[haldujai]

There is weak evidence to support testing over 70 due to increasing risks of biopsy/treatment and no evidence to support improved overall mortality.

Some guidelines suggest that it's reasonable to continue in patients with >10-15 year life expectancy if the patient desires, but there is no strong recommendation or evidence to support this recommendation or screening in this age group.

Some guidelines actually have a strong recommendation to stop screening men with < 15 year life expectancy.

Even less evidence for a DRE. PSA by a GP is sufficient if you desire screening.

[e40]

> Even less evidence for a DRE. PSA by a GP is sufficient if you desire screening.

I believe my father's prostate cancer was found via DRE and not PSA. That is, PSA was in the normal range. That is what made me get a DRE from a urologist once a year (since then).

[haldujai]

It’s hard to comment accurately as prostate cancer isn’t a single disease.

PSA cutoff trades sensitivity and specificity. It isn’t a binary positive/negative.

There are certain highly aggressive but very rare subtypes (e.g. neuroendocrine) that will present with low PSA levels. Rarely an aggressive adenocarcinoma (Gleason 8+) will present with low PSA. Screen detected prostate cancers with low PSA are most likely clinically insignificant [0].

If you are known to have a first degree relative with a rare subtype then routine screening guidelines don’t apply to your circumstance.

Important points to keep in mind:

Just because a prostate cancer is “found” it doesn’t mean it needs to be treated.

There is no survival benefit when comparing treating early prostate adenocarcinoma (conventional and most common type representing 99% of prostate cancers) at very low PSA vs using 4ng/mL as a cutoff.

There are verifiable and proven harms with over treatment of low grade prostate cancer, workup of a “nodule” felt on DRE in the context of normal PSA is more likely to harm a patient than benefit them even if cancerous which forms the basis of current guidelines.

All forms of cancer screening will have edge cases that are missed. Even in your father’s case only the peripheral zone is palpable by DRE (would miss transitional zone or 20% of cancers). When considering recommendations to make at a population level harms vs benefits have to be carefully weighed, in the case of prostate the evidence strongly suggests against DRE, and weakly against prostate cancer screening in general.

Looking towards the future, there is probably a role for prostate MRI somewhere which is good at detecting clinically significant (Gleason 7+) cancers but this is still being actively studied and we don’t have enough evidence at this time to support screening.

[0] https://bjui-journals.onlinelibrary.wiley.com/doi/full/10.11...