Prostate Cancer: Screening, Risk Stratification & Personalized Treatment

Prostate cancer is one of the most clinically nuanced malignancies in medicine — a disease whose management is shaped by an inherent paradox that confuses patients, divides physicians, and generates ongoing public debate. On one hand, prostate cancer is the second leading cause of cancer death in American men, killing more than 34,000 annually. On the other, the majority of prostate cancers discovered through PSA-based screening are indolent — growing so slowly that they will never cause symptoms, metastasize, or shorten a man's life. Understanding this paradox is not merely academic: it is the foundation of every sound prostate cancer decision. At UrologyMax, we invest the time to ensure every patient grasps this distinction fully before any treatment recommendation is made.

The controversy over PSA-based screening intensified in 2012 when the U.S. Preventive Services Task Force issued a Grade D recommendation against PSA testing for all men — a position since reversed to Grade C, recommending individualized decision-making for men aged 55–69. The original recommendation was built on data suggesting that screening led to over-diagnosis and over-treatment of clinically insignificant cancers, exposing men to incontinence and erectile dysfunction without commensurate survival benefit. This critique was legitimate — but incomplete. Simultaneously, multiple large randomized trials, including the European Randomized Study of Screening for Prostate Cancer (ERSPC), demonstrated a 29% reduction in prostate cancer mortality over 16 years of follow-up in screened populations. The critical insight: the harm of PSA screening arose not from screening itself, but from the reflexive, non-individualized approach to biopsy and treatment that characterized the early era.

During the first two decades of widespread PSA testing — roughly 1990 through 2010 — a PSA value exceeding 4.0 ng/mL served as the near-universal trigger for prostate biopsy. This binary threshold failed to account for prostate volume, PSA velocity, patient age, race, or family history, and predictably resulted in biopsies of enormous numbers of men whose PSA elevation reflected benign prostatic hyperplasia rather than malignancy. When cancer was detected in this era, it was frequently low-grade, low-volume disease with no realistic potential to cause harm — yet was routinely treated aggressively with surgery or radiation, exposing patients to incontinence, erectile dysfunction, and bowel injury without meaningful survival benefit. This is the origin of the over-treatment problem that rightly drew scrutiny.

Most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at UroMax. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today.

Contemporary PSA interpretation has evolved dramatically. Today, a thoughtful urologist examines PSA not as a single value but as a longitudinal trend — tracking PSA velocity (rate of rise over time) and PSA doubling time, adjusting for prostate volume (PSA density), and incorporating age-specific reference ranges. Men with a slowly rising PSA in the context of known BPH require very different management than a 55-year-old with a rapidly doubling PSA of 5.8 and a family history of prostate cancer. This individualized, trend-based approach transforms PSA from a blunt screening tool into a nuanced diagnostic instrument that, when used correctly, identifies men who genuinely need biopsy while sparing those who do not.porary medicine to possibly the best of all screening tests available today. The philosophy most commonly employed now is one where the goal of screening for prostate cancer is to find only aggressive cases, the ones responsible for the deaths in America. We call these significant cancers. Thus, the old adage that all men will eventually get prostate cancer if they live long enough may be true if one includes low grade cancers that are not harmful as well as cancer grades that are now not even called cancer. We don’t look for those anymore, and if found we try not to treat them. So, the first step in understanding prostate cancer is to first understand these points about PSA screening and how it has evolved.

Please learn far more by watching Dr. Grant’s webinar regarding up to date prostate cancer screening on our site, found on the homepage. Now let’s move to the concept of significant versus insignificant prostate cancer.

To avoid finding insignificant prostate cancer in the first place, Dr. Grant generally will not offer a biopsy until at least two, or perhaps even three successive rises of the PSA are seen in a patient. It is only a consistent trend, not singular peaks in a bouncing PSA pattern nor any particular set number that will be deemed suspicious. These days, there is much interest in non-invasive tests such as 3-D Ultrasound, MRI, and others to see if these technologies can be sensitive and specific enough to supplant an actual biopsy to look for prostate cancer. There also is an ever growing and evolving list of risk stratification tests also designed to guide us as to whether a biopsy is necessary or not. Dr. Grant has not found any of these tests to be particularly helpful in his practice yet and feels that the philosophy of demanding successive rises of the PSA before biopsy when applied to the individual patient circumstances is far more specific for finding aggressive cancers and excluding insignificant ones. In the same light, Dr. Grant is generally not an advocate for MRI targeted/fusion biopsies as an initial step. Using all of these extra steps seems to take a step backward into the days of overdiagnosis and overtreatment – a place best not to go. We try to protect our patients from that.

The Prostate Cancer Paradox — Why Both Sides Are Right

Dr. Grant and his partners have delivered the diagnosis of prostate cancer or educated patients on the topic well over 5000 times. What has always impressed him from patients diagnosed elsewhere is how little the patient has been educated on the topic. This is a stressful and confusing time for the patient and his spouse and family, and the first step that should be taken is education. Dr. Grant takes that very seriously; Perhaps you have been instructed to read this essay before your next visit for this very purpose. Perhaps you are with another Urologist and hopefully, you will find this education helpful as you move along on your journey.

After understanding first whether a biopsy is indicated, it is important for a patient to then understand what cancer is in general. Cancer is the uncontrolled growth of cells in an organ or the blood. When enough of these cells are present, this is called a tumor. Unlike cells in a benign tumor which also grows in an uncontrolled manner, malignant (cancer) cells can spread throughout the body. This process is called metastasis, and it is metastasis that can lead to death and thus should be seen as the real enemy. It is worth noting that all cancers have a specific pattern of where cancer tends to spread. With prostate cancer, it is to bones and lymph nodes primarily.

The challenge with all cancers is to catch them early before they have spread, which is of course what PSA seeks to do. If found and treated at that early stage, cancers are not much different than benign tumors. The term prostate cancer refers to the malignancy transformation happening in the prostate. When cancer spreads, let’s say to a bone, it is not called bone cancer but rather a metastasis from the originally named cancer. Patients will often see the term adenocarcinoma in their biopsy/pathology report. This just refers to the cell type that transformed into prostate cancer. In the case of prostate cancer, well over 95% of cases are this cell type.

Risk Stratification: Significant vs. Insignificant Prostate Cancer

Patients must then understand the details of their prostate cancer and really should do their best to be educated which includes obtaining their pathology report and being conversant about it. One of the most important concepts to first understand is that prostate cancer, like breast cancer, exists over a wide range of how aggressive each case is. So first, one needs to get a sense of where they stand on this range, and this process is called risk stratification. One’s risk stratification determines if a cancer needs to be treated at all, and if so, what treatments are best suited for their particular case.

Several variables contribute to risk stratification. These include parameters such as how much cancer was present on their biopsy (number of needles), the percentage of each needle or core that contains cancer, the PSA pattern and velocity of rise (much more important than just the latest PSA), and the highest grade of cancer seen on the biopsy report (Gleason grade). One thing to note regarding PSA is that patients found before their PSA gets to 10 ng/dl are considered to have been caught early, with a far lower risk of metastasis. In terms of Gleason’s score, Dr. Grant tries to explain this as four grades, just like most other cancers have. The lowest grade is a 6(3+3). All Gleason grades lower than this are no longer called cancer. There are two grades of seven, 3+4 and 4+3, in order of aggressiveness, and finally, Gleason scores 8-10, the most aggressive. So, he will discuss these grades as grade groups one, two, three, and four with four being the most aggressive. Most pathologists have started to present things this way as well on pathology reports.

So, now you and see that just to be told one has prostate cancer does not say much. We will learn about all of these variables and then we will assign a risk stratification. Dr. Grant often uses the terms:

• No risk
• Low risk
• Moderate risk and
• High risk

Learn more about risk stratification and treatment for prostate cancer

Treatments for prostate cancer may include:

• Watchful Waiting
• Active Surveillance
• Radiation Therapy Delivered Via Different Protocols
• Brachytherapy
• Cryotherapy
• Surgery (Robotic Prostatectomy)

Learn more about treatment for prostate cancer

Next Steps

If you have been diagnosed recently with prostate cancer, Dr. Grant (robotic prostatectomy, cryotherapy) would be happy to have a consultation with you in our office. We will make sure we review your case with you, make sure you understand the problem first thoroughly, and will then go over all treatment options before zeroing in on the right one for you.

Decision Making Once Diagnosed with Prostate Cancer

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When coming for your consultation, please bring all pathology, radiology, and lab reports with you. Also, we encourage you to bring your spouse, family, or significant other as usually these people are also integral to your education and decision process.