Who Should Get Screened?

Efforts to increase screening are important as a prominent medical journal this month predicted prostate cancer cases worldwide will surge by millions. In what seemed like an undersized recommended response, the authors suggested that these mobile screening units, sometimes called “man vans,” could help slow the estimated rise in prostate cancer cases, which are projected to double by 2040.

The new report in the journal The Lancet said Black men should be targeted for a simple blood screen called a PSA test starting at age 45, and other populations could be targeted from ages 50 to 69. The testing needs to be done along with education and outreach programs, the authors wrote, but they also said these types of mobile screenings are a possible tool for more and more communities with limited access to health care.

A simple blood test is the first step toward detecting the disease in its early stages, when it’s most treatable. Called a PSA test, the analysis looks for a protein called prostate-specific antigen that can be produced by both cancerous and non-cancerous tissue in the prostate, which is a gland that plays a role in men’s hormonal, reproductive, and urinary functions. 

The problem is that the PSA test alone can’t always tell the types of prostate cancer that are very dangerous from the types that men perhaps can live with their entire lives and never have any problems. And once people hear the word “cancer,” they often will pursue treatment that some experts say isn’t necessary and carries risks such as impotence and infertility.

A paper published last year in a prominent British medical journal concluded that PSA testing “remains highly controversial because it is unclear whether the benefits of reduced prostate cancer mortality offset the harms of overdiagnosis and overtreatment.” 

“Do not get a PSA test, and do not get a biopsy, unless you are comfortable hearing you have cancer and not treating it,” said Andrew Vickers, PhD, lead author of the British paper and a biostatistician at Memorial Sloan Kettering Cancer Center in New York City.

That’s because many doctors will recommend approaches such as active surveillance, observation, or watchful waiting for prostate cancers that aren’t causing symptoms, are small and haven’t spread outside the prostate, and are likely to grow very slowly.

The current PSA testing recommendation in the U.S. is for men ages 55 to 69 years old to talk to their doctor about the benefits and risks of getting a PSA test. But Mahal and his co-authors of the new recommendations in The Lancet argue that it is worthwhile to strongly recommend screening for high-risk groups like Black men. 

He called the current recommendation in the U.S. “not a very strong statement,” noting that a string of changes to it in recent years may be tough for primary care providers to keep up with. The website for the task force that makes the recommendations says that more changes are being considered, including perhaps changes based on age, race, ethnicity, or family history.

“Recommendations about cancer screenings are made around population benefits, not individuals,” explained Erin Kobetz, PhD, MPH, a professor of medicine and public health sciences at the University of Miami. “It’s a strategy for public health management, so sometimes these recommendations shift because yes, there may be benefits doing a certain test for a high-risk individual or a certain group of high-risk individuals, but endorsing it for all individuals within a certain age range may create more problems than the solution is intended to solve. The PSA is one of them.”

Current figures suggest that 1 in 8 men in the U.S. will get prostate cancer, which is the second-leading cause of cancer deaths in men, behind lung cancer.

The potential changes being considered by the influential U.S. Preventive Services Task Force signal that once again, the task force may be seeking to strike a more refined balance between the harms and potential life-saving outcomes of PSA testing.

Precision Medicine Meets PSA Screening

A cancer screening on one of the mobile units in Miami is typically just a walk-up visit. The vehicles are meant to attract attention and are brightly decorated by a famous Miami artist. The artwork can be a conversation starter in itself.

The mobile cancer education and screening vehicles operated by the University of Miami’s Sylvester Comprehensive Cancer Center are called “Game Changer Vehicles,” or GCVs. The community health worker teams speak English, Haitian Creole, and Spanish. Team members typically come from the same communities they serve, and all have a quality of being a natural helper.