Effective cancer screening protocols can dramatically alter outcomes for patients. Prostate cancer, for example, has been one of the most common cancers (Opens in a new window) among men in the United States for decades. In the mid-1900s, prostate cancer had a relatively low (Opens in a new window) 5-year survival rate, with many patients receiving a diagnosis when the cancer was more advanced and harder to treat effectively. The introduction of the prostate-specific antigen (PSA) test was seen as revolutionary for the prostate cancer community. Initially approved to monitor disease progression in the 1980s and cancer screening in the late 1990s (Opens in a new window), the PSA test is a simple blood test that can indicate prostate problems when levels are elevated.
The PSA test, however, has been a subject of controversy ever since its approval for prostate cancer screening. While extremely valuable for assessing the health of the prostate, elevated PSA levels don’t necessarily indicate whether a person has prostate cancer. Other factors can contribute (Opens in a new window) to elevated PSA levels, including infection, inflammation, and innocuous activities, such as sexual activity or long distance bicycle riding. Enlargement of the prostate, which happens as men age, can also lead to an elevated PSA level. To verify a prostate cancer diagnosis, patients must undergo a prostate biopsy, but that can be expensive, invasive, and ultimately unnecessary. Nearly 75% (Opens in a new window) of all biopsies that are performed after detection of elevated PSA levels are negative for prostate cancer.
Discourse over prostate cancer screening, particularly the PSA test, exploded in the early 2000s after Dr. Richard Albin, the man who discovered PSA, penned an op-ed in the New York Times titled “The Great Prostate Mistake (Opens in a new window),” in which he reiterated his point that the cost and unclear results from the PSA test make it a poor choice for a prostate cancer screening method. Much of this controversy stemmed from overtreatment of low grade prostate cancer, but this has decreased dramatically with new risk stratification tests and the increased use of active surveillance. Currently, the US Preventative Services Task Force (Opens in a new window) recommends that prostate cancer screening using the PSA test should be an individual decision for men aged 55 to 65.
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The state of prostate cancer screening and diagnosis
Now, 30 years after the approval of the PSA test as a cancer screening tool, approaches to prostate cancer screening and diagnosis vary, but recent trends indicate an uptick in its prevalence. Since 2014 (Opens in a new window), US diagnoses have risen by 3% each year, and advanced-stage prostate cancer diagnoses have risen by 5% each year. Worldwide, prostate cancer cases are projected (Opens in a new window) to rise from 1.4 million in 2020 to 2.9 million by 2040. Survival rates for prostate cancer have improved since the 1980s, but early detection is still critical. Patients with early-stage cancer (that is still localized or has only spread regionally) have a >99% (Opens in a new window) 5-year relative survival rate, while men with later-stage cancer that has spread to distant parts of the body have a 5-year relative survival rate of 34%.
A rise in cancer cases has physicians and public health officials wondering what contributing factors are at play. First is age. Prostate cancer is more prevalent in men over 65, and it’s estimated that the number of Americans crossing this age threshold will increase by 47% (Opens in a new window) between 2022 and 2050. Second is the high (Opens in a new window) incidence of obesity in the US. Research has shown a link (Opens in a new window) between obesity and increased prostate cancer aggressiveness (and subsequent mortality). The third likely contributing factor is limited access to testing. While PSA testing only requires a blood draw and may be relatively affordable to the average patient, subsequent imaging and biopsies to confirm a cancer diagnosis are not as widely accessible. Given the high rate of false alarms with PSA testing and the cost of follow-up testing methods, some patients may make the decision to opt out of prostate cancer screening entirely.
Urologists are an important asset in the face of rising costs and often vague screening protocols. However, like many other medical fields, urology is experiencing a shortage of physicians. According to the American Urological Association (AUA), over 60 percent (Opens in a new window) of all US counties don’t have a practicing urologist. This shortage can have real impacts on patient experiences, with physicians having less time to provide care and education to patients. These factors combine to create a clear need for low-cost, easy-to-interpret tests that provide insights into the likelihood of high-grade cancer and can be performed by a PCP or urologist.
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Alternative approaches and the future of prostate cancer diagnosis
The path to a prostate cancer diagnosis can be long and winding. Physicians need options to help them navigate the aftermath of an elevated PSA result. This testing gap between an elevated PSA result and a prostate biopsy is where the field is ripe for innovation.
One area with great potential is DNA and RNA-based molecular diagnostics. Tests like these, particularly multi-cancer early detection (Opens in a new window) (MCED) tests, look for cancer biomarkers in blood. MCED tests are exciting developments because they have the potential to provide information about multiple types of cancer in one test. However, MCED tests have a few drawbacks. They aren’t truly accessible for many patients due to the expensive equipment needed to run them and the fact that they aren’t likely to be fully covered by most insurance carriers. Beyond their cost and required equipment is the additional concern that many of these genetic tests vary in their accuracy across cancer types. Thus, MCEDs have potential but aren’t developed enough to serve as a valuable screening method for prostate cancer.
Protein structure analysis is another technology that holds great promise for prostate cancer screening. As opposed to focusing on genetic tests, which identify the presence of cancer-causing genes, protein structure analysis is a simple, cost-effective blood test that assesses for the presence of proteins produced by cancer cells. In this way, these tests are a cancer-specific indicator, filling in a layer of much-needed clarity that imaging and PSA tests cannot do on their own. With a prostate-specific protein structure analysis, a physician can identify patients at the greatest risk for prostate cancer, separating patients likely to be cancer-free or experiencing indolent disease from those likely to have high-grade cancer. In studies, this kind of information was able to inform physician biopsy decisions, resulting in a 55% net reduction (Opens in a new window) in biopsy orders. Considering an estimated $2.5 billion (Opens in a new window) is spent annually on prostate biopsies, this level of reduction could be significant in the long term. In events where a physician wants additional information to inform their decision-making, protein structure analysis can be used in partnership with imaging (Opens in a new window) to provide a clearer picture.
The future of cancer diagnosis
The future of prostate cancer diagnosis (and cancer diagnostics as a whole) lies in alternative testing methods that provide clear guideposts for physicians making difficult screening and diagnosis decisions. By providing cancer-specific intel, tests like these can enable physicians and patients to make more educated choices, ultimately saving precious time while also saving lives.
Photo: 3283197d_273, Getty Images
Aaron D. Berger, M.D. (Opens in a new window) earned his Bachelor of Science degree from the University of Wisconsin with a major in biochemistry and molecular biology. Dr. Berger attended medical school at the David Geffen School of Medicine at University of California Los Angeles to earn his M.D. He completed his residency in Urology at the NYU Langone Medical Center in New York. Dr. Berger completed a fellowship at the University of California San Francisco in Laparoscopy, Endourology and Robotic Surgery. Dr. Berger is a member of the American Urological Association, the Endourological Society, the American Medical Association and the Chicago Urologic Society.
Dr. Berger is the current Chief Medical Officer and Director of Clinical Research of Associated Urological Specialists (Opens in a new window) (AUS). He has a special interest in prostate cancer from robotic surgery to state of the art treatments of advanced and metastatic prostate cancer.
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