Why Prostate Screenings Matter as You Age

About Nicole Pajer

Nicole Pajer is a Los Angeles-based freelance published in The New York Times, Woman's Day, AARP, Parade, Wired, Glamour, People and more.

a senior man speaking to a doctor holding a clipboard

Around 1 in 8 men will be diagnosed with prostate cancer during their lifetime. It’s also the second leading cause of cancer-related death among men in America, just behind lung cancer. While prostate cancer can be a deadly disease, mortality rates due to prostate cancer have been on the decline.

In fact, the prostate cancer death rate dropped by about half between 1993 and 2022, likely due to factors like earlier detection and advances in treatment.

A man’s risk of developing prostate cancer varies based on things like age, race and family history. But increasing age remains the biggest risk factor. About 6 in 10 cases are diagnosed in men ages 65 and older, with the average age at diagnosis being around 67. When prostate cancer is caught before it has spread to other parts of the body, the five-year relative survival rate is greater than 99%. But prostate cancer doesn’t always show obvious symptoms in early stages, which makes it important to talk with your healthcare provider about whether screening is appropriate for you.

Prostate cancer can be silent in its early stages

One of the challenges in diagnosing prostate cancer is that patients can’t necessarily rely on symptoms to alert them that something is wrong. While symptoms are uncommon in early stages, they can include:

Difficulty urinating, such as a slow or weak urinary stream or the need to urinate more frequently at night
Blood in urine or semen

“I advise making consultations with doctors, regardless, if you are having symptoms because prostate cancer is usually asymptomatic in the beginning,” says Julio Pow-Sang, MD, chair of the Department of Genitourinary Oncology at Moffitt Cancer Center.

Screening can help find prostate cancer before symptoms develop. Advanced prostate cancer, in which the cancer has potentially spread to other areas of the body, can cause symptoms such as:

Erectile dysfunction
Pain in the hips, spine, ribs or other areas from cancer that has spread
Numbness or weakness in the legs or feet
Loss of bladder or bowel control
Unexplained weight loss
Fatigue

Many of these symptoms can be attributed to other conditions but should be evaluated by your healthcare provider.

How is prostate cancer screened?

The most common way to screen for prostate cancer is with a prostate-specific antigen (PSA) test. This is a blood test that measures the level of PSA, a protein produced by cells in the prostate, in your blood. It’s normal for men to have some level of PSA in their blood, but higher levels can sometimes be a sign of prostate cancer. “A PSA test of the patient's blood might reveal prostate cancer at an early stage,” says Pow-Sang. Thus, your doctor may compare your PSA results with previous tests to see how your levels have changed over time.

A PSA test, however, can’t tell you for certain whether you have prostate cancer. This is because PSA levels can also rise due to some noncancerous conditions such as benign prostatic hyperplasia (BPH), an enlarged prostate that becomes more common with age, and prostatitis, or inflammation of the prostate. In general, PSA levels also naturally tend to increase as you get older.

A digital rectal exam (DRE) may also be used as part of prostate cancer screening. This is when a doctor inserts a gloved, lubricated finger into a man’s rectum to feel for abnormalities in the prostate. DRE alone is less effective than PSA testing at finding prostate cancer, but it may sometimes be used along with PSA testing.

Understanding prostate cancer screening guidelines

When it comes to prostate cancer screening, there isn’t one set schedule that’s right for everyone. Experts recommend talking with your healthcare provider about the potential benefits and risks of screening based on factors like your age, family history and overall health.

The American Cancer Society recommends that men at average risk who are expected to live at least another 10 years begin discussing prostate cancer screening with their healthcare provider at age 50. Men at higher risk should start the conversation at age 45. This includes Black men and men who have a father or brother who was diagnosed with prostate cancer before age 65. Men at even higher risk — those with more than one first-degree relative diagnosed with prostate cancer before age 65 — should start the discussion at age 40.

The current U.S. Preventive Services Task Force recommendation states that men ages 55 to 69 should make an individual decision about PSA-based screening after discussing the potential benefits and harms with their healthcare provider. The USPSTF recommends against routine PSA-based screening for men ages 70 and older because the potential benefits do not outweigh the expected harms. Men 70 and older who are considering screening should discuss the reduced likelihood of benefit and increased risk of harms with their healthcare provider.

“The issue is that we are now living longer and chronological age doesn't necessarily correlate to physiological,” says Ajay Bhatnagar, MD, MBA, an interventional radiation oncologist and founder of the Prostate Cancer Institute of America. Thus, he says, there can be some controversy surrounding what age people should start and stop screening for prostate cancer. “I believe this should be a personalized individual decision and can't give a blanket recommendation based solely on age,” he explains.

And the American Cancer Society does not recommend prostate cancer screening for men who have no symptoms and a life expectancy of less than 10 years because they aren't likely to benefit from it. Some providers, like Bhatnagar, are looking more towards life expectancy as a guideline when determining whether screening makes sense for an older patient. “I would base the decision of prostate cancer screening on life expectancy, and if their life expectancy is less than five years, I would not recommend prostate screening,” he says.

What happens if your PSA is elevated?

An elevated PSA doesn’t automatically mean that you have prostate cancer. Your healthcare provider will interpret your results and also factor in things such as your age, medical history, previous PSA results and other individual risk factors.

“It is not enough to just identify all elevated PSAs, rather it is important to also take into account the individual's medical history and make a determination as to whether further testing (repeat testing), imaging studies, referral to a specialist or biopsy are warranted,” says Kyle Hoedebecke, MD, a board-certified family medicine physician and clinical advisor at Alpas Wellness NOVA.

Depending on your results, your doctor may recommend repeating the PSA test or ordering additional blood or urine tests. They may also send you for imaging such as an MRI or refer you to a urologist, who may recommend a biopsy to determine whether cancer is present.

Some prostate cancers also grow so slowly that they may never cause health problems or require treatment. Thus, doctors may adopt an “active surveillance” approach, where the cancer is closely monitored with regular tests. Treatment may be recommended if tests show the cancer is progressing. Another option is “watchful waiting,” which generally involves less testing and focuses on managing symptoms if they develop.

“A well thought out screening program weighs the potential benefits of finding an aggressive form of cancer at an early stage versus identifying a small tumor that would likely not impact the man's health,” Hoedebecke says.

Questions to ask your doctor about prostate cancer screening

Since prostate cancer screening isn’t one-size-fits-all, especially as you get older, it’s important to have an open conversation with your healthcare provider about whether screening is right for you. Some questions to ask your doctor include:

Based on my age and overall health, should I continue prostate cancer screening?
How often should I have a PSA test?
How have my PSA levels changed over time?
Does my family history or race put me at higher risk?
What happens if my PSA comes back elevated?
At what point might it make sense for me to stop screening?

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