006 found that some 36 percent of veterans over the age of 85 were screened even though fewer than 10 percent of them were expected to live more than 10 years.

3. You're a healthy, 75-year-old African-American with a father and younger brother who both died of rapidly spreading prostate cancer.

While your advancing age argues against screening, you may want to think twice, since you're in good health and potentially have many years to live. Also, African-American men have an especially high risk of developing aggressive forms of prostate cancer. And your family history puts you at even greater risk. Make sure your doctor clearly explains both the risks and benefits of the test for men with your profile when the two of you talk it over.

4. You're an obese but otherwise healthy 70-year-old South Asian man with no family history of prostate cancer.

A tough call. If you think you're healthy enough that you'll still be kicking 10 to 15 years down the road, it might be worth considering the test. On the other hand, South Asians get prostate cancer less than other ethnic groups. However, when they do, it's often a particularly aggressive and lethal form, warns Ash Tewari, a urologist at the Weill Medical College of Cornell University.

5. You're a very healthy 65-year-old man who has a family history of prostate cancer.

Your family history and good health suggest that a PSA test might be worthwhile. But pay close attention to the nature of the family history, cautions Eric Singer, a urology and bioethics resident at the University of Rochester Medical Center. Having a relative who was killed by an aggressive cancer, especially if it happened at a young age, is concerning—and increases the urgency of getting a PSA test. But having a family member who developed a nonlethal prostate tumor late in life is less worrisome, he says.

6. You're a recently married 55-year-old who plans to have kids soon, values an active sex life, and whose father has prostate cancer.

Three doctors might well give you three different recommendations. One might automatically order the test for you without even discussing it on the grounds that you have a family history and presumably want to do everything possible to stay cancer free. Another might think it's better to steer clear of the test so that there's no chance that an unnecessary procedure will hamper your sex life. A third might discuss the risks and benefits of PSA screening and leave the choice up to you. If you do get tested and get diagnosed with the cancer, you might—under the watchful supervision of a doctor—be able to postpone aggressive treatment for at least a few years, during which you could start a family.

7. You're a healthy 50-year-old man with no history of prostate cancer.

Again, doctors tend to disagree for men like you. One argument for getting screened, many doctors say, is that knowing your baseline PSA—and tracking it over the years—could help you and your doctor recognize a dangerously rapid rise.

8. You're a 45-year-old Caucasian man who struggles with anxiety.

You probably want to hold off, at least for now. You're still younger than 50, the age that most medical groups recommend men consider getting screened. Plus, knowing the details of your PSA could take a psychological toll in someone who is prone to anxiety. If you get screened, you might end up worrying about a higher-than-expected score even if it doesn't actually reflect the presence of cancer. Simple enlargement of the prostate, which is very common among older men, can cause high scores.

9. You're a 40-year-old African-American man. Your race puts you at elevated risk.

In fact, the American Urological Association recommends that African-Americans start getting screened at age 40; it recommends age 50 for most men of other backgrounds.