The US Preventive Services Task Force (USPSTF) is a group of experts who make rules about health screenings. Right now, they say men over 70 should not get routine PSA tests for prostate cancer. PSA stands for prostate-specific antigen. It is a blood test that can hint at prostate cancer.
Why do they say this? Prostate cancer often grows very slowly. Many men over 70 will die from other causes before prostate cancer ever causes trouble. Treating slow-growing prostate cancer can cause side effects that may do more harm than good.
That means older men might only get checked once they have symptoms, like trouble peeing, feeling very tired, or having bone pain. To learn more about testing and treating older men with advanced prostate cancer, we spoke with Dr. Marc B. Garnick from Harvard Medical School.
Q. Should men over 70 get PSA tests?
Official guidelines say no, but some doctors still check PSA after talking with their patients. It’s not rare to find advanced prostate cancer this way. Symptoms may show up late, so a PSA test can sometimes catch the cancer earlier.
The last USPSTF advice came out in 2018. Since people are living longer, new advice is overdue and may appear soon.
Q. What happens if a PSA test is high?
First, a doctor might do a digital rectal exam (DRE). That is when the doctor feels the prostate through the rectum to check for lumps. Then most men get a prostate biopsy. This uses a small needle to take tissue samples.
Nowadays, doctors also use MRI scans to look at the prostate in more detail. MRI helps find areas that need a biopsy.
Q. How do you tell if the cancer is serious?
Pathologists look at the biopsy under a microscope. They grade the cancer cells by how odd they look. A system called the Gleason score adds up two patterns of cells. To make it simpler, doctors now use Grade Groups 1 through 5. Grade Group 1 is low risk, and Grade Group 5 is high risk.
Doctors also check how fast the cells are dividing. Genetic tests can show if a man has certain inherited changes, like BRCA1 or BRCA2. These changes can make the cancer more aggressive and also matter for family members’ cancer risks.
Q. How do you find out if the cancer has spread?
In the past, men got CT scans of the belly and pelvis and a bone scan. Now, many doctors use a PSMA scan. It finds tiny cancer spots by looking for a protein called PSMA on prostate cancer cells. If cancer has spread to a few spots, it is called oligometastatic disease.
Q. How is metastatic prostate cancer treated?
For cancer that has spread but is still low in volume, doctors start with two drugs that lower testosterone. One drug (like leuprolide) stops the body from making testosterone. The other drug (an ARPI such as enzalutamide or abiraterone) blocks testosterone from working. This approach is called doublet therapy.
If the cancer grows despite this, chemotherapy may be added. Then it is called triplet therapy. Some men with PSMA-positive cancer can get a special treatment called Lutetium-177. It delivers tiny radiation particles directly to cancer cells. Men with only a few spread spots might also get focused radiation to those spots.
Q. What if a man has a genetic test that shows BRCA or other mutations?
Then doctors can add a targeted drug called a PARP inhibitor (for example, olaparib or rucaparib). If a man has a different gene issue called microsatellite instability, he might get another targeted drug called pembrolizumab.
Q. Is the outlook for men with metastatic prostate cancer better now?
Yes. In the past, metastatic prostate cancer had a very poor outlook. Today, many men live 10 years or more. We also sometimes treat the original prostate tumor with radiation, even if the cancer has spread. This was not common before but now shows benefit.
Q. Any final advice?
Before starting hormonal treatment, men should get a heart checkup. Hormonal drugs can raise the risk of heart problems, so any heart issues should be managed first.
We thank Dr. Garnick for his clear explanations.