Why Prostate Cancer Screening Belongs in Primary Care

Primary care clinicians have a central role in prostate cancer detection because they know a patient’s health history and are often best positioned to begin a risk-based screening conversation, according to Mina Fam, MD, a urologic oncologist at Hackensack Meridian Health in New Jersey. Fam describes a spectrum ranging from indolent tumors that may never cause harm to aggressive disease that can threaten survival. The goal is not simply to find more cancer; it is to identify clinically significant disease while limiting unnecessary diagnosis and treatment.

Prostate cancer remains a major US health burden. According to the National Cancer Institute, prostate cancer is the most common nonskin cancer among US men and the second-leading cause of cancer death in this population. Yet screening requires balance because prostate-specific antigen (PSA) testing can produce false-positive results and detect tumors that would not otherwise become clinically important.

Fam argues that primary care is the appropriate setting for shared decision-making because clinicians can place a PSA result in the context of age, family history, ancestry, comorbidities, previous values, and patient preferences. The 2023 American Urological Association and Society of Urologic Oncology guideline similarly recommends shared decision-making before PSA screening and identifies Black ancestry, germline mutations, and a strong family history as factors associated with increased risk.¹ The guideline also supports tailoring rescreening intervals or discontinuation to PSA level, age, health, risk, and preference rather than applying one schedule to every patient.

The practical takeaway is to treat screening as a longitudinal process. Clinicians should identify higher-risk patients, explain benefits and harms, and interpret PSA in context. An abnormal value should trigger confirmation and risk assessment—not an assumption that cancer is present. This approach preserves the potential benefit of early detection without losing sight of overdiagnosis and treatment-related morbidity.

Reference:

1. Wei JT, Barocas D, Carlsson S, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023;210(1):46-53. doi:10.1097/JU.0000000000003491