Prostate Cancer Screening Saves Lives in an Era of Active Surveillance

When used in conjunction with active surveillance – a practice in which doctors actively monitor rather than immediately treat certain patients who show elevated PSA levels – prostate cancer screenings can detect cancers early, before they spread beyond the prostate, and are especially important for men at high risk of the disease – particularly African American men and men with a family history of the disease.

Drs. Tia Schellato and Laurence Belkoff (ends) with prostate cancer survivor Rick Wexler and wife Lynn Nash-Wexler at the Gary Papa Run, raising funds for prostate cancer research and education.

In an era of “active surveillance” – a practice designed to avoid unnecessary treatment in which physicians actively monitor, rather than immediately treat, certain patients who show elevated levels of prostate-specific antigen through PSA screenings – current recommendations by the U.S. Preventive Services Task Force stating that healthy men should no longer receive PSA blood tests as part of routine cancer screenings may be resulting in undiagnosed and untreated cancers in men for whom early detection could have resulted in lifesaving treatment, said Laurence Belkoff, DO, FACOS, a urologist with Urologic Consultants of Southeastern Pennsylvania.

“The task force’s current recommendation may needlessly put into harm’s way men who are most at risk: those who are underinsured, have a family history of prostate cancer, and particularly African American men,” said Dr. Belkoff. “All men, especially those in higher risk categories, should make an informed decision about prostate cancer screening in consultation with their doctors. Active surveillance and PSA testing can work together to avoid over treatment, while ensuring that patients whose cancers are more aggressive can receive life-saving treatment.”

Prostate Specific Antigen is a protein made by the prostate gland that may be higher in men with prostate cancer. However, other factors can cause an elevated PSA level, such as prostatitis (an inflammation of the prostate) and benign prostatic hyperplasia (BPH.)

The task force, an independent, volunteer panel of national experts in prevention and evidence-based medicine, gives the PSA test a grade of “D,” discouraging the use of the screening because, it says, “There is a moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”

“I’m a prostate cancer survivor,” said Rick Wexler, a Urologic Consultants patient. “I’m the guy the current recommendations said didn’t need to be screened, but I was screened. I was not over treated. I was wondering a few years ago if I was ever going to be able to see grandchildren … so I am glad to be here.”

Dr. Belkoff emphasizes that early detection – before the cancer has spread beyond the prostate to other parts of the patient’s body – is critical to successful treatment of the disease and that the PSA test remains the most effective manner in which to achieve an early diagnosis, despite the task force’s current recommendations.

“The PSA blood test is still the best, first-line test for prostate cancer, especially when combined with a physical exam of the prostate known as a digital rectal exam (DRE),” said Dr. Belkoff. “We have seen a nearly 40 percent reduction in prostate cancer deaths in the last two decades mostly because PSA testing became commonplace for higher risk men over 40,” he said.

Wexler was healthy and in excellent shape when a routine exam showed a slightly elevated PSA level. A follow up exam four months later showed a higher level, leading his doctor to refer him to Urologic Consultants for a biopsy.

“I never expected it to be positive,” said Wexler. “I was mountain biking with my brother in Colorado the day before. I had no symptoms. I was about the healthiest guy I knew. If I had followed the task force’s recommendation, I might not be here now. My cancer had already spread beyond the prostate gland.”

A diagnosis of prostate cancer is determined when a biopsy of the prostate gland confirms the cancer. The earlier the diagnosis, the better the chance of a cure after treatment. According to the United States Centers for Disease Control, prostate cancer is the most common non-skin cancer among men, and the second-leading cause of cancer-related deaths in men in the United States.

“If your PSA level is mildly elevated, you and your doctor may choose to do PSA testing on a regular basis to watch for any changes,” said Dr. Belkoff. “If you have a concerning rectal exam or a high PSA level, especially in conjunction with symptoms and/or risk factors, your doctor may recommend a biopsy.”

Prostate cancer tends to grow slowly compared with most other cancers. Many men will develop prostate cancer as they age, but it will not become a serious threat to their health. Unfortunately, in some men it may grow and eventually spread before they have symptoms. By the time symptoms appear, the cancer may already be advanced.

“While the PSA test has limitations, we believe that, when combined with a DRE and interpreted appropriately, it provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer,” said Dr. Belkoff. “These tests enable us to establish a baseline PSA level and to find prostate cancer at its earliest stages, while it is still confined to the prostate and has not spread to other parts of the body.” As the lead investigator at Urologic Consultants Research Center, Dr. Belkoff also notes that “better technologies are emerging that will help urologists determine with more certainty which men have more aggressive prostate cancer that needs to be treated.”

The American Urological Association recommends that men age 55 to 69 talk with their doctors about their risk factors for prostate cancer -- which include age, race, and family and personal medical history – as well as the risks and benefits of the screening. Men who are African-American, men who smoke, and those who have a family history of prostate cancer should begin the discussion with their doctors sooner.

Dr. Belkoff says patients who are diagnosed with prostate cancer now have many treatment options, including simply monitoring the disease in men whose cancer does not appear to be aggressive. Patients who do require treatment are now benefitting from the latest surgical techniques, such as robotic-assisted laparoscopic surgery and other treatments that often have fewer side effects such incontinence or erectile dysfunction. He adds that men who do experience side effects now have more treatment options such as reconstructive surgery.

“Every case is different and requires individual consideration of the type of cancer and risk factors,” says Dr. Belkoff. “It’s important for all men age 55 and older – age 40 if they are African American or have a family history of prostate cancer – to have a frank discussion with their doctors.”

“I was exactly the guy they said didn’t need to do this,” said Wexler. “I don’t believe for a second that I was over treated and didn’t need surgery.

“I have two sons and three nephews,” he added. “I’ve told them they are at increased risk due to our family history. I know when each of them turns 40. They will hear from me!”

Risk factors for prostate cancer:

  • Age. Men who are age 55 or older have a higher risk for prostate cancer.
  • Race. African-American men have the highest risk for prostate cancer—the disease tends to start at younger ages and grows faster than in men of other races.
  • Family history. Men whose fathers or brothers have had prostate cancer have a higher risk than men who do not have a family history of the disease. Prostate cancer risk also appears to be slightly higher for men from families with a history of breast cancer.
  • Diet. Risk may be higher for men who eat high-fat diets.

Possible Symptoms, though not everyone with prostate cancer experiences symptoms:

  • Difficulty passing urine
  • Frequent urge to pass urine, especially at night
  • Weak or interrupted urine stream
  • Pain or burning when passing urine
  • Blood in the urine or semen
  • Difficulty having an erection
  • Painful ejaculation
  • Nagging pain in the back, hips, pelvis or upper thighs


Posted October 05, 2015