Why Men Aged Over 50 Years With Lower Urinary Tract Symptoms Should Undergo Prostate Cancer Test

Men aged 50 and above with lower urinary tract symptoms (LUTS) should consider getting a Prostate-Specific Antigen (PSA) test.

By Dr Manav Suryavanshi

Prostate cancer, a prevalent and often challenging health concern for men, arises in the prostate, a walnut-sized gland that produces seminal fluid. As one of the most common cancers among men, understanding its nuances, proactive screening, and personalised approaches are crucial for effective management. Prostate cancer's variable nature, from slow-growing and confined tumours to aggressive forms that may spread beyond the gland, necessitates a nuanced and comprehensive approach to diagnosis and treatment. One key diagnostic tool in this endeavour is the Prostate-Specific Antigen (PSA) test, particularly for men aged 50 and above experiencing lower urinary tract symptoms (LUTS). The PSA test, coupled with risk-adapted strategies, enhances precision in diagnosis and guides personalised interventions, underlining the importance of tailored approaches for navigating the complexities of prostate health and ensuring optimal well-being.

Men aged 50 and above with lower urinary tract symptoms (LUTS) should consider getting a PSA test. If there is a family history of prostate cancer or if you are of African descent, consider PSA testing from the age of 45. Men with BRCA2 mutations should think about PSA testing from the age of 40.

Implementing a risk-adapted strategy is pivotal in the management of prostate health. The initial PSA level serves as a crucial determinant for establishing follow-up intervals. Individuals with a PSA level surpassing 1 ng/mL at age 40 or exceeding 2 ng/mL at age 60 are advised to undergo more frequent check-ups, occurring every 2 years. Conversely, those not meeting these risk parameters may opt to delay testing for up to 8 years. It's essential to recognize that for individuals with limited life expectancy and compromised overall health, the benefits of PSA screening may be diminished. This underscores the importance of tailoring screening approaches based on individual risk profiles and health considerations.

Before recommending a prostate biopsy, a multiparametric MRI with PIRADS (Prostate Imaging Reporting And Data System) scoring is performed to better understand the disease and reduce unnecessary biopsies. For those who haven't had a biopsy before, a combination of targeted and systematic biopsies is recommended when the MRI shows suspicious findings. If the MRI is negative (PI-RADS ≤ 2) and there is low clinical suspicion of prostate cancer, the decision to have a biopsy should be made together with your doctor.

Typically, 10 to 12 core biopsies are recommended for the prostate, as more than 12 cores don't significantly improve the accuracy. If the MRI shows a suspicious lesion, a targeted biopsy can be performed using different guidance methods like cognitive guidance, US/MR fusion software or direct in-bore guidance. Ensure that biopsies from different areas are processed and reported separately.

For patients with high-risk localised or locally advanced prostate cancer, it's important to perform metastatic screening, including imaging of the abdomen, pelvis, and a bone scan to rule out the spread of the disease into various parts of the body.

For asymptomatic patients with localised prostate cancer and a life expectancy of less than 10 years, a watchful waiting approach may be suitable. Patients should be aware that all active treatments have side effects. Robotic radical prostatectomy is the most common surgical approach for localised prostate cancer, with benefits such as smaller incisions, less pain, and good outcomes. In cases where lymph node dissection is necessary, an extended template is recommended for optimal staging. 

Radiotherapy with hormone therapy with its own set of benefits and side effects is an alternate form of treatment when a patient chooses not to undergo surgery. Cryotherapy, high-intensity focused ultrasound and Focal therapy should only be considered within clinical trials or well-designed studies.

After a radical prostatectomy, PSA levels should be undetectable (below 0.1 ng/mL). Any rise in PSA indicates a relapse and requires further evaluation. The decision for subsequent salvage therapy depends on the PSA rise, risk classification, and a discussion with the patient. Regular follow-up involves a history check and PSA measurements every three months with your URO oncologist.

(The author is the Head of Urology, and Clinical Lead, Uro-Oncology & Robotic Surgery).

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