By Eric Kline, M.D., urology

What is PSA and why do doctors use it to screen for prostate cancer?

Prostate-specific antigen (PSA) is a protein that is only made by prostate tissue. Every person with a prostate will have some PSA in their bloodstream. Cancerous tissue typically produces much more PSA than noncancerous tissue. An elevated PSA in the bloodstream may indicate prostate cancer, but it also can be seen with enlarged benign prostate hyperplasia (BPH) and/or prostate inflammation. A PSA test is a blood test that measures the concentration of PSA.

What PSA levels are considered normal, and what factors determine whether an elevated level is cause for concern?

The normal PSA level is less than 4 ng/mL (nanograms per milliliter), though this varies by age — younger men are held to a lower level then older men:

• 40 to 49 years – 0 to 2.5 ng/mL
• 50 to 59 years – 0 to 3.5 ng/mL
• 60 to 69 years – 0 to 4.5 ng/mL
• 70 to 79 years – 0 to 6.5 ng/mL

When evaluating PSA results, two factors are equally important: the level and the rate at which it rises.  A stable PSA is far less concerning than one that is rapidly increasing.  Prostate size is also a consideration.  A larger prostate naturally produces more PSA, so an elevated level in that case is less alarming than the same reading in a man with a smaller prostate.

If a man has a PSA level that is elevated for his age, or one that is rising rapidly, he should speak with a urologist.

Are there risks associated with prostate cancer screening?

Screening with a PSA test and an exam carries little to no risk. However, if results are abnormal, further testing with a prostate biopsy introduces some risks, such as bleeding and infection. Ultimately, a significant risk with PSA screening is overdiagnosis and overtreatment — finding cancers that may never cause harm and treating them with surgery, radiation or hormone therapy, which have associated side effects. There are many prostate cancers that grow slowly and would not affect a person in their lifetime. But there are types of prostate cancer that are more aggressive, can spread and become life threatening if left untreated.

Currently, the medical profession does not have testing that can reliably identify which prostate cancers need treatment and which ones do not. This means that some men may be treated for a cancer that would never have harmed them. As a result, not all prostate cancers require immediate treatment. Low-grade, slow-growing cancers are sometimes monitored over time rather than treated because they may not progress, cause symptoms or become life-threatening.

Prostate cancer diagnosis rates fell for nearly a decade, then started to rise again after 2014. Can you explain this shift?

In 2012, the U.S. Preventive Services Task Force (USPSTF) came out with recommendations against PSA screening, a position not endorsed by the American Urologic Association. The result was a significant decline in PSA screening, which was followed by an increase in more advanced prostate cancer diagnosis. According to the American Cancer Society, the incidence rate increased 3% per year, with advanced-stage diagnosis rising 4.6% to 4.8% annually. The USPSTF revised their position in 2018, stating that screening is an individual decision and should include a discussion of risks and benefits with a doctor.

Why is advanced-stage prostate cancer rising in younger people?

There are many potential causes: Genetic factors have been found to be linked to a higher risk of aggressive prostate cancer, and lifestyle factors, such as poor dietary habits, lack of physical activity and obesity can contribute to risk. Environmental exposure to certain chemicals and toxins may also increase risk.

What advice would you give a healthy man in his 50s or 60s who is wondering whether to get screened for prostate cancer?

Get screened. Of course, this should involve a discussion with your doctor about the risks and benefits of screening, as well as the natural course of the disease. But ultimately, men in this age group should get screened.

What symptoms should prompt someone to talk to their doctor about prostate cancer?

Prostate cancer is often a silent disease until it has significantly progressed, which is why screening is so important. Increased difficulty urinating is typically associated with enlarged prostate, which is something that should be evaluated.  Blood in the urine has multiple causes but should also be evaluated by a doctor.

How much has treatment changed in the past decade, and what should a newly diagnosed man expect today?

For localized disease, there has not been significant changes in treatment over the past decade. The main treatments continue to be radiation or surgery. Surgery is typically robotic-assisted laparoscopic, and radiation is typically given by external beam.

Although there is not enough data yet to support using polygenic risk scores as a primary marker for screening, it is worth noting there are genomic tests specific to prostate cancer that are different from polygenic risk scores. These tests analyze the tumor to help guide decisions about whether to proceed with prostate biopsy and to inform treatment options. Because treatment decisions can be complex and highly individual, a man newly diagnosed with prostate cancer should talk with his doctor to understand the risks and benefits of all available options.

Dr. Eric Kline practices at the Northeast and Tigard clinics, and the Alberty Surgical Center. His focus is kidney stones, benign prostatic disease, urologic cancers and no-scalpel vasectomies. His expertise is in minimally invasive robotic surgical techniques.