With the rising awareness that prostate cancer is not exclusively an old man’s disease, a much-needed first step in the overhaul of the long-established prostate cancer screening guidelines is tiptoeing its way into medical practice. For now, at least, this first step is being described as “smarter screening.”
A number of prominent prostate cancer centers are leading the introduction of this new thinking, including the University of California San Francisco and the Cleveland Clinic. Looking back, had I experienced this smarter screening, my cancer would have been detected much earlier, significantly improving my outlook and changing my treatment strategies.
It was eight years ago, at the young age of fifty-seven, that I was shockingly diagnosed with advancing prostate cancer. Despite regular screening in my forties, my cancer was missed for several years because my urologist and I followed the long-established, and shall I say less-smart, screening guidelines.
The most common screening procedure is a blood test that measures the level of prostate specific antigen (PSA), a protein made only by the prostate gland. The amount of PSA detected in the blood is an indicator of a man’s age and the health of his prostate gland. For many years the standard guideline for men of all ages has been 0-4 ng/mL. To date, the thinking has been that if a man’s PSA result, regardless of age, falls within this range, all is presumed to be okay. This was the case for me through my forties, so we were complacent. As I entered my fifties my PSA ticked up above 4 ng/mL, but this was explained as typical with aging. Unknowingly, I became dangerously complacent.
The change in thinking for the PSA blood test is that the standard range of 0-4 ng/mL should not be the guideline for all age groups, and perhaps not for any age group. For it is now being recognized that PSA values for men in their 40’s and early 50’s should be much lower. As a man ages, this screening method is less and less reliable as PSA can rise for reasons other than the presence of cancer.
Smarter screening suggests men should begin screening for prostate cancer in their early forties, looking for a PSA value near 1.0 ng/mL, if not lower. If the test result is much above 1.0, further investigative methods are becoming more readily available in standard clinical practice—although men may still have to ask and prod their doctors.
Today, men can benefit from additional investigative methods such as the more advanced 4Kscore™ and IsoPSA™ blood tests. Imaging with a multiparametric 3T MRI prior to biopsy and true image-guided biopsy procedures are becoming more common across the US. Back in 2015, I had to travel to London, England for my multiparametric MRI. Additionally, new genomic and biomarker testing of biopsy tissues provide further risk stratification analysis prior to treatment decisions.
A second, generally unwelcomed, screening procedure is the DRE, the digital rectal exam. While the DRE is considered invasive and may be repulsive to men, we simply need to check our reservations against the screening’s women endure. The doctor gently inserts a gloved and lubricated finger into the rectum to examine the prostate gland to feel if cancer is present. With the “all clear” finding, we leave the consultation feeling good, often awaiting the PSA result.
The critical and necessary understanding about the DRE procedure is that it misses many (most) early stage prostate cancers, as in my case. It is therefore important that men do not casually accept the all clear, for the doctor may not have felt the cancer that is actually present. Perhaps sooner rather than later, standard clinical practice will replace the DRE with the much more informative multiparametric 3T MRI or similar.
Despite my cancer being missed for too many years, today, at 65, after three curative treatment attempts, including advanced imaging and a second surgery (both done in Europe), I have a most favorable outlook. Based on my experiences and those of many others I have met along the way, I encourage all men in their forties to begin PSA blood testing and, if their result is much above 1.0 ng/mL, to utilize these newer investigative techniques.
For older men, if you have yet to begin screening, I encourage you to begin PSA screening soon. Fortunately for all men, should you find yourself facing prostate cancer, the newer investigative and risk assessment methods should help you achieve a better outcome than many of us face.
Murray Keith Wadsworth, the author of Prostate Cancer: Sheep of Wolf?, is passionate about spreading the dark truth about prostate cancer. His sudden diagnosis and shocking process to treatment continues to drive him to untangle and share the systemic misinformation around the disease.