Myth-Busting — Prostate Cancer Screening: Understanding PSA, Digital Exams & Family Risk

“PSA screening should begin around the age of 45 to 50 and can be done every two to four years, although I believe most urologists and primary care physicians do an annual screening,” Dr. Shirin Razdan, director of the robotic surgery department at the Comprehensive Urological Surgery Institute in Miami, tells SurvivorNet.

“There is a recommendation, however, to start that screening as young as 40 in men who are high-risk. Now, who are those men? [Those with] family history and African-American men,” she adds.

Why Is Prostate Cancer Screening Controversial?

Prostate cancer is one of the most common cancers in men, particularly in those over 50. However, not all prostate cancers grow quickly or require aggressive treatment. Some grow so slowly that they may never cause symptoms or affect life expectancy. As a result, screening can sometimes lead to the detection and treatment of cancers that would never have caused harm. This overtreatment can carry risks such as urinary incontinence, erectile dysfunction, and other complications.

Because of this, many organizations, including the U.S. Preventive Services Task Force (USPSTF), now recommend a shared decision-making approach. This means your doctor should explain the risks and benefits and help you decide what’s best based on your personal risk factors and preferences.

Should I Undergo PSA Screening?

The prostate-specific antigen (PSA) blood test is the most common screening tool for prostate cancer. PSA is a protein made by the prostate gland, and elevated levels can suggest prostate cancer. However, high PSA levels can also be caused by non-cancerous conditions like benign prostatic hyperplasia (BPH) or prostatitis (inflammation of the prostate).

Currently, widely-support recommendations are:

• Men age 55 to 69 are the group most likely to benefit from PSA screening. If you are in this age range, discuss screening with your doctor.
• Men younger than 55 with high risk — which includes those with a strong family history, African American men, or those with known genetic mutations (like BRCA1 or BRCA2) — may need to start screening earlier, even in their 40s.
• For men age 70 and older, routine screening is generally not recommended unless you are in excellent health and have a long life expectancy.

There are both benefits and risks to undergoing regular PSA screening. Benefits include:

• May detect cancer before it spreads
• Offers the possibility of early treatment with curative intent
• Can provide peace of mind in high-risk individuals

Risks include:

• False positives that may lead to unnecessary biopsies
• Detection of indolent cancers that would never cause harm
• Psychological stress from ambiguous results

How Often Do I Need A Digital Rectal Exam (DRE)?

The Digital Rectal Exam (DRE) involves your doctor manually examining the prostate through the rectum to feel for abnormalities like nodules or asymmetry. Although less sensitive than the PSA test, the DRE can sometimes catch cancers that a PSA test might miss.

However, the role of the DRE in routine screening has diminished, especially when PSA testing is already being done. Current guidelines do not recommend DRE as a standalone screening tool, but it may still be used in conjunction with PSA, especially in men with lower PSA levels but high suspicion due to symptoms or risk factors.

“Although guidelines don’t state that it’s absolutely imperative to do a digital rectal exam, it can give us a lot of information about the prostate,” Dr. Razdan explains. “It’s not the most sensitive … you feel the prostate, you’re checking for nodules, but it can give us a pretty good guestimate, if you will, about the size of the prostate.”

Your urologist or primary care doctor will decide whether a DRE is needed based on your overall risk profile and findings from other tests.

Are There Other Prostate Cancer Tests I Need?

In recent years, more advanced tools have become available to improve the accuracy of prostate cancer diagnosis and reduce unnecessary biopsies.

Additional tests include:

• Free vs. Total PSA Ratio: Measures different forms of PSA to help distinguish between cancer and benign conditions
• PSA Density or PSA Velocity: Looks at PSA relative to prostate size or how quickly levels are rising
• 4Kscore or PHI (Prostate Health Index): Blood tests that provide a more nuanced risk score for prostate cancer
• Urine Tests (like PCA3): These look for specific gene markers associated with prostate cancer
• MRI of the Prostate: Multiparametric MRI can identify suspicious areas in the prostate before a biopsy, helping to target only areas of concern
• Genomic Testing: In some cases, your doctor might recommend a test that analyzes gene expression to predict the aggressiveness of a detected cancer

These tests help avoid unnecessary biopsies and better select patients who might truly benefit from further evaluation or treatment.

What If I Have A Family History?

A strong family history significantly increases your risk of developing prostate cancer. If your father, brother, or other close male relatives were diagnosed — especially before age 65 — your risk may be more than double that of the general population.

Additionally, men with a family history of other cancers, particularly breast, ovarian, or pancreatic cancers, should discuss genetic testing with their healthcare provider. Inherited mutations in genes such as BRCA1, BRCA2, or HOXB13 can increase prostate cancer risk and may influence screening strategies.

If you fall into this high-risk group, you may benefit from:

• Earlier screening (starting at age 40-45)
• More frequent monitoring
• Advanced testing, even if PSA levels are normal

Questions To Ask Your Doctor

• What is my risk of prostate cancer?
• What are the pros and cons of screening in my case?
• If my PSA is elevated, what is the next step?
• Will I need a biopsy right away, or are there additional tests?

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