By Dr. Dave LaMond
For a long time, PSA screening has been treated like a simple yes-or-no test.
A man gets his blood drawn. The PSA comes back “normal,” and everyone moves on. Or it comes back “high,” and suddenly the room gets tense. The patient worries he has cancer. The doctor may start talking about urology, MRI, biopsy, or treatment. Before long, one lab number has created a lot of anxiety.
But that is not how PSA should be used.
PSA is not a diagnosis of prostate cancer. It is a clue. More specifically, it is a risk marker which becomes more useful when we look at it over time and interpret it in the context of the whole person. A single PSA value can be misleading. A PSA trend, interpreted alongside age, family history, medications, prostate size, MRI findings, race and genetic risk, symptoms, and patient goals, gives us a much better picture.
That is the direction prostate cancer screening needs to go. Not “PSA is good” or “PSA is bad,” but “How do we use PSA intelligently?”
The goal is not to find every tiny prostate cancer. The goal is to find the dangerous ones early enough to cure, while avoiding unnecessary biopsies and unnecessary treatment for slow-growing cancers that may never cause harm.
Why this matters
Prostate cancer is common. About one in eight men will be diagnosed with it during his lifetime, and the risk is higher in older men and in Black men. The American Cancer Society estimates more than 333,000 new prostate cancer cases and more than 36,000 prostate cancer deaths in the United States in 2026.
Those numbers matter, but they do not tell the whole story. Most men diagnosed with prostate cancer do not die from it. Many prostate cancers grow slowly. Some are found late in life and never become a threat. Others, however, are aggressive. They can spread beyond the prostate, become much harder to treat, and ultimately take lives.
That difference is the entire point of smart screening.
When prostate cancer is found early, while it is still localized or regional, outcomes are generally excellent. Once it has spread to distant sites, the situation changes dramatically. The disease is often no longer curable in the same way, and treatment becomes more about control than cure.
So when we talk about screening, we are not talking about chasing every abnormal number. We are talking about preventing men from showing up with advanced disease that might have been detected earlier.
Why PSA screening got a bad reputation
PSA screening became controversial for understandable reasons.
The old pathway was too blunt. A man had an elevated PSA, then often went directly to ultrasound-guided biopsy. If cancer was found, treatment frequently followed. That treatment might have been surgery or radiation, and while those treatments can be lifesaving for the right cancer, they can also cause real side effects, including erectile dysfunction, urinary leakage, and bowel problems.
The biopsy itself was not risk-free either. Traditional transrectal prostate biopsy carries an infection risk because the needle passes through the rectal wall. Men also experienced pain, bleeding, worry, and sometimes hospitalization for infection.
Then there was the issue of overdiagnosis. Some men were diagnosed with low-risk prostate cancers that may never have threatened their lives. But once the word “cancer” enters the conversation, many patients understandably want it out of their body. That fear can lead to aggressive treatment even when careful monitoring might have been the better option.
This is why broad PSA screening fell out of favor for a period of time. The concern was not that PSA had no value. The concern was that we were using it in a way that created too many false alarms, too many biopsies, and too much treatment of low-risk disease.
I think that criticism was fair. But the answer is not to ignore PSA. The answer is to use PSA better.
PSA should be followed like a vital sign over time
One of the biggest mistakes in prostate cancer screening is treating PSA like a single pass-fail result.
A PSA of 3.8 in one man may be reassuring. In another man, it may be concerning. It depends on his age, his prior PSA values, his prostate size, his medications, his family history, and how quickly the PSA has changed.
For example, a man whose PSA has been stable around 3.5 for several years may be in a very different situation from a man whose PSA went from 1.2 to 3.5 in a short period of time. The number is the same, but the story is different.
That is why baseline PSA matters. When we check PSA earlier in the right patient, we are not just looking for cancer that day. We are establishing a personal reference point. That baseline helps us understand what is normal for that individual man.
PSA also varies. It can rise from benign prostate enlargement, inflammation, infection, urinary retention, recent ejaculation, vigorous cycling, prostate manipulation, or simple lab variation. That is why a newly elevated PSA should usually be repeated before anyone escalates to biopsy or even advanced testing.
In other words, one unexpected PSA should start a thoughtful conversation, not a stampede.
When should men start talking about screening?
For many average-risk men, I think it is reasonable to begin the conversation around age 45 to 50, especially if they are interested in prevention and have a life expectancy long enough to benefit from early detection.
For higher-risk men, that conversation should start earlier, usually around age 40 to 45. That includes Black men, men with a strong family history of prostate cancer, men with known genetic risk, and men who have a first-degree relative with advanced or metastatic prostate cancer.
The key word is “conversation.” This should not be a reflexive test ordered without explanation, and it should not be dismissed without discussion either. Men deserve to understand what PSA can tell us, what it cannot tell us, and what we would do with the result.
A good screening strategy begins with shared decision-making, but it should not end there. Once a man chooses to screen, we should track PSA thoughtfully and consistently.
What I want to know with every PSA
A PSA result by itself is not enough. When I look at a PSA, I want the story around it.
How old is the patient? What was his PSA last year? Has it been rising slowly or quickly? Does he have urinary symptoms? Has he had prostatitis or a urinary tract infection? Has he ever had a prostate biopsy? Is there a family history of prostate cancer? Is he on testosterone therapy? Is he African American? Does he have any known genetic risk?
And very importantly: is he taking finasteride or dutasteride?
That last question is easy to miss, and it can make a huge difference.
Finasteride and dutasteride are medications used for enlarged prostate, and finasteride is also commonly prescribed for hair loss. These medications can lower PSA substantially, often by about 50%. That means a PSA that looks “normal” on paper may not actually be normal for that patient.
This is one of the highest-yield safety points in prostate screening. Every PSA should come with a medication check. That includes prescriptions from urology, primary care, dermatology, and increasingly from telehealth hair-loss services.
If a man is taking finasteride or dutasteride and his PSA is rising, we should take that seriously, even if the absolute number still appears to fall within the normal range.
A rising PSA is a signal, not a diagnosis
When PSA is rising, the first question is not “Does this man need a biopsy?” The first question is “Why is this rising, and does the pattern suggest meaningful risk?”
In my practice, a rise of more than about 0.5 ng/mL per year over roughly 18 months gets my attention in men with lower baseline PSA values. If the PSA is already above 4.0, a rise of more than about 0.75 ng/mL per year is also concerning.
But I want to be clear: these are not automatic biopsy triggers. They are red flags. They tell us to slow down, repeat the test if needed, review the full context, and decide whether additional evaluation makes sense.
That evaluation may include a prostate exam when appropriate, additional blood or urine markers, PSA density, and increasingly, prostate MRI.
This is how we move from panic to precision.
MRI has changed the prostate cancer pathway
Modern prostate MRI has made PSA screening much smarter.
In the old days, an elevated PSA often led to a relatively blind biopsy. Today, MRI can help us see whether there is a suspicious lesion in the prostate. It can also estimate prostate volume, which allows us to calculate PSA density. That matters because a large benign prostate can produce more PSA, and PSA density can help separate benign enlargement from a more concerning pattern.
MRI can also guide targeted biopsy. Instead of randomly sampling the prostate and hoping to hit the right area, we can use imaging to identify areas that deserve closer attention.
This does not mean every man with a mildly elevated PSA needs an MRI. It means MRI is now an important tool when the risk remains elevated after we have repeated PSA and reviewed the clinical context.
There are also newer MRI approaches that may make this easier for patients. Shorter, contrast-free MRI protocols are being studied and may help improve access while reducing time, cost, and burden. That is important because the best screening strategy in the world is not very useful if patients cannot realistically access it.
If biopsy is needed, the approach matters
Sometimes biopsy is the right next step. If the PSA trend, risk factors, MRI findings, and overall clinical picture suggest a meaningful chance of significant cancer, we should not avoid biopsy out of fear. We should do it as safely and accurately as possible.
One major improvement is transperineal biopsy.
Traditional transrectal biopsy passes through the rectal wall, which increases infection risk. Transperineal biopsy approaches the prostate through the skin between the scrotum and rectum, avoiding the rectal wall. When available and appropriate, this can reduce infection risk and may also improve sampling of certain parts of the prostate.
That matters because the goal is not just to find cancer. The goal is to find the clinically significant cancer while minimizing harm.
Finding cancer does not always mean treating cancer
This is another point that patients need to hear clearly: a prostate cancer diagnosis does not automatically mean surgery or radiation.
Many low-grade prostate cancers can be monitored safely through active surveillance. That may include repeat PSA testing, symptom review, MRI, selected biomarkers, and repeat biopsy only when the risk changes.
Active surveillance is not “doing nothing.” It is structured monitoring. It is a way to respect the biology of low-risk disease while preserving the option to treat if the cancer shows signs of becoming more aggressive.
This is how modern prostate cancer screening becomes much more balanced. We can find dangerous cancers early without automatically overtreating every low-risk finding.
The message I want men to take away
A PSA test does not diagnose prostate cancer. It helps us decide whether the prostate deserves closer attention.
A high PSA does not automatically mean cancer. A rising PSA does not automatically mean biopsy. And even if prostate cancer is found, that does not automatically mean treatment.
The smarter approach is to use PSA as a trend. We compare it to prior results. We repeat unexpected values. We review medications, especially finasteride and dutasteride. We look at family history, race, genetic risk, urinary symptoms, prostate size, and overall health. When appropriate, we use MRI or additional biomarkers before deciding whether biopsy makes sense.
That is the future of prostate cancer screening.
Not fear-based screening. Not blind screening. Not ignoring PSA because it is imperfect.
The right approach is thoughtful, individualized, prevention-centered screening. We want to catch the dangerous cancers early enough to cure, while safely watching the low-risk cancers that may never become dangerous.
That is better medicine for men. And done well, it can save lives.
We do screen for prostate cancer as part of our blue sky HRT panels for men and help with detection. Schedule a hormone panel today!
