What is cancer screening?

Cancer is a disease when the cells of the body grow out of control. Cancer screening is having tests to look for signs of cancer before you have any symptoms. By the time cancer causes symptoms, it may have already spread to other parts of your body. A screening test may help find cancer early, when it may be easier to treat.

Cancer screening only tells you whether you might have cancer. It doesn't diagnose cancer. If a screening test shows signs of cancer, you'll need to have other tests to find out if you do have cancer and how serious it may be.

What is prostate cancer screening?

Prostate cancer screening looks for signs of cancer in the prostate. The prostate is a gland in the male reproductive system. It lies just below the bladder. It makes fluid that is part of semen.

Prostate cancer is most common in people over age 50. It usually grows slowly and doesn't cause health problems. In fact, it's possible to live a long life with prostate cancer and never know you have it. But in certain cases, prostate cancer may spread to other parts of the body and can be very serious.

The goal of prostate cancer screening is to find prostate cancers that may be more likely to spread so they can be treated early.

What tests screen for prostate cancer?

Two tests are commonly used to screen for prostate cancer:

• A prostate-specific antigen test, also called a PSA blood test. PSA is a protein made by your prostate. A high level of PSA in your blood may mean you have prostate cancer, but it's not proof of cancer. That's because many other things may cause high PSA levels, including:
  
  
  • Having an enlarged prostate (benign prostatic hyperplasia or BPH)
  • Having other common prostate problems
  • Taking certain medicines
  
  In general, the higher your PSA, the more likely it is that you have cancer. But a low PSA blood level isn't a guarantee that you don't have cancer.
  
  
• Digital Rectal Examination (DRE). The DRE is a prostate exam. In this exam, your health care provider inserts a lubricated, gloved finger into your rectum to feel your prostate for lumps or anything unusual. A DRE can check only one side of the prostate.

A PSA test or a DRE may be able to detect prostate cancer at an early stage. But it is not clear whether early detection and treatment lower the risk of dying from prostate cancer. You should talk with your provider about the benefits and harms of prostate cancer screening.

What are the possible benefits and harms of prostate cancer screening?

The possible benefits of prostate cancer screening include:

• Finding and treating prostate cancer early before it spreads
• Getting a better sense of your prostate cancer risk (based on your PSA test)
• Peace of mind if your screening shows you're unlikely to have prostate cancer now
• The option to choose further testing and closely monitor your prostate if your screening shows you may have cancer

The possible harms of prostate cancer screening include:

• Getting a false positive result. This means that your PSA test shows you may have prostate cancer when you really don't. A false positive may lead to:
  
  
  • Worry while you have more tests to look for signs of cancer.
  • A prostate biopsy. In a biopsy, a doctor removes tissue from your prostate so it can be studied under a microscope to look for cancer cells. This is the only way to diagnose cancer. The possible harms of a prostate biopsy include:
    • Fever
    • Pain
    • Blood in semen
    • Urinary tract infection
• Having prostate cancer treatment that you may not have needed. Prostate cancer screening may lead to a cancer diagnosis, but it's not always clear whether the cancer is likely to grow and spread. You could have unnecessary treatment for cancer that would never have caused any health problems. And the common prostate cancer treatments may have serious, permanent complications, such as:
  
  
  • Urinary incontinence
  • Erectile dysfunction
  • Problems controlling your bowel movements (BMs)

Should I be screened for prostate cancer?

Since there are benefits and risks to prostate screening, you should talk with your provider to decide if screening is right for you. You and your provider should consider:

• Your age. The risk of prostate cancer increases after age 50.
• Your family health history. If members of your family have had prostate cancer, your risk may be higher.
• Your race. Prostate cancer is more common in African Americans. They also have a higher risk of developing prostate cancer at a younger age and having more serious disease.
• Your general health. Are you well enough to have treatment for prostate cancer if it's found?
• What you prefer. How do you feel about the possible benefits and harms of screening, diagnosis, and treatment?

Screening is looking for cancer before a person has any symptoms. This can help find cancer at an early stage. When abnormal tissue or cancer is found early, it maybe easier to treat. By the time symptoms appear, cancer may have begun to spread.

Scientists are trying to better understand which people are more likely to get certain types of cancer. They also study the things we do and the things around us to see if they cause cancer. This information helps doctors recommend who should be screened for cancer, which screening tests should be used, and how often the tests should be done.

It is important to remember that your doctor does not necessarily think you have cancer if he or she suggests a screening test. Screening tests are given when you have no cancer symptoms. Screening tests may be repeated on a regular basis.

If a screening test result is abnormal, you may need to have more tests done to find out if you have cancer. These are called diagnostic tests.

Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate.

The prostate is a gland in the male reproductive system located just below the bladder (the organ that collects and empties urine) and in front of the rectum (the lower part of the intestine). It is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that makes up part of semen.

As men age, the prostate may get bigger. A bigger prostate may block theflow of urine from the bladder and cause problems with sexual function. This condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may beneeded to correct it. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may besimilar to symptoms of prostate cancer.

Prostate cancer is the most common non skin cancer among men inthe United States.

Prostate cancer is found mainly in older men. Although the number of men with prostate cancer is large, most men diagnosed with this disease do not die from it. Prostate cancer causes more deaths in men than any other cancer except lung cancer. Prostate cancer occurs more often in African American men than in White men. African American men with prostate cancer are more likely to die from the disease than White men with prostate cancer.

Different factors increase or decrease the risk of developing prostate cancer.

Anything that increases a person's chance of developing a disease is called a risk factor. Anything that decreases your chance of getting a disease is called a protective factor.

Tests are used to screen for different types of cancer when a person does not have symptoms.

Scientists study screening tests to find those with the fewest harms and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) helps a person live longer or decreases a person's chance of dying from the disease. For some types of cancer, the chance of recovery is better if the disease is found and treated at an early stage.

There is no standard or routine screening test for prostate cancer.

Although there are no standard or routine screening tests for prostate cancer, the following tests are being used or studied to screen for it:

Digital rectal exam

Digital rectal exam (DRE) is an exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel the prostate for lumps or anything else that seems unusual.

Prostate-specific antigen test

A prostate-specific antigen (PSA) test is a test that measures the level of PSA in the blood. PSA is a substance made mostly by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. The level of PSA may also be high in men who have an infection or inflammation of the prostate or benign prostatic hyperplasia (BPH; an enlarged, but noncancerous, prostate).

A PSA test or a DRE may be able to detect prostate cancer at an early stage, but it is not clear whether early detection and treatment decrease the risk of dying from prostate cancer.

Studies are being done to find ways to make PSA testing more accurate for early cancer detection.

A prostate cancer gene 3 (PCA3) RNA test may be used for certain patients.

If a man had a high PSA level and a biopsy of the prostate did not show cancer and the PSA level remains high after the biopsy, a prostate cancer gene 3 (PCA3) RNA test may be done. This test measures the amount of PCA3 RNA in the urine after a DRE. If the PCA3 RNA level is higher than normal, another biopsy may help diagnose prostate cancer.

What is the PSA test?

Prostate-specific antigen, or PSA, is a protein produced by normal, as well as malignant, cells of the prostate gland. The PSA test measures the level of PSA in the blood. For this test, a blood sample is sent to a laboratory for analysis. The results are usually reported as nanograms of PSA per milliliter (ng/mL) of blood.

The blood level of PSA is often elevated in people with prostate cancer, and the PSA test was originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed with the disease. In 1994, FDA approved the PSA test to be used in conjunction with a digital rectal exam (DRE) to aid in the detection of prostate cancer in men 50 years and older. Until about 2008, many doctors and professional organizations had encouraged yearly PSA screening for prostate cancer beginning at age 50.

PSA testing (along with a DRE) is also often used by health care providers for individuals who report prostate symptoms to help determine the nature of the problem.

In addition to prostate cancer, several benign (not cancerous) conditions can cause a person’s PSA level to rise, particularly prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH) (enlargement of the prostate). There is no evidence that either condition leads to prostate cancer, but someone can have one or both of these conditions and develop prostate cancer as well.

Is the PSA test recommended for prostate cancer screening?

Beginning around 2008, as more was learned about both the benefits and harms of prostate cancer screening, a number of professional medical organizations began to caution against routine population screening with the PSA test. Most organizations recommend that individuals who are considering PSA screening first discuss the risks and benefits with their doctors.

Some organizations do recommend that men who are at higher risk of prostate cancer begin PSA screening at age 40 or 45. These include Black men, men with germline variants in BRCA2 (and to a lesser extent, in BRCA1), and men whose father or brother had prostate cancer.

In 2018, the United States Preventive Serves Task Force (USPSTF) updated its recommendation statement for prostate cancer screening Exit Disclaimer from a “D” (not recommended) to a “C” (selectively offering PSA-based screening based on professional judgment and patient preferences) in men ages 55 to 69. (The USPSTF continues to recommend against PSA screening for men 70 years and older.) The updated recommendation, which applies to the general population as well as those at increased risk due to race/ethnicity or family history, is as follows:

• For individuals ages 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one. Before making the decision, a person should discuss the potential benefits and harms of screening with their clinician and consider these in the context of their own values and preferences.
• PSA-based screening for prostate cancer is not recommended for individuals 70 years and older.

Currently, Medicare provides coverage for an annual PSA test for all Medicare-eligible individuals ages 50 and older. Many private insurers cover PSA screening as well.

What is a normal PSA test result?

There is no specific normal or abnormal level of PSA in the blood. In the past, PSA levels of 4.0 ng/mL and lower were considered normal. However, some individuals with PSA levels below 4.0 ng/mL have prostate cancer and many with higher PSA levels between 4 and 10 ng/mL do not have prostate cancer.

In addition, various factors can cause someone’s PSA level to fluctuate. For example, the PSA level tends to increase with age, prostate gland size, and inflammation or infection. A recent prostate biopsy will also increase the PSA level, as can ejaculation or vigorous exercise (such as cycling) in the 2 days before testing. Conversely, some drugs—including finasteride and dutasteride, which are used to treat BPH—lower the PSA level.

In general, however, the higher a man’s PSA level, the more likely it is that he has prostate cancer.

What is done if a screening test shows an elevated PSA level?

If someone who has no symptoms of prostate cancer chooses to undergo prostate cancer screening and is found to have an elevated PSA level, the doctor may recommend another PSA test to confirm the original finding. If the PSA level is still high, the doctor may recommend that the person continue with PSA tests and digital rectal exams (DREs) at regular intervals to watch for any changes over time (also called observation or watchful waiting).

If the PSA level continues to rise or a suspicious lump is detected during a DRE, the doctor may recommend additional tests to determine the nature of the problem. These may include imaging tests, such as magnetic resonance imaging (MRI) or high-resolution micro-ultrasound.

Alternatively, the doctor may recommend a prostate biopsy. During this procedure, multiple samples of prostate tissue are collected by inserting hollow needles into the prostate and then withdrawing them. The biopsy needle may be inserted through the wall of the rectum (transrectal biopsy) or through the perineum (transperineal biopsy). A pathologist then examines the collected tissue under a microscope. Although both biopsy techniques are guided by ultrasound imaging so the doctor can view the prostate during the biopsy procedure, ultrasound cannot be used alone to diagnose prostate cancer. An MRI-guided biopsy may be performed for patients with suspicious areas seen on MRI.

In the past, men with elevated PSA levels and no other symptoms were sometimes prescribed antibiotics to see if an infection might be causing the PSA increase. However, according to the American Urological Association, there is no evidence to support the use of antibiotics to reduce PSA levels in men who are not experiencing other symptoms.

What are some of the limitations and potential harms of the PSA test for prostate cancer screening?

Detecting prostate cancer early may not reduce the chance of dying from prostate cancer. When used in screening, the PSA test can help detect small tumors. Having a small tumor found and treated may not, however, reduce the chance of dying from prostate cancer. That is because many tumors found through PSA testing grow so slowly that they are unlikely to be life threatening. Detecting such tumors is called “overdiagnosis,” and treating them is called “overtreatment.”

Overtreatment exposes a person unnecessarily to the potential complications associated with prostate surgery and radiation therapy. These include urinary (e.g., urinary incontinence, or leaking of urine following surgery and increased frequency and urgency of urination following radiation), gastrointestinal (e.g., loose stools or, less commonly, rectal bleeding following radiation), and sexual side effects (loss of erections or decreased erections following both surgery and radiation).

In addition, finding cancer early may not help someone who has a fast-growing or aggressive prostate tumor that may have spread to other parts of the body before being detected.

The PSA test may give false-positive results. A false-positive test result occurs when the PSA level is elevated but no cancer is actually present. A false-positive test result may create anxiety and lead to additional medical procedures, such as a prostate biopsy, that can be harmful. Possible side effects of biopsies include serious infections, pain, and bleeding.

False-positive test results are common with PSA screening; only about 25% of people who have a prostate biopsy due to an elevated PSA level are found to have prostate cancer when a biopsy is done.

What have randomized trials of prostate cancer screening found?

Several large, randomized trials of prostate cancer screening have been carried out. One of the largest is the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which NCI conducted to determine whether certain screening tests can help reduce the numbers of deaths from several common cancers. In the prostate portion of the trial, the PSA test and digital rectal exam were evaluated for their ability to decrease a man’s chances of dying from prostate cancer.

The PLCO investigators found that men who underwent annual prostate cancer screening had a higher incidence of prostate cancer than men in the control group but had about the same rate of deaths from the disease. Overall, the results suggest that many men were treated for prostate cancers that would not have been detected in their lifetime without screening. Consequently, these men were exposed unnecessarily to the potential harms of treatment.

A second large trial, the European Randomized Study of Screening for Prostate Cancer (ERSPC), compared prostate cancer deaths in men randomly assigned to PSA-based screening or no screening. As in the PLCO, men in ERSPC who were screened for prostate cancer had a higher incidence of the disease than control men. In contrast to the PLCO, however, men who were screened had a lower rate of death from prostate cancer.

A subsequent analysis of data from the PLCO used a statistical model to account for the fact that some men in the PLCO trial who were assigned to the control group had nevertheless undergone PSA screening. This analysis suggested that the level of benefit in the PLCO and ERSPC trials was similar and that both trials showed some reduction in prostate cancer death in association with prostate cancer screening.

Such statistical modeling studies have important limitations and rely on unverified assumptions that can render their findings questionable (or more suitable for further study than to serve as a basis for screening guidelines). More important, the model could not provide an assessment of the balance of benefits versus harms from screening.

The third and largest trial, the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), conducted in the United Kingdom, compared prostate cancer mortality among men whose primary care practices were randomly assigned to offer their patients a single PSA screening test or to provide usual care in which screening was not offered. After a median follow-up of 10 years, more low-risk prostate cancers were detected in the single PSA test group than in the usual (unscreened) care group (even though only about a third of men in the screening group actually had the PSA test), but there was no difference in prostate cancer mortality.

A systematic review and meta-analysis of all randomized controlled trials comparing PSA screening with usual care in men without a diagnosis of prostate cancer concluded that PSA screening for prostate cancer leads to a small reduction in prostate cancer mortality over 10 years but does not affect overall mortality.

The United States Preventive Services Task Force has estimated that, for every 1,000 men ages 55 to 69 years who are screened for 13 years:

• About 1.3 deaths from prostate cancer would be avoided (or 1 death avoided per 769 men screened). [However, based on 3 additional years of follow-up in the ERSPC trial, about 1.8 deaths from prostate cancer would be avoided per every 1,000 men screened, or 1 death in 570 men screened].
• 3 men would avoid developing metastatic cancer
• 5 men would die from prostate cancer despite screening, diagnosis, and treatment
• 240 men would have a positive PSA test result, many of whom would have a biopsy that shows that the result was a false-positive; some men who had a biopsy would experience at least moderately bothersome symptoms (pain, bleeding, or infection) from the procedure (and 2 would be hospitalized).
• 100 men would be diagnosed with prostate cancer. Of those, 80 would be treated (either immediately or after a period of active surveillance) with surgery or radiation. Many of these men would have a serious complication from treatment, with 50 experiencing sexual dysfunction and 15 experiencing urinary incontinence.
• 200 men would die of causes other than prostate cancer

How is the PSA test used in men who have been treated for prostate cancer?

The PSA test is used to monitor men after surgery or radiation therapy for prostate cancer to see if their cancer has recurred (come back). If a man’s PSA level begins to rise after prostate cancer treatment, it may be the first sign of a recurrence. Such a “biochemical relapse” typically appears months or years before the recurrence causes symptoms.

However, a single elevated PSA measurement in someone who has a history of prostate cancer does not always mean that the cancer has come back. Someone who has been treated for prostate cancer should discuss an elevated PSA level with their doctor. The doctor may recommend repeating the PSA test or performing other tests to check for evidence of a recurrence. The doctor may look for a trend of rising PSA level over time rather than a single elevated PSA level.

A rising trend in PSA level over time in combination with other findings, such as an abnormal result on imaging tests, may lead the doctor to recommend further cancer treatment.

How are researchers trying to improve the PSA test?

Scientists are investigating ways to improve the PSA test to give doctors the ability to better distinguish cancerous from benign conditions and slow-growing cancers from fast-growing, potentially lethal cancers. And other potential biomarkers of prostate cancer are being investigated. None of these tests has been proven to decrease the risk of death from prostate cancer. Some of the methods being studied include

• Free versus total PSA. The amount of PSA in the blood that is “free” (not bound to other proteins) divided by the total amount of PSA (free plus bound) is denoted as the proportion of free PSA. Some evidence suggests that a lower proportion of free PSA may be associated with more aggressive cancer.
• PSA density. The blood level of PSA divided by the volume of the prostate gland. Some evidence suggests that this measure may be more accurate at detecting prostate cancer than the standard PSA test.
• PSA velocity and PSA doubling time. PSA velocity is the rate of change in a man’s PSA level over time, expressed as ng/mL per year. PSA doubling time is the period of time over which a man’s PSA level doubles. These measures are most useful in men with a biochemical recurrence following surgery or radiation therapy.
• Pro-PSA. Pro-PSA refers to several different inactive precursors of PSA. There is some evidence that pro-PSA is more strongly associated with prostate cancer than with BPH. One blood test combines the measurement of a form of pro-PSA called [-2]proPSA with measurements of PSA and free PSA into a mathematical formula called the Prostate Health Index. The resulting “phi score” calculated from this formula can be used to help a man with a PSA level between 4 and 10 ng/mL decide whether he should have a biopsy.
• IsoPSA. PSA exists in different structural forms (called isoforms) in the blood. The IsoPSA test, which measures the entire spectrum of PSA isoforms rather than the concentration of PSA in the blood, may be better than traditional PSA testing for identifying men with an increased risk for developing high-grade prostate cancer who should undergo biopsy (11).
• 4Kscore Test. The 4Kscore test takes into account four different prostate-specific biomarkers, namely, total PSA, free PSA, intact PSA, and human kallikrein 2, as well as the patient’s age, prior biopsy history, and DRE status to assess the risk of aggressive prostate cancer in someone with an abnormal screening result.
• Urinary biomarkers. Prostate cancer antigen 3 (PCA3) mRNA and the TMPRSS2-ERG gene fusion are biomarkers that are tested in a urine sample. They have increased specificity for prostate cancer compared with PSA testing alone, but do not appear to preferentially identify clinically significant disease. The use of these two biomarkers in combination can help reduce the number of (unnecessary) biopsies.

What are prostate tests?

Prostate tests are performed to check for problems with your prostate. The tests can show if your prostate is enlarged, if it is causing bladder problems, or if there are signs of cancer.

Why do health care professionals use prostate tests?

Different prostate problems can have similar symptoms. A medical exam followed by prostate testing is important for diagnosing your problem.

Health care professionals may recommend prostate tests if you have symptoms such as

• urinary frequency, urinary urgency, or nocturia
• trouble starting a urine stream or a weak or interrupted urine stream
• urine blockage
• urinary retention
• bladder control problems, known as urinary incontinence
• urine with an unusual color or odor
• painful urination or painful ejaculation

What steps will your health care professional take before ordering prostate tests?

Before ordering any prostate tests, your health care professional will review your medical history, including any major illnesses or surgeries, perform a physical exam, and may ask

• if you have a family history of prostate problems
• when your problem or symptoms started and how often they occur
• whether you consume caffeine and alcohol
• how much water or other liquids you typically drink each day

Some prostate problems may require a series of medical exams and tests for diagnosis.

What prostate tests do health care professionals use?

Health care professionals may use the following tests to diagnose prostate problems.

Digital rectal exam

Many health care professionals perform a digital rectal exam (DRE) as part of a routine physical exam for males ages 50 or older. Some males may start receiving a DRE as part of a physical exam earlier, at age 40, whether or not they have any urinary problems.

During a DRE, your health care professional will feel your prostate for any abnormalities that could need more tests. The DRE may be slightly uncomfortable, but it is brief. You will either stand and bend forward or lie on your side on the exam table with your knees bent for the exam.

If an infection is suspected, your health care professional might gently massage the prostate to collect a sample of fluid to examine under a microscope. The DRE may also help determine if a prostate biopsy or other tests are needed, especially if your health care professional feels a mass within the prostate.

Prostate-specific antigen test

Prostate-specific antigen (PSA) is a protein made only by the prostate gland. The PSA test is a blood test that measures the amount of PSA protein in your blood.

The PSA test is most often used along with the DRE to rule out prostate cancer. Finding high levels of PSA in your blood could be a sign of prostate cancer or of less serious problems, such as benign prostatic hyperplasia or prostatitis.

The PSA test is a screening test that may be difficult to interpret, particularly if the test has been only done once. The difficulties in interpreting the PSA can lead to potentially unnecessary prostate biopsies and treatment. For example,

• the PSA test is known to have false-positive and false-negative results. Repeating the test and establishing a trend for your number is helpful to reduce some of this inaccuracy.
• a high PSA level could be a sign of prostate cancer, but it could also indicate other problems with the prostate.
• follow-up diagnostic tests, such as a prostate biopsy, could cause side effects, including bleeding and infection.

If you are between the ages of 55 and 69, the PSA test may be recommended for you to consider. If you are age 70 or older, the test is not usually recommended. Talk with your health care professional about any concerns and whether the PSA test is right for you.

Prostate health index

The prostate health index (PHI), approved by the U.S. Food and Drug Administration, combines your PSA score in a mathematical formula with results from two additional blood tests. Your health care professional may order those two additional blood tests if your PSA score is between 4 and 10. The PHI measures your risk for prostate cancer more accurately, and it might save you an unnecessary biopsy.

Biopsy

Most prostate biopsies are guided by transrectal ultrasound (TRUS). However, health care professionals are increasingly using more targeted and accurate imaging techniques with biopsies.

TRUS-guided biopsy

TRUS is most often used to examine the prostate and is usually combined with a biopsy. A health care professional inserts a probe that is slightly larger than a finger into the rectum next to the prostate. The ultrasound image shows the size of the prostate and might identify abnormal-looking areas within the prostate, such as tumors. Your health care professional will perform a biopsy by inserting a needle through the rectum next to the ultrasound probe or through the perineum into several areas of the prostate. Tissue samples are removed and examined by a pathologist to see if any of them are cancerous. This technique has the risk of missing tumors that are outside the sampling areas.

Magnetic resonance imaging/TRUS-fusion-guided biopsy

A health care professional will take an image of your prostate during magnetic resonance imaging (MRI). The health care professional will load the MRI image into special software where it is fused with real-time TRUS images. The combined images allow for targeted guidance and precise biopsy of any concerning areas. These targeted biopsies might be combined with a systematic biopsy to sample other parts of the prostate.

MRI-guided biopsy

During an MRI, biopsy needles are inserted through the rectum or perineum into targeted areas seen on the MRI. This technique is not used often because it can be complicated and expensive.

Cognitive fusion

MRI images are taken before and during a TRUS biopsy to provide guidance on biopsy targets. This technique is more accurate at finding prostate cancer than a TRUS biopsy alone. However, health care professionals must have special training in this technique to perform it, and there may not be a professional available in your area.

What additional tests do health care professionals use?

Your health care professional may order additional tests for more information, such as

• urinalysis to see if you have an infection in your bladder
• urodynamic tests to measure the pressure in your bladder while you urinate to see if your bladder is obstructed
• cystoscopy to make sure your urinary symptoms are not due to bladder cancer or a bladder stone and to check your prostate’s shape and size
• ultrasound of the abdomen to see if there are any blockages in your urinary tract, including the kidneys
• MRI or computed tomography (CT) scans to identify abnormalities in the urinary tract

How do I prepare for prostate tests?

Some tests may require preparation, while others may not. You may need to

• drink two to three glasses of water, without going to the bathroom, about an hour before some abdominal ultrasounds or some urodynamic tests
• if prescribed, take antibiotics to prevent infection before tests that involve inserting instruments into the urethra or rectum, or before biopsy

Ask your health care professional if there is anything you need to do before your test.

What should I expect after prostate tests?

You may feel some discomfort shortly after your tests, but you can usually go back to your normal activities. Some people may experience additional symptoms after certain prostate tests.

DRE

You may bleed slightly from the rectum afterward. This is more likely to happen if you have hemorrhoids or anal fissures, which are small tears in your anus that may cause itching, pain, or bleeding.

PSA

You may have slight pain or bruising at the spot where the needle was inserted to draw the blood, but most symptoms go away quickly.

Prostate biopsy

You may see some blood in your urine or ejaculate, or from your rectum for a short while after the procedure. You may be asked to take antibiotics to prevent infection.

It may take several days to weeks to get your test results. Your health care professional will talk with you about the results and ways to treat the problem.

What are the risks of prostate tests?

Risks of side effects or complications from prostate tests vary. Before any test, talk with your health care professional about risks, benefits, and potential complications.

Low-risk prostate tests include the PSA test, DRE, ultrasound, and MRI. Prostate biopsy may have a higher risk for side effects or complications such as

• blood in the urine or ejaculate, or rectal bleeding—these may be temporary
• urinary tract infections
• severe infection of the blood, called sepsis
• urinary retention or erectile dysfunction
• injury to the wall of the rectum

Seek care right away

After a prostate test, call or see a health care professional right away if you

• feel severe discomfort
• feel pain when urinating, have cloudy urine, or cannot urinate
• have blood in your urine or ejaculate, or coming from the rectum or around your anus
• have a fever or chills

This first step lets your doctor hear and understand the "story" of your prostate concerns. You'll be asked whether you have symptoms, how long you've had them, and how much they affect your lifestyle. Your personal medical history also includes any risk factors, pain, fever, or trouble passing urine. You may be asked to give a urine sample for testing.

Digital Rectal Exam (DRE)

DRE is a standard way to check the prostate. With a gloved and lubricated finger, your doctor feels the prostate from the rectum. The test lasts about 10-15 seconds.

This exam checks for:

• The size, firmness, and texture of the prostate
• Any hard areas, lumps, or growth spreading beyond the prostate, and
• Any pain caused by touching or pressing the prostate

The DRE allows the doctor to feel only one side of the prostate. A PSA test is another way to help your doctor check the health of your prostate.

PSA (Prostate-Specific Antigen) Test

The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a DRE to help detect prostate cancer in men age 50 and older. PSA is a protein made by prostate cells. It is normally secreted into ducts in the prostate, where it helps make semen, but sometimes it leaks into the blood. When PSA is in the blood, it can be measured with a blood test called the PSA test. In prostate cancer, more PSA gets into the blood than is normal. However, a high PSA blood level is not proof of cancer, and many other things can cause a false-positive test result. For example, blood PSA levels are often increased in men with prostatitis or BPH. Even things that disturb the prostate gland--such as riding a bicycle or motorcycle, or having a DRE, an orgasm within the past 24 hours, a prostate biopsy, or prostate surgery--may increase PSA levels.

Also, some prostate glands naturally produce more PSA than others. PSA levels go up with age. African-American men tend to have higher PSA levels in general than men of other races. And some drugs, such as finasteride and dutasteride, can cause a man's PSA level to go down. PSA tests are often used to follow men after prostate cancer treatment to check for signs of cancer recurrence. It is not yet known for certain whether PSA testing to screen for prostate cancer can reduce a man's risk of dying from the disease.

Researchers are working to learn more about the PSA test's ability to help doctors tell the difference between prostate cancer and benign prostate problems, and the best thing to do if a man has a high PSA level. For now, men and their doctors use PSA readings over time as a guide to see if more follow-up is needed.

PSA test results

PSA levels are measured in terms of the amount of PSA per volume of fluid tested. Doctors often use a value of 4 nanograms (ng) or higher per milliliter of blood as a sign that further tests, such as a prostate biopsy, are needed. Your doctor may monitor your PSA velocity, which means the rate of change in your PSA level over time. Rapid increases in PSA readings may suggest cancer. If you have a mildly elevated PSA level, you and your doctor may choose to do PSA tests on a scheduled basis and watch for any change in the PSA velocity.

Free PSA test

This test is used for men who have higher PSA levels. The standard PSA test measures total PSA, which includes both PSA that is attached, or bound, to other proteins and PSA that is free, or not bound. The free PSA test measures free PSA only. Free PSA is linked to benign prostate conditions, such as BPH, whereas bound PSA is linked to cancer. The percentage of free PSA can help tell what kind of prostate problem you have.

• If both total PSA and free PSA are higher than normal (high percentage of free PSA), this suggests BPH rather than cancer.
• If total PSA is high but free PSA is not (low percentage of free PSA), cancer is more likely. More testing, such as a biopsy, should be done.

You and your doctor should talk about your personal risk and free PSA results. Then you can decide together whether to have follow-up biopsies and, if so, how often.

Prostate Biopsy

If your symptoms or test results suggest prostate cancer, your doctor will refer you to a specialist (a urologist) for a prostate biopsy. For a biopsy, small tissue samples are taken directly from the prostate. Your doctor will take samples from several areas of the prostate gland. This can help lower the chance of missing any areas of the gland that may have cancer cells. Like other cancers, prostate cancer can be diagnosed only by looking at tissue under a microscope. Most men who have biopsies after prostate cancer screening exams do not have cancer.

A positive test result after a biopsy means prostate cancer is present. A pathologist will check your biopsy sample for cancer cells and will give it a Gleason score. The Gleason score ranges from 2 to 10 and describes how likely it is that a tumor will spread. The lower the number, the less aggressive the tumor is and the less likely it will spread. Treatment options depend on the stage (or extent) of the cancer (stages range from 1 to 4), Gleason score, PSA level, and your age and general health. This information will be available from your doctor and is listed on your pathology report.

Reaching a decision about treatment of your prostate cancer is a complex process. Many men find it helpful to talk with their doctors, family, friends, and other men who have faced similar decisions.

In 2018, the U.S. Preventive Services Task Force (USPSTF) made the following recommendations about prostate cancer screening—

• Men who are 55 to 69 years old should make individual decisions about being screened for prostate cancer with a prostate specific antigen (PSA) test.
• Before making a decision, men should talk to their doctor about the benefits and harms of screening for prostate cancer, including the benefits and harms of other tests and treatment.
• Men who are 70 years old and older should not be screened for prostate cancer routinely.

This recommendation applies to men who—

• Are at average risk for prostate cancer.
• Are at increased risk for prostate cancer.
• Do not have symptoms of prostate cancer.
• Have never been diagnosed with prostate cancer.

Other organizations, like the American Urological Association, the American Cancer Society, and the American College of Physicians may have other recommendations.

Talk to Your Doctor

If you are thinking about being screened, you and your doctor should consider—

• If you have a family history of prostate cancer.
• If you are African-American.
• If you have other medical conditions that may make it difficult for you to be treated for prostate cancer if it is found, or that may make you less likely to benefit from screening.
• How you value the potential benefits and harms of screening, diagnosis, and treatment.

The U.S. Preventive Services Task Force (USPSTF) is an organization made up of doctors and disease experts who look at research on the best way to prevent diseases and make recommendations on how doctors can help patients avoid diseases or find them early.

In 2018, the U.S. Preventive Services Task Force (USPSTF) made the following recommendations about prostate cancer screening—

• Men who are 55 to 69 years old should make individual decisions about being screened for prostate cancer with a prostate specific antigen (PSA) test.
• Before making a decision, men should talk to their doctor about the benefits and harms of screening for prostate cancer, including the benefits and harms of other tests and treatment.
• Men who are 70 years old and older should not be screened for prostate cancer routinely.

The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread. However, most prostate cancers grow slowly or not at all.

Possible Benefits of Screening

The benefits of screening for prostate cancer may include—

• Finding prostate cancers that may be at high risk of spreading, so that they can be treated before they spread. This may lower the chance of death from prostate cancer in some men.
• Some men prefer to know if they have prostate cancer.

Possible Harms

The possible harms of screening for prostate cancer include harms from screening, diagnosis, and treatment.

Possible Harm from Screening

False positive test results: This occurs when a man has an abnormal PSA test but does not have prostate cancer. False positive test results often lead to unnecessary tests, like a biopsy of the prostate. They may cause men to worry about their health. Older men are more likely to have false positive test results.

Possible Harms from Diagnosis

Screening finds prostate cancer in some men who would never have had symptoms from their cancer in their lifetime. Treatment of men who would not have had symptoms or died from prostate cancer can cause them to have complications from treatment, but not benefit from treatment. This is called overdiagnosis.

Prostate cancer is diagnosed with a prostate biopsy. A biopsy is when a small piece of tissue is removed from the prostate and looked at under a microscope to see if there are cancer cells. Older men are more likely to have a complication after a prostate biopsy.

A prostate biopsy can cause—

• Pain.
• Blood in the semen or ejaculate.
• Infection.

Possible Harms from Treatment

The most common treatments for prostate cancer are surgery to remove the prostate and radiation therapy.

The most common harms from prostate cancer treatment are—

• Urinary incontinence (accidental leakage of urine). About 1 out of every 5 men who have surgery to remove the prostate loses bladder control.
• Erectile dysfunction (impotence). About 2 out of every 3 men who have surgery to remove the prostate become impotent, and about half of men who receive radiation therapy become impotent.
• Bowel problems, including fecal incontinence (accidental leakage of bowel movements) and urgency (sudden and uncontrollable urge to have a bowel movement). About 1 out of every 6 men who has radiation therapy has bowel problems.

Facts About Prostate Cancer Screening

• For every 1,000 men between the ages of 55 and 69 years old who are screened, about 1 death will be prevented, and 3 men will be prevented from getting prostate cancer that spreads to other places in the body.
• Many men with prostate cancer never experience symptoms and, without screening, would never know they had the disease.

Screening tests have risks.

Decisions about screening tests can be difficult. Not all screening tests are helpful and most have risks. Before having any screening test, you may want to discuss the test with your doctor. It is important to know the risks of the test and whether it has been proven to reduce the risk of dying from cancer.

The risks of prostate screening include the following:

Finding prostate cancer may not improve health or help a man live longer.

Screening may not improve your health or help you live longer if you have cancer that has already spread to the area outside of the prostate or to other places in your body.

Some cancers never cause symptoms or become life-threatening, but if found by a screening test, the cancer may be treated. Finding these cancers is called overdiagnosis. It is not known if treatment of these cancers would help you live longer than if no treatment were given.

Treatments for prostate cancer, such as radical prostatectomy and radiation therapy, may have long-term side effects in many men. The most common side effects are erectile dysfunction and urinary incontinence.

Some studies of patients with newly diagnosed prostate cancer showed these patients had a higher risk of death from cardiovascular (heart and blood vessel) disease or suicide. The risk was greatest in the first weeks or months after diagnosis.

Follow-up tests, such as a biopsy, may be done to diagnose cancer.

If a PSA test is higher than normal, a biopsy of the prostate may be done. Complications from a biopsy of the prostate may include fever, pain, blood in the urine or semen, and urinary tract infection. Even if a biopsy shows that a patient does not have prostate cancer, he may worry more about developing prostate cancer in the future.

False-negative test results can occur.

Screening test results may appear to be normal even though prostate cancer is present. A man who receives a false-negative test result (one that shows there is no cancer when there really is) may delay seeking medical care even if he has symptoms.

False-positive test results can occur.

Screening test results may appear to be abnormal even though no cancer is present. A false-positive test result (one that shows there is cancer when there really isn't) can cause anxiety and is usually followed by more tests, (such as biopsy) which also have risks.

Your doctor can advise you about your risk for prostate cancer and your need for screening tests.

Most prostate cancers found by screening are small and slow growing and may not be fatal. Some men may have a faster growing prostate cancer and will benefit from early treatment.

Older men, African-American men, and men who have a family history of prostate cancer have a greater risk for developing prostate cancer. If you are concerned that you may have a greater risk for prostate cancer, talk to your doctor about screening.

Screening for Prostate Cancer

One screening test for prostate cancer is a prostate-specific antigen (PSA) blood test, which can be abnormal (not normal) for several reasons besides prostate cancer.

The only way to know if an abnormal test is due to cancer is to do a biopsy. A biopsy is a surgery to get small pieces of the prostate to look at under a microscope. If the biopsy shows there are cancer cells, then your doctor will discuss treatment options.

Treatment of prostate cancer may include—

• Close monitoring and follow-up visits.
• Radiation.
• Surgery to remove the prostate.

Side effects from radiation or surgery may include—

• Impotence.
• Loss of bladder control.
• Problems with your rectum.

Some medical groups have different screening recommendations.

Talk with your doctor or nurse to decide together if prostate cancer screening is right for you.

Questions to Ask Your Doctor

Here are some questions you can ask your doctor about prostate cancer screening—

• Am I at a greater risk for prostate cancer?
• At what age should I start to think about screening for prostate cancer?
• If I get my blood test, and it is not normal, what other things could I have besides prostate cancer?
• What is a biopsy, and how is it done?
• What are the side effects or risks of a biopsy?
• If my biopsy shows some cancer cells, what does that mean?
  Ask about all treatment options: close monitoring and follow-up visits, radiation, or surgery to remove the prostate.
• What are the side effects or risks of each treatment?