Prostate cancer is one of the most prevalent cancers worldwide, affecting hundreds of thousands of individuals in the U.S. alone.  It is the second leading cause of cancer deaths in men. While prostate cancer has long been associated with cisgender male populations, a growing body of research highlights its occurrence in trans women and non-binary individuals as well. Comprehensive prostate screenings are more essential than ever for all individuals with a prostate. 

At-home diagnostic testing offers a convenient and accessible way to begin the screening process. However, if initial results indicate an elevated Prostate-Specific Antigen (PSA) level, prostate cancer marker (PCM) testing is an important next step. Proactive screening not only helps with early detection, it also paves the way for personalized and inclusive treatment plans.

What is PSA Testing?

First and foremost, it's crucial to understand the significance of PSA testing. Widely regarded as the primary screening method for prostate health, PSA tests are simple blood tests that measure the level of prostate-specific antigen  in the blood. Regular monitoring of PSA levels can lead to early detection of potential prostate issues, including prostate cancer, ensuring timely intervention and improved outcomes. 

However, due to a number of different reasons, this crucial test has often been overlooked by healthcare professionals. Those reasons include:

Generalization of Risk: Traditionally, prostate health concerns have been mostly associated with older cisgender men. This narrow viewpoint has led to the sidelining of PSA testing for other demographics, including younger men, trans women, and non-binary individuals, despite the clear evidence of its relevance across the board.

Concerns Over False Positives: Some clinicians have expressed reservations about PSA testing due to concerns about false positives, which might lead to unnecessary, invasive procedures or psychological distress. However, newly developed biomarker tests, called prostate cancer markers (PCMs), substantially reduce the risk of unnecessary treatment. One study found that use of PCMs with men with abnormal PSA results cuts unnecessary biopsies by 40%.

Lack of Updated Guidelines: Medical protocols and guidelines should be reevaluated over time. Yearly PSA tests were commonplace for men over 50 until 2012, when the United States Preventive Services Task Force issued updated guidelines recommending against PSA testing for men of all ages. The guidelines asserted that the downsides of the PSA test, including overtreatment, outweighed the benefits. After these guidelines were issued, the number of men receiving PSA tests decreased and the rate of advanced prostate cancer diagnoses has subsequently increased. Although guidelines were updated in 2018, they still did not recommend standardized PSA screening and have not incorporated the use of PCM tests.

Research continues to underscore the importance of PSA screening and follow-up PCM testing for a broader spectrum of individuals. There's an urgent need to integrate this screening more consistently and equitably into routine healthcare visits. 

Pairing PSA Screening with Additional Prostate Cancer Biomarker Testing for Better Insights

When administered as part of a comprehensive care flow, a PSA test is a crucial first step in detecting prostate cancer in its earliest stages when treatment results in 100% five-year survivorship, according to the National Cancer Institute. 

At-home testing allows individuals to easily conduct the test from the comfort of their home. A reactive or higher-than-normal result (a PSA level above 1.5 ng/mL) signals the need for clinical PSA testing conducted by a healthcare provider with follow-up PCM testing (also called biomarker testing) for appropriate [MC1] patients with abnormal results.

When indicated, biomarker tests at the initial screening stage are non-invasive urine and blood tests that can help determine if a patient is more likely to have prostate cancer and should be referred for a biopsy. PCMs used in conjunction with biopsies can help detect false negatives and also determine if a patient’s prostate cancer is low risk or a more aggressive form that requires treatment.  Additional types of PCMs can help providers determine the most effective treatment options.

This type of diagnostic care flow, in which initial screening is followed by comprehensive testing when indicated, is becoming increasingly common in healthcare. Its adoption is a testament to the shift toward proactive health management.

PSA testing: Not Just for Cisgender Men Over 50

While PSA testing is traditionally conducted for men over 50, it's essential to recognize its broader relevance. This screening is critical for cisgender men, trans women, and non-binary individuals with prostates, regardless of age. Research indicates that early screening, at age of 40 or earlier can be vital for many, particularly those with risk factors such as family history or those undergoing hormone therapies. By advocating for earlier and more inclusive PSA testing, providers prioritize a proactive approach, ensuring that everyone has the best chance of early detection and effective intervention.

Inclusivity in Healthcare: Addressing the Needs of Trans and Non-Binary Individuals

When discussing prostate cancer screening, it's vital to highlight its importance for trans women and non-binary individuals who often face numerous barriers in accessing healthcare, stemming from a lack of provider understanding, bias, and system inadequacies. LGBTQ+ patients may face difficulties with at-home diagnostic testing programs that do not center their unique needs. 

Ash Wellness provides two crucial, personalized tools to help our clients support LGBTQ+  patients who want to use at-home diagnostics: :

1. Three-Site Testing: STI testing recommendations are often based on heteronormative standards of sex. LGBTQ+ people may have sex with additional body parts, and are at risk for infections in these areas. For this reason, patients should be tested based on how they have sex rather than heteronormative standards of sex. Three-site testing screens for the presence of an infection in a patient’s genitals, anus, and throat. For patients who engage in oral or anal sex, such as LGBTQ+ patients, three-site screening is crucial to assess STI status. 
2. Gender Affirming Lab API: When ordering a diagnostic test, the processing lab requires a set of validating information known as a requisition. The requisition ties the order to the patient with basic information like  name, date of birth, and sex. This is not only confusing for queer people who may not identify with their sex assigned at birth, but could also lead to misrepresented results, when a reference range is tied to sex without context. Another problem is that patients may prefer to use a chosen name and not realize that lab testing does not require a legal name, just that the lab order and sample names match. System should differentiate between gender and sex assigned at birth, as well as notify patients that a legal name is not required, so patients know what information to submit and results can be interpreted accurately based on the individual.  

By providing these small but important care differentiators, Ash Wellness is positioned to support LGBTQ+ patients in the at-home diagnostics ecosystem. 

The Importance of PSA Testing for the Trans and Non-Binary Community: Early and Often

Many trans women and some non-binary individuals have prostates, and the associated health risks, such as prostate cancer, remain relevant. Hormone therapies, often prescribed to trans individuals during their transition, can have implications for prostate health. By regularly checking PSA levels, they can establish a vital health baseline and engage in proactive monitoring or biomarker testing, as needed.

However, this call to action is about more than just physical health. The trans and non-binary communities have historically faced neglect and outright exclusion in healthcare settings, from research to direct care. By emphasizing the significance of PSA testing for these communities, providers can take  a step toward redressing this oversight. 

Beyond diligently screening for potential health concerns, these tests offer reassurance. Regular health screenings, inclusive of PSA tests, symbolize not only a commitment to health but also a recognition of the unique healthcare needs and histories of the trans and non-binary community. 

What This Means for Healthcare Providers: Public Health Implications and HEDIS Scores

For public health departments and insurance companies aiming to improve their Healthcare Effectiveness Data and Information Set (HEDIS) ratings, integrating PSA testing and follow up biomarker testing (as needed) into routine care can be an impactful move. The HEDIS score is an indicator of an organization's commitment to providing quality care. By recognizing the importance of prostate cancer screening and ensuring these tests are accessible to all individuals, especially marginalized groups such as trans and non-binary communities, organizations can significantly boost their STAR and HEDIS scores.

Embracing PSA Testing as a Preventative Health Measure

Embracing PSA testing as part of a comprehensive care flow not only improves health and extends life but also signifies an important step towards inclusivity and personalized care. For public health entities, insurers, and healthcare providers, this is an opportunity to showcase commitment to quality healthcare for everyone, irrespective of gender identity.

This article was written with input from PC Markers.