Don't Fear the Finger

Prostate testing usually starts with a blood test,

For generations of men, the words “prostate exam” have conjured up one uncomfortable image: a doctor snapping on a glove and performing a digital rectal exam.

That expectation may be keeping some men from discussing prostate-cancer screening after age 50. But here is the part many do not know: Today, the conversation usually begins with a simple blood test—not a rectal exam.

The prostate-specific antigen, or PSA, test measures the level of a protein produced by the prostate. A higher-than-expected level can be a warning sign of cancer, although it can also be caused by an enlarged prostate, inflammation, infection, recent ejaculation or other noncancerous conditions.

A digital rectal exam, commonly called a DRE, is still used in some circumstances. During the brief exam, a clinician inserts a lubricated, gloved finger into the rectum to feel the prostate for abnormalities. But it is not automatically required for every man seeking routine screening. The American Cancer Society describes the DRE as an option that can be used with PSA testing, while noting that it is not as effective as the blood test at finding prostate cancer.

In other words, fear of the physical exam should not prevent you from having the larger conversation.

Why screening matters

Prostate cancer is one of the most commonly diagnosed cancers among American men. It can often grow for years without producing noticeable symptoms. By the time a man develops trouble urinating, blood in his urine or semen, bone pain or unexplained weakness, the cancer may be more advanced.

A PSA test may identify a problem before symptoms appear, when cancer is more likely to be confined to the prostate and easier to treat. The National Cancer Institute says PSA screening may reduce a man’s risk of dying from prostate cancer by detecting the disease earlier.

The potential benefit, however, is not enormous. The U.S. Preventive Services Task Force estimates that, among 1,000 men ages 55 to 69 who receive periodic PSA screening for about 13 years, screening may prevent approximately 1.3 prostate-cancer deaths and about three cases of metastatic cancer.

That modest benefit is why major medical organizations do not recommend identical annual testing for every man over 50.

The American Cancer Society’s guidelines say men at average risk who expect to live at least 10 more years should discuss screening with a health care provider beginning at 50. Black men and men whose father or brother developed prostate cancer before 65 should begin the discussion at 45. Men with more than one close relative diagnosed at an early age should start at 40.

The Preventive Services Task Force recommends individual decision-making for men ages 55 to 69. It advises against routine PSA screening after 70 because the possible harms are more likely to outweigh the benefits. A man’s health and life expectancy, rather than age alone, may also influence the decision.

The argument against automatic testing

PSA screening has genuine drawbacks, and men deserve to understand them.

An elevated PSA does not mean you have cancer. It may lead to repeat blood tests, an MRI, referral to a urologist or a biopsy. Biopsies can cause pain, bleeding or infection, and the waiting and uncertainty can create considerable anxiety.

Screening can also find slow-growing cancers that would never have threatened a man’s health. This is known as overdiagnosis. If those cancers are treated unnecessarily, surgery or radiation may cause urinary incontinence, erectile dysfunction and bowel problems without extending the patient’s life.

That does not mean every positive finding leads directly to treatment. Increasingly, men with small, low-risk cancers are offered “active surveillance”—regular monitoring through PSA tests, imaging and sometimes follow-up biopsies. Treatment begins only if the cancer shows signs of becoming more aggressive.

Newer diagnostic approaches can also help doctors decide who needs a biopsy. Instead of reacting to one elevated number, a clinician may repeat the test, review how PSA levels change over time, consider prostate size and order an MRI or additional biomarker testing.

The test should begin a conversation

There is no universal PSA number that proves cancer is present, and there is no single screening schedule appropriate for everyone. Men with lower PSA levels may be able to wait longer between tests, while those with higher or rising results may need closer follow-up.

The practical takeaway for men over 50 is not that everyone must demand an annual test. It is that everyone should know his risk and have an informed conversation with a primary-care provider. Ask these questions:

• Should I have a PSA test? How do my race and family history affect my risk?

• Would a digital rectal exam add useful information in my case?

• If my PSA is elevated, what happens before we consider a biopsy?

If you have never discussed prostate health with your doctor, put that topic on the list for your next appointment. You may discover that the first step is far less intimidating than you imagined: rolling up your sleeve for a blood draw, not dropping your drawers.