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DEAR DR. ROACH: I am a 53-year-old healthy male, and I always request to check my PSA levels each year. My 57-year-old brother's new doctor denied his request for a routine PSA check on their initial visit. She said that the test now produces more false positives and unnecessary procedures and surgeries, so she said "no" and wouldn't order it.

Are primary care physicians discouraging the PSA test for older men now? I don't get any push back when I request to check it. Also, I heard the digital rectal exam (DRE) isn't as valid anymore for screening. His new doctor also did not do a DRE. I'm curious to know your thoughts are on the current DRE and PSA screening guidelines for primary care physicians? -- C.C.

ANSWER: The prostate-specific antigen (PSA) test is a screening blood test for cancer, and the recommendation for its use has gone back and forth over decades since it's been introduced. Since screening and prevention are my areas of expertise, I have followed the literature on the use of PSA and other screening tests very closely.

In my opinion, your brother's doctor was wrong to refuse to order the test. She was right that it does produce false positives, which could potentially lead to unnecessary surgeries; however, there are good ways to reduce unnecessary treatment while still ordering the test, which can save lives.

Most prostate cancer is so slow-growing that it is likely never to bother a man until he dies from something else. So, we don't want to operate on these relatively indolent cancers because there's a possibility of a serious side effect from surgery, such as urinary incontinence or erectile dysfunction (neither of which any man wants).

Before operating, careful testing is done on the prostate cancer, including imaging (ideally by MRI scan), biopsy with pathological examination, and often genetic testing of the tumor. Along with the PSA results, we can separate prostate cancer into categories of very low risk and low risk versus intermediate and high risk.

Once we have the diagnosis, we can make good recommendations so that we can identify the rare high-risk cancers while not unnecessarily treating the low-risk cancers. Without screenings, we can't keep rare, small and aggressive tumors from spreading until it's too late.

Now I have to tell you that age 53 and 57 isn't so much "older," at least from the perspective of prostate cancer screening. The most important time for prostate cancer screening is age 50 to age 70. There are some men who may benefit from starting screening at a younger age (those with a family history, Black men, and men with certain genetic risks) and some who benefit from starting screening when they're older than 70.

The DRE does not add much to the blood test. Approximately 1% of men will get prostate cancer that is diagnosed by the DRE as part of combined screening. Many men will refuse screening if it includes a rectal exam. It's estimated that 90% of abnormal rectal exams will be false positives. On the other hand, I've had instances where quite a few men don't feel like they have been adequately screened unless they have the DRE.

I have a discussion with every man about PSA testing, and I recommend it for most men in this age group. But I only rarely have had a man say that he doesn't want it once he understands that we won't recommend surgery unless the combination of all the studies show that this is a high-risk situation.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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