Prostate cancer screening guidelines

The diagnosis of advanced and metastatic prostate is rising, despite the availability of screening tools to catch the cancer at an early stage.  In fact, there are better screening tools available for early prostate cancer diagnosis than most other cancers.  The prostate is a small gland in the male reproductive system that makes fluid for semen. 

In the USA it has now come to light that the current screening guidelines were based on flawed data, while in South Africa and elsewhere in Africa there are a number of barriers to proper screening programs, such as the lack of patient education and a lack of resources.

The incidence of prostate cancer:

Prostate cancer is the most widespread solid organ cancer in males, and it ranks as the fifth leading cause of all-cause deaths globally.  Prostate cancer is the second leading cause of cancer death in American men, with only lung cancer claiming more lives amongst men.  The early detection of prostate cancer results in a 15-year survival rate of 97%, from the first (early) diagnosis.   According to the World Cancer Research Fund, prostate cancer is the fourth most common cancer and the second most common cancer in men worldwide.

Although simple early detection tools are widely available, the rates of advanced stage prostate cancer are climbing.  Data from the USA and Canada indicates that these cancers are increasingly only identified after they have already metastasized and spread in the body.  Once the cancer has advanced to stage 4, the 5-year survival rate falls to 38% and the median time from diagnosis to death is about 2,5 years.  The statistics point to a lack of regular screening programmes for men over 50.

Prostate cancer screening:

Prostate cancer screening is done with a simple blood test to determine prostate specific antigen (PSA) levels in the blood stream.

According to the Prostate Cancer Foundation, PSA is a protein enzyme produced by the prostate and found mostly in the semen to liquify it, with very small amounts released into the bloodstream.  A PSA blood test measures the concentration of this protein in your blood, typically measured in nanograms per milliliter (ng/mL).  When there’s a problem with the prostate, more PSA can be released and can eventually reach a level that can be easily detected in the blood. This can be the first indicator of prostate cancer.

A PSA test may be performed alongside a digital rectal exam (DRE), where a physician inserts a gloved, lubricated finger into the rectum to check the prostate for physical irregularities in size or texture.  The two tests together provide a more complete picture of prostate health.

 A high PSA level does not automatically mean you have cancer. Elevated levels can be caused by a number of factors:

• Prostate cancer where malignant cells produce higher amounts of PSA. 
• Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate common in older age.
• Inflammation or infection of the prostate gland, known as prostatitis.
• Urinary tract infections, normal aging, or recent physical irritation of the gland, such as using a catheter.

The Prostate Cancer Foundation says that early prostate cancer almost never causes symptoms.  Regular PSA screening is recommended to detect aggressive, higher-risk cancers early when they are small and more likely to be effectively treated.  Early detection leads to treatment with fewer side effects compared to treating advanced disease.

Certain factors can cause a temporary increase in PSA levels.  For at least 48 hours before a PSA test, it is best to avoid ejaculation and intense physical activity.  Also avoid medical procedures involving the urethra or bladder (such as catheterization), as these can irritate the prostate and temporarily increase PSA levels.  Medication such as finasteride or dutasteride are widely used to prevent male hair loss and both can suppress PSA levels by up to 50%, giving incorrect PSA levels during screening.  (Both drugs belong to a class called 5-alpha-reductase inhibitors (5ARIs), which stop testosterone from turning into dihydrotestosterone (DHT), the hormone responsible for male pattern baldness.) 

Prostate cancer screening guidelines:

The USA usually sets the tone in health guidelines due to ample funds available for medical related research.  However, over time these guidelines may prove to be outdated.

According to Dr Peter Attia, the United States Preventative Service Task Force (USPSTF) stopped recommending PSA screening for men over 70 in 2008, and by 2012 they extended that recommendation against screening to men of all ages.  They leaned heavily on data from a large American trial called the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO).  The prostate arm of this study randomized men to either undergo PSA screening or not, and it found essentially no difference in prostate cancer mortality between the 2 groups.  The implication was that PSA screening saved at best 1.3 lives per thousand men tested.

Dr Attia points out the impact of reduced PSA screening over the past 15 years, namely rising rates of late-stage prostate cancer and worsening population-level outcomes.  Recent datapaints a very troubling picture.  Data published recently from both the American and Canadian registries, show that more and more prostate cancers are only discovered after they’ve become metastatic.  Grouping together all prostate cancers caught at stages 1 through 3, the 5-year survival exceeds 99% (these are non-metastatic cancers).   But at stage 4 prostate cancer (which is metastatic disease with tumours that have spread beyond the prostate), survival plummets to 38%, with a median survival of about 30 months from diagnosis.  But what’s even more alarming is that it’s not just older men who are affected.

Dr Attia says the timing of when you find the cancer is not a minor detail, it’s arguably the determining factor in life and death.  It is not that more men are getting cancer, it’s that we’re only finding it once it’s too late to cure.  Newer treatments have extended survival for men with metastatic disease, but overall survival across the population has actually worsened compared to when regular screening was recommended, as there are now so many more men presenting with incurable cancer. 

Interestingly, the South African prostate screening guidelines from 2024 still says do not offer prostate cancer screening to men 70 years and older, or with a life expectancy of less than 10 years, as the potential survival benefits from treatment are statistically minimal, and they do not outweigh the significant adverse effects that the patient may experience due to treatment.

Now try telling that to an otherwise healthy 70-year-old!  As Dr Attia says, when you catch it early, the prognosis is outstanding.

Modern cancer screening tools:

Over the last 5 years, the single biggest conceptual shift is that PSA is most valued as a longitudinal trend, not a single snapshot.  No single PSA value in isolation tells you very much, as day-to-day PSA readings values can fluctuate by as much as 15%.  If a man has recently ejaculated, his PSA can spike by as much as 40% and the person-to-person variability is staggering.  A healthy man in his 60s might have a median PSA of 1.0 to 1.2 ng/mL, but the 95th percentile (of the normal distribution curve) for that exact same demographic in men with no prostate cancer extends all the way up to 4.9 ng/mL.

The table below shows the variability between the median PSA and the 95th percentile level of PSA in men without prostate cancer and breaks it down by decade of life:

AGE RANGE	MEDIAN PSA (95th percentile in brackets)
40-49	0.7 ng/mL (1.8 ng/mL)
50-54	0.9 ng/mL (3.2 ng/mL)
55-59	1.0 ng/mL (3.2 ng/mL)
60-69	1.0-1.2 ng/mL (4.9 ng/mL)
70-79	1.2-1.6 ng/mL (6.5 ng/mL)

PSA velocity is superior to a one-time measure of PSA and refers to tracking changes in PSA value over time.   The prostate naturally enlarges with age, so some gradual PSA increase is expected, but rapid increases are cause for suspecting something pathological, as either the prostate is enlarging abnormally, or a higher proportion of PSA is leaking into the blood relative to the amount of prostate tissue, or both   Disrupted prostate architecture and vascular leakage are the hallmarks of malignant growth.  In general, doctors look at increases sustained over an 18-month window, depending on the baseline value per age group.

As a healthy prostate grows with age, PSA and volume tend to increase proportionally.  With a malignancy, the tumour can disrupt the normal architecture of the prostate and in this situation, PSA starts escaping into the bloodstream at a rate that outpaces what you’d expect from the size of the gland alone.  So, when PSA is rising disproportionately to prostate volume, that’s a strong indicator that something is wrong.

The next step would now be an MRI, which serves as a much higher resolution test, and it’s much less invasive than directly proceeding to a biopsy, as earlier guidelines suggested.  The MRI gives another metric, namely PSA density, which refers to the PSA concentration in the blood divided by the volume of the prostate, as provided by the MRI imaging.

Even with all of these improvements in non-invasive screening, some men are still going to need a biopsy when the MRI flags something suspicious.  Progress has been made there as well, because the biopsy itself has gotten both safer and more accurate.  The traditional approach was a transrectal approach, with certain limitations such as carrying the inherent risk of poking bacteria from the rectum into a sterile space.  It also has its anatomical limitations, as it biases the sampling towards the back of the prostate near the rectal wall, and this can miss the front and base of the gland.

The alternative to this is called a transperineal approach, where the biopsy enters through the skin between the anus and the scrotum, and this completely bypasses the rectum.  This reduces infection risk and it offers much better access to the anterior and apical portions of the prostate than the transrectal route does. 

When a pathologist examines a biopsy specimen, they look at the cells under the microscope and they decide how abnormal the cells look relative to healthy cells, and they use a grading scale.  The higher the number, the greater the malignant potential of the cell.  A grade 1 or 2 is a relatively low risk tumour, with regular monitoring recommended.  Higer grade tumours, such as 3 or 4, indicate aggressive cancers, with immediate treatment warranted.

Conclusion:

The lack of regular screening for prostate cancer due to outdated screening guidelines in the USA and elsewhere, and barriers to screening in South Africa and elsewhere in Africa, such as the lack of resources, meant that doctors stopped screening for early disease, and then often diagnosing at a late stage.  A 16-year European study found that repeated PSA screening significantly reduces prostate cancer mortality.

With the latest understanding of PSA velocity and density, the increasing accessibility of very high-quality MRI, the advent of transperineal biopsies, and the sophistication of active surveillance protocols for low grade disease, the field of prostate cancer screening has made enormous progress over the past 5 years.

Regular PSA screening for men over 50 and the resulting timing of when the cancer is found, the earlier the better, is arguably the determining factor in life and death.

References:

Prostate cancer screening: why current PSA guidelines are failing men and how modern tools improve early detection and save lives.  Podcast 20 April 2026 by Dr Peter Attia.  Dr. Peter Attia is a physician, author, and podcast host focused on longevity and health optimization.  (www.peterattiamd.com)

The South African prostate cancer screening guidelines.  Published in the South African Medical Journal.  Vol 114, No 5, May 2024.  (www.samajournals.co.za)

Updated guidelines for prostate cancer screening in South Africa.  Published 22 May 2024.  Juta Medical Brief.  (www.medicalbrief.co.za)

A 16-yr Follow-up of the European Randomized Study of Screening for Prostate Cancer.  Published July 2019 in the journal European Urology.  Volume 76, Issue 1.  Science Direct.  (www.sciencedirect.com)

Prostate Cancer Statistics.  Published online.  World Cancer Research Fund.  (www.wcrf.org)

What is a PSA test?  Understanding prostate specific antigen.  Published online.  Prostate Cancer Foundation.  Santa Monica, USA.  (www.pcf.org)

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