Prostate cancer testing has changed

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There is no screening program for prostate cancer. That's because the PSA blood test which doctors have relied upon has been controversial and accused of encouraging overtreatment. That in turn has meant men needlessly experiencing complications such as erectile dysfunction and urinary incontinence, not to mention infections from prostate biopsies.

MRI scanning of the prostate has made a big difference.

But things have changed and while there is still no official screening program, new guidelines help men and their doctors make better informed decisions. The guidelines also reduce the need for biopsies and in some men, safely delay or avoid treatments such as surgery to remove the prostate (radical prostatectomy) or radiation therapy.

The first thing is for men to know their risk and at each stage for their doctor to fully inform them of the benefits and risks to aid their decision making. Men with a brother with prostate cancer, or whose father had prostate cancer below the age of 65, or who had two or more second degree relatives who died from prostate cancer, or who carry the cancer gene BRCA2, or who have Black sub-Saharan African ancestry should be offered two yearly PSA tests from the age of 45.

In other men, routine PSA testing is not recommended under the age of 50, but two-yearly testing should be offered from 50 to men who decide to be tested. If the PSA is raised for a man's age, it should be repeated between one and three months later. If it's still raised, then a referral to a specialist should be offered. And here is where things have changed a lot. In the old days there weren't many alternatives to jumping in and doing a biopsy. MRI scanning of the prostate has made a big difference. It allows the urologist to see what if anything is going on inside the prostate. In many cases that avoids a biopsy and if there is something, it tells the surgeon where to biopsy in the gland. The biopsy itself should be done through the skin between the scrotum and the anus (the perineum) rather than from inside the bowel, which risks a blood infection.

Sometimes the biopsy shows that it's safe to wait and watch carefully, because sometimes an early cancer doesn't progress. This is called active surveillance and is tailored to what the biopsy found, the PSA testing and the man's preferences. Such surveillance does reduce the need for surgery or radiation, but if intervention is needed it can occur in safety.

The bottom line is that prostate cancer testing and early detection is complex and needs thought on the part of doctors and their patients so that the best decisions can be made.