Although somewhat based on age, a PSA above 4 typically indicates a 25% higher risk of PCa. Once it heads above 10, your risk of PCa rises significantly to between 50% - 70%.

So, what exactly is PSA and why do we use it as one of the markers for disease? The PSA (prostate-specific antigen) test measures a protein produced by the prostate gland and circulates in the blood. While elevated PSA levels can indicate PCa, it can also result from benign conditions like inflammation or urinary tract issues. This is one reason some physicians dismiss PSA testing. Not because it’s useless, but because it isn’t perfect. But no early PCa marker is perfect.

That being said, I have lost count of the number of men who have told me that PSA testing saved their life. The PSA test is not the enemy. Misinterpretation and overreaction are the culprits.

I believe the problem lies in how it is interpreted and then, what is done with those results. Traditionally, doctors have recommended a biopsy for men with an elevated PSA once it reaches a target value. Sometimes the biopsy causes unwanted side effects like pain or bleeding, which is why other methods of confirmation using MRI or blood and urine samples are showing promising results.

In 2012, an independent panel of medical experts called the U.S. Preventive Services Task Force (USPSTF) issued a “Grade D” recommendation (discouraging the use of PSA testing) against PSA screening for all men, concluding that the potential harms outweighed the benefits. They had previously (2008) advised against screening men over 75 since their remaining lifespan was likely less than 10 years. Other groups like the American Academy of Family Physicians aligned with this guidance, so PSA testing dropped dramatically.

What followed was an unintentional public health experiment on millions of men. As a result of the USPSTF 2012 recommendation, PSA screening declined by up to 40% in men over age 50. Since prostate screening declined, early-stage PCa diagnoses dropped as a result, while metastatic cases rose. In other words, if you’re not testing for PCa, you’re not finding as many cases early. Remember when China reported that they had only 2 cases of COVID-19 when we had a million in the US? (but they also weren’t testing for it.)

Advanced prostate disease comes with symptoms and is more difficult to treat, so those cases kept rising. Biopsies decreased by 41%, yet high-grade cancer detections increased by 72% overall and as much as 92% in men who were between 55-69 years of age. This is what I find most troubling. The only reason the incidence of early PCa “decreased” is because doctors stopped recommending their patients get tested.

No testing = no positive results.

According to the American Cancer Society, PCa incidence fell from 2001 to roughly 2013 (likely due to declines in PSA screening), but reversed course in 2014, with overall rates increasing, especially advanced-stage cancers. Notably, metastatic PCa rose by 6.7% per year between 2011 and 2021.

My personal experience with this disease has brought me to a place where I feel I can be an agent for change and increase awareness to help men make better choices. I did everything “right,” (so I thought), and still wound up in the bad bucket. That changed how I view screening. This mission has been made more difficult for several reasons. Conflicting messages from medical groups; some of which are against routine testing. This causes confusion. And, as you know, when we are confused, we don’t act. One thing we all understand is that it is far easier to treat problems, medical or otherwise, when they are addressed early on.

So how do we use the PSA test wisely, without ignoring it and without panicking over it? Many men are not aware of the risk-benefit balance of PSA testing. I believe the rules are simple. If you have a parent or sibling who has had breast or PCa, start talking to your Doctor about PSA screening at 40 years old because you are up to twice as likely to develop PCa. This also holds true for men of African or Caribbean descent, independent of whether they have a family history of cancer. For everyone else, 50 is the age you should start talking with your doctor about your prostate and whether PSA testing is appropriate at that time.

Since 2008, screening after 70 is discouraged, but aggressive cancer can still appear in older men and newer treatments can extend your life considerably. Use your own judgement and be your own advocate. Get your PSA tested yearly.

And if there’s one thing I’ve learned, it’s this:

If you’re waiting for symptoms, you’re already behind.