To screen or not to screen — that is the question.

Prostate cancer is unique among major cancers in that routine screening is actually controversial. If cancer is found, it’s usually slow growing and harmless.

That’s why clinicians worry about creating anxiety and exposing patients to unnecessary treatment that can leave patients with long-term impacts.

Now, the American Cancer Society (ACS) has released new guidelines, reversing recommendations that had been in place for 16 years.

For men at average risk for the disease ages 50 to 69, the organization is recommending blood tests called prostate-specific antigen (PSA) tests every two years.

But for black men or those with a family history of prostate cancer, they recommend starting at age 45 and getting annual testing.

This is a significant change from ACS’s previous advice, which was for average-risk patients to work with their doctors to decide whether to screen. One expert described the ACS’s new guidance to the Times as a “reversal.”

The new recommendations

Fortunately, most people with prostate cancer get diagnosed during an early stage — and many are cured.

But over 36,000 people will die from the disease this year, a vast majority from metastatic, advanced cancer. It is the second leading cause of cancer dєatᩚh in men in the US, behind lung cancer.

Since their last recommendations in 2010, the ACS said that stronger evidence has shown that screening for prostate cancer with a PSA blood test saves lives by catching it earlier.

When former President Joe Biden was diagnosed with prostate cancer last year, it was at an advanced stage (Stage 4) and had spread to his bones. Many were shocked to learn he hadn’t had a PSA test since 2014 — over 10 years — but at age 82, guidelines did not and still do not recommend screening.

If you’re not black and don’t have a family history of prostate cancer, you can rely on age-related guidance:

• For men ages 50 to 69: Get PSA-based screening every two years.
• For men ages 70 to 74: The ACS recommends patients decide with their doctors whether to screen as the “balance of benefits and harms remains uncertain.”
• Men ages 75 and up: Screening is not recommended, though they note that men ages 75 to 79 who are very healthy may want to continue screening if PSA levels were rising on previous tests, but screening should be discussed with a doctor.

Some groups are at higher risk and should get screened every year. These include:

• Black men ages 45 to 69. “Black men experience a 67% higher incidence and nearly double the mortality rate compared with White men, an inequity that needs immediate reversal,” said Dr. William Dahut, chief scientific officer for the ACS.
• Men 45 to 69 with a parent, sibling or child (first-degree relatives) with prostate cancer diagnosed before age 65
• Men 45 to 69 with multiple first-degree relatives diagnosed at any age

How PSA screening works

In healthy men, small amounts of PSA are in the blood. A PSA test — a small vial of blood drawn from the arm — can find elevated levels, which could point to prostate cancer or other conditions, like enlarged or inflamed prostates.

The ACS says it’s a first step. Men with elevated PSA levels would wait a period of time — between two weeks and three months — and get a repeat test.

The ACS recommends that after getting a second test confirming elevated levels, men should get an MRI and/or a validated biomarker (other blood and urine tests) to decide whether they want to get a biopsy done.

Biopsy is the only way to get a definitive diagnosis. If a patient is diagnosed with a cancer that has a low risk of growing or spreading, the ACS says they should be offered active surveillance — regular testing without treatment — as the initial option.

“PSA testing remains the cornerstone of detecting prostate cancer early, and we now have stronger evidence of its benefits,” said Robert Smith, a cancer epidemiologist, in the ACS statement. “We also have better approaches to catching lєthaℓ tumors while avoiding unnecessary tests for slow-growing cancers that may never need aggressive care.”