Dear Dr. Roach: I am a 65-year-old male, generally in good health and on no medication. I recently went for a checkup, and the doctor did not take a PSA blood test, nor did he perform a digital exam on me. I don’t have severe issues with urinating, but the stream is not as strong as it used to be. According to my doctor, I have prostate gland enlargement, but he seems unconcerned with my prostate health. He said that they no longer perform PSA tests. I know a few people who have had prostate cancer, but they have been treated and are well, except they no longer have a prostate. Should I be insisting on these tests? — P.O.
Answer: I am disappointed by the quality of care you report. PSA tests are still done, but they aren’t right for everyone. The goal of screening is to identify high-risk prostate cancer so that it can be treated early. You should have a chance to hear about your options.
Many cases of prostate cancer, especially those found by screening, are what could be termed “low-risk” prostate cancer. In this case, the best option is careful monitoring; this also is called “active surveillance.” Men with low-risk prostate cancer in an active surveillance program are carefully monitored and later can be reclassified as high risk, at which point treatment is considered. Men who are comfortable with active surveillance are good candidates for prostate cancer screening. Men who are uncomfortable NOT treating prostate cancer, even if it is low risk, will be more likely to see harm than benefit from prostate cancer screening.
In the less-common case that high-risk prostate cancer is found, the ability to intervene early may give some survival benefit. The goal of this screening strategy is to avoid unnecessary (and potentially harmful) treatment of low-risk prostate cancer while still trying to identify people who would benefit from early intervention.
A slow urinary stream is a near-universal finding in 65-year-old men, and is not a reason to change screening strategies.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.