Prostate cancer screening
Prostate cancer screening is the screening process used to detect undiagnosed prostate cancer in men without signs or symptoms. When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early detection reduces mortality rates.
Screening precedes a diagnosis and subsequent treatment. The digital rectal examination is one screening tool, during which the prostate is manually assessed through the wall of the rectum. The second screening tool is the measurement of prostate-specific antigen in the blood. The evidence remains insufficient to determine whether screening with PSA or DRE reduces mortality from prostate cancer. A 2013 Cochrane review concluded PSA screening results in "no statistically significant difference in prostate cancer-specific mortality...". The American studies were determined to have a high bias. European studies included in this review were of low bias and one reported "a significant reduction in prostate cancer-specific mortality." PSA screening with DRE was not assessed in this review. DRE was not assessed separately.
Most recent guidelines have recommended that the decision whether or not to screen should be based on shared decision-making, so that men are informed of the risks and benefits of screening. In 2012, the American Society of Clinical Oncology recommended screening be discouraged for those who are expected to live less than ten years, while for those with a longer life expectancy, a decision should be made by the person in question. In general, they concluded that based on recent research, "it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment."
Prostate biopsies are used to diagnose prostate cancer but are not done on asymptomatic men and therefore are not used for screening. Infection after prostate biopsy occurs in about 1%, while death occurs as a result of biopsy in 0.2%. Prostate biopsy guided by magnetic resonance imaging has improved the diagnostic accuracy of the procedure.
Prostate-specific antigen
is secreted by the epithelial cells of the prostate gland and can be detected in a sample of blood. PSA is present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer or other prostate disorders. PSA is not a unique indicator of prostate cancer, but may also detect prostatitis or benign prostatic hyperplasia.A 2018 United States Preventive Services Task Force recommendation adjusted the prior opposition to PSA screening, suggesting shared decision-making regarding screening in healthy males 55 to 69 years of age. The recommendation for that age group states screening should only be done in those who wish it. In those 70 and over, screening remains not recommended.
Screening with PSA has been associated with a number of harms including over-diagnosis, increased prostate biopsy with associated harms, increased anxiety, and unneeded treatment. The evidence surrounding prostate cancer screening indicates that it may cause little to no difference in mortality.
On the other hand, up to 25% of men diagnosed in their 70s or even 80s die of prostate cancer, if they have high-grade prostate cancer. Conversely, some argue against PSA testing for men who are too young, because too many men would have to be screened to find one cancer, and too many men would have treatment for cancer that would not progress. Low-risk prostate cancer does not always require immediate treatment but may be amenable to active surveillance. A PSA test cannot 'prove' the existence of prostate cancer by itself; varying levels of the antigen can be due to other causes.
Digital rectal examination
During a digital rectal examination, a healthcare provider slides a gloved finger into the rectum and presses on the prostate, to check its size and to detect any lumps on the accessible side. If the examination suggests anomalies, a PSA test is performed. If an elevated PSA level is found, a follow-up test is then performed.A 2018 review recommended against primary care screening for prostate cancer with DRE due to the lack of evidence of the effectiveness of the practice.
The USPSTF recommends against digital rectal examination as a screening tool due to a lack of evidence of benefits. Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age.
The American Urological Association in 2018 stated that for men aged 55 to 69, they could find no evidence to support the continued use of DRE as a first-line screening test; however, in men referred for an elevated PSA, DRE may be a useful secondary test.
A study by Krilaviciute et al. examined the effectiveness of the DRE as a standalone screening test for prostate cancer in >46,000 young men in Germany. It was found that DRE has a much lower detection rate for prostate cancer compared to PSA screening. Therefore, the authors recommend not to use DRE as a screening test for prostate cancer in young men, as it does not provide an improvement in detection compared to PSA screening.
Follow-up tests
Biopsy
are considered the gold standard in detecting prostate cancer. Infection after the biopsy procedure is a possible risk. MRI-guided techniques have improved the diagnostic accuracy of the procedure. Biopsies can be done through the rectum or perineum. The biopsy technique includes factors such as needle angle and prostate mapping method. People who have localized cancer and perineural invasion may benefit more from immediate treatment rather than adopting a watchful waiting approach.Ultrasound
has the advantage of being fast and minimally invasive, and better than MRI for the evaluation of superficial tumors. It also gives details about the layers of the rectal wall, accurate and useful for staging primary rectal cancer. While MRI is better in visualization of locally advanced and stenosing cancers, for staging perirectal lymph nodes, both TRUS and MRI are capable. TRUS has a small field of view, but 3D TRUS can improve the diagnosis of anorectal diseases.Magnetic Resonance Imaging
MRI is used when screening suggests a malignancy. This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield. Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective. MRI imaging can be used for patients who have had a previous negative biopsy but whose PSA continues to increase. Online open-access datasets of Prostate Cancer MRI examinations are available for review and training. Consensus has not been determined as to which of the MRI-targeted biopsy techniques is more useful. In a study involving 400 men aged 50 – 69, MRI screening identified more men with prostate cancer than PSA tests or ultrasound and did not increase the number of men who needed a biopsy. A large-scale trial of MRI screening, TRANSFORM, began in the UK in spring 2024.Multiparametric MRI
Multiparametric magnetic resonance imaging has emerged as a transformative tool in prostate cancer screening, helping to reduce unnecessary biopsies while improving detection of clinically significant cancers. Current American guidelines recommend mpMRI before initial biopsy in biopsy-naïve patients, as studies demonstrate mpMRI can identify 28% more clinically significant cancers while reducing unnecessary biopsies by up to 30%. The PI-RADS scoring system standardizes mpMRI interpretation, with PI-RADS 3–5 lesions warranting targeted biopsy. Studies in 2024 showed that 96% of patients with normal MRI results do not develop aggressive prostate cancer within three years, supporting an "MRI-first" screening approach.Other imaging
-PSMA PET/CT imaging has become, in a relatively short period of time, the gold standard for restaging recurrent prostate cancer in clinical centers in which this imaging modality is available. It is likely to become the standard imaging modality in the staging of intermediate-to-high risk primary prostate cancer. The potential to guide therapy, and to facilitate more accurate prostatic biopsy is being explored. In the theranostic paradigm, 68Ga-PSMA PET/CT imaging is critical for detecting prostate-specific membrane antigen-avid disease which may then respond to targeted 177Lu-PSMA or 225Ac-PSMA therapies. For local recurrence, 68Ga-PSMA PET/MR or PET/CT in combination with mpMR is most appropriate. PSMA PET/CT may be potentially helpful for locating the cancer when combined with multiparametric MRI for primary prostate care. Prostate multiparametric MR imaging is helpful in evaluating recurrence of primary prostate cancer following treatment.Other
Several biomarkers for screening, diagnosing, and determining the prognosis of prostate cancer are supported by evidence and used widely.- EpiSwitch® PSE is a blood test used for screening and diagnosing prostate cancer utilizing epigenetic markers to identify specific changes in regulatory looping structures associated with prostate cancer. Used in conjunction with a PSA test, the PSE test boosts accuracy from 55% to 94% offering a more effective and precise method for detecting and diagnosing prostate cancer.
- The 4Kscore combines total, free, and intact PSA with human kallikrein 2. It is used to try to determine the risk of a Gleason score greater than 6.
- The Prostate Health Index is a PSA-based blood test for early prostate cancer screening. It may be used to determine when a biopsy is needed.
- Prostate cancer antigen 3 is a urine test that detects the overexpression of the PCA3 gene, an indicator of prostate cancer.
- ConfirmMDx is performed on tissue taken during a prostate biopsy. The test identifies men with clinically significant prostate cancer who would benefit from further testing and treatment. It can also help men without significant prostate cancer avoid unnecessary repeat biopsies.