PSA testing and prostate cancer: screening, biopsy and treatment choices
Prostate cancer is the most common cancer in men, and most of it is very treatable. Many cases are slow-growing enough to watch rather than treat. Hearing "you have cancer, but it's very treatable" in one breath is the honest summary for most men.
When to start PSA screening
Most men should begin talking with a doctor about PSA testing by around age 50. Men at higher risk should start between 40 and 45: Black men, and men with a father or brother who had prostate cancer or with a family history of BRCA mutations. A single high PSA should be repeated before acting on it. Infection, recent ejaculation and an enlarged prostate can all raise it.
Before a biopsy: MRI
A prostate MRI before biopsy helps avoid unnecessary biopsies and lets the urologist target suspicious areas. Many practices now take biopsies through the skin behind the scrotum (transperineal), which sharply lowers infection risk compared with the older approach through the rectum. Ask which approach the practice uses.
Treatment choices
Active surveillance is the preferred approach for most low-risk cancers: regular PSA tests, MRI and repeat biopsies, with treatment only if the cancer changes. It avoids side effects for men who would never have been harmed by their cancer.
Robotic radical prostatectomy removes the prostate through small incisions. Leakage and erectile changes are the main side effects. Both improve over months, and surgeon experience matters a great deal.
Radiation (external beam or seed implants), sometimes with hormone therapy, has cure rates similar to surgery for many cancers, with a different side-effect profile.
Focal therapies (HIFU, cryotherapy) treat only the tumor area. They are offered at some centers, and long-term data are still maturing.
Questions to ask
- What is my risk group, and is active surveillance an option?
- Do you use MRI before biopsy, and do you biopsy transperineally?
- How many prostatectomies do you perform each year, and what are your continence results?