Prostate cancer is one of the most common—and most misunderstood—health risks men face.
It is the second leading cause of cancer death in men, behind lung cancer. About 1 in 8 men will be diagnosed in their lifetime, and roughly 36,000 men die each year in the U.S.
But here’s the part that should change how you think about screening:
👉 When caught early, prostate cancer has about a 99% survival rate.
So why are we still missing it?
What Went Wrong With Prostate Cancer Screening
About 15 years ago, there was a major shift away from PSA testing. The concern was that we were diagnosing too many harmless cancers and performing unnecessary biopsies.
That sounds reasonable—but the recommendation was based on flawed interpretations of the data.
The unintended consequence?
👉 We are now diagnosing more prostate cancers later, when they are harder to treat.
What Is a PSA Test (And Why It Matters)?
PSA stands for Prostate-Specific Antigen, a protein made by the prostate gland.
- A small amount normally leaks into the bloodstream
- PSA levels tend to increase with age and prostate size
- The key issue is not just the number—but how it changes over time
Done correctly, routine PSA testing can reduce prostate cancer mortality by up to 64% over 15 years.
The Biggest Mistake: Looking at a Single PSA Value
PSA is not a one-time test. It’s a trend over time.
Levels can fluctuate due to:
- Infection or inflammation
- Recent ejaculation (can raise PSA up to ~40%)
- Normal biological variation (~15% day-to-day)
👉 A single elevated PSA doesn’t mean much.
👉 A pattern is what matters.
What Actually Raises Concern
These are the kinds of PSA changes that deserve attention:
- A sustained rise >0.35 ng/mL per year over ~18 months
- A significant jump from baseline (for example, a meaningful increase when PSA is already elevated)
- A steady upward trend over time—not just a one-off spike
👉 The goal is to establish a baseline early and watch what happens.
What Happens If PSA Is Concerning?
The next step is usually:
Prostate MRI (without contrast)
This has changed the game:
- Helps identify suspicious areas
- Reduces unnecessary biopsies
- Provides PSA density (PSA ÷ prostate volume), which improves accuracy
Biopsies Are Safer Than They Used to Be
If needed, biopsies are now typically done through the perineum (skin between the scrotum and rectum) rather than through the rectum.
This means:
- Much lower infection risk
- Better access to the entire prostate
Why PSA Goes Up With Cancer
Prostate cancer disrupts the normal structure of the gland.
👉 That disruption allows more PSA to leak into the bloodstream
A Critical Detail Most People Miss: Medications That Lower PSA
Drugs like:
- Finasteride (Propecia/Proscar)
- Dutasteride (Avodart)
are commonly used for hair loss and prostate enlargement.
These medications:
- Lower PSA by about 33% at 6 months
- Lower PSA by about 50% at 1 year
So if you’re taking them:
- PSA values must be adjusted (roughly doubled)
- After long-term use (>7 years), adjustment may be closer to 2.5x
👉 Most important point:
PSA should not rise while on these medications.
Any increase should be taken seriously until proven otherwise.
The Reality of Prostate Cancer
If men live long enough, many will develop some degree of prostate cancer.
But:
- Early-stage (Stage 1–3): ~99% cure rate
- Stage 4: ~38% survival
That’s the difference screening makes.
Bottom Line
- PSA testing is still one of the most useful tools we have—but only when used correctly
- It’s about trends, not single numbers
- Early detection dramatically changes outcomes
- Modern imaging and biopsy techniques have reduced the risks that originally caused concern
My Take (What I Tell My Patients)
Don’t ignore PSA testing—but don’t misuse it either.
Start with a baseline, follow it over time, and interpret it in context.
That’s how you catch the cancers that matter—and avoid the ones that don’t.
Best,
Dr. MIke