Veterans Prostate Cancer and PSA Testing: The Cost of Uncertainty

9-07-2025

By Dr. Howard Friedman MD | Veteran | U.S. Army Medical Corps | Internal Medicine | HHOM LLC

A number on a page, not a man. Veterans deserve screening that sees the whole story—risk, exposure, and dignity—not just a test result.

A quiet number on a page,

Not pain, not blood, not age.

A whisper: maybe, maybe not—

The war you fought, the years you got.

I choose the path that cuts the harm,

Find what matters, spare the arm.

Not fear, not fate, but seeing clear—

Precision over guesswork here.

—Dr. Howard Friedman, M.D.

Thesis

Prostate cancer is no longer just an old man’s disease, quietly discovered in the twilight years of life. It is striking younger men, and when it does, it strikes harder. For veterans, the risks climb even higher—Agent Orange, burn pits, and toxins that shadowed service now echo back in the form of cancer years later. Screening for prostate cancer has long been controversial, built on an imperfect test—the PSA—that can mislead as often as it guides. But ignoring the disease is not an option. The challenge is balance: finding cancers early, when they matter, while sparing veterans the pain and risks of unnecessary biopsies. With new tools—free PSA, modern biomarkers, MRI guidance, and safer biopsy techniques—we can do better. Veterans deserve screening strategies that reflect both their unique risks and the changing face of cancer itself. For veterans, prostate cancer and PSA testing remain inseparable—both a source of early detection and a source of confusion.

Introduction – Veterans and Exposure

Prostate cancer does not announce itself with weight loss, pain, or blood. It grows quietly, often without symptoms, until it is advanced. That silence is part of the problem. For veterans, the risk is even greater. Years of exposure to toxins—Agent Orange in the jungles of Vietnam, oil fires in Kuwait, burn pits in Iraq and Afghanistan—have left an imprint on the body that no discharge paper erases. These exposures are not “maybes”; they are well documented, and they raise the baseline risk of cancer for anyone who served in their shadow. Veterans cannot be measured against the so-called average man, because their risk is not average.

Introduction – Cancer in Younger Men

When I began practicing medicine, the rule was simple: colon cancer screening started at age 50 for people with no added risk. Today it begins at 40, because too many younger patients are showing up with advanced disease. The same shift is true for prostate cancer. Once thought to belong mainly to men in their seventies and eighties, it is now being diagnosed with increasing frequency in men in their forties and fifties. And the pattern is striking: the younger the man, the more aggressive the cancer tends to be.

A man in his eighties may live out his years with prostate cancer, never threatened by it. But a man in his forties may lose those years to it. Even at the highest levels of government, we see how quickly the ground can shift. President Biden’s last routine screening was in 2014. Within a decade, he was diagnosed with aggressive prostate cancer—an unsettling reminder that time and risk do not pause for anyone.

PSA – A Step Forward, and a Source of Trouble

The prostate-specific antigen, or PSA, changed the landscape of prostate cancer. For the first time, we had a simple blood test that could give a clue long before symptoms appeared. It was a game changer. Cancers that once slipped by until they were advanced could now be spotted when treatment still had a chance to cure.

But every breakthrough carries its shadows. PSA was never meant to be a perfect cancer test. A very high level almost always signals trouble. But the gray zone—the slightly elevated results—brings more questions than answers. An enlarged prostate can push PSA upward just as easily as a tumor can. For many men, that gray zone led straight to biopsy, and half the time, no cancer was found. Relief, yes—but not without the pain, fear, and risk of infection from an unnecessary procedure.

The controversy over screening was born here. Some studies looked at the flood of biopsies, surgeries, and side effects that followed PSA testing and concluded the test “didn’t save lives.” But that conclusion missed the point: it was not PSA itself that failed, it was how we used it. Instead of a scalpel, we treated it like a hammer. The result was more scars than solutions.

For veterans, the equation is even more complex. The risks they carry from toxic exposures make it harder to dismiss an elevated PSA as “just an enlarged prostate.” Yet they are still caught in the same medical debate—between too much testing and not enough. PSA was a step forward, but it opened a new battlefield: the fight between early detection and over diagnosis.

Refinements – Free PSA and Biomarkers

Medicine rarely stands still. Once PSA revealed its shortcomings, researchers began searching for ways to sharpen the picture. One of the first steps was looking not just at the total PSA, but at how much of it was circulating in a “free” form. A lower percent of free PSA is more suspicious for cancer, while a higher percent leans toward simple prostate

enlargement. For men stuck in the gray zone—PSA levels between 4 and 10—this added lens often made the difference between watchful waiting and a trip to the biopsy table.

Beyond free PSA came a wave of new markers: the Prostate Health Index (PHI), the 4 Kscore, the PCA3 urine test, and others still in development. Each tries to answer the same basic question: does this man have the kind of cancer that matters, or is his elevated PSA a false alarm? These tests are not perfect, but they help cut down on unnecessary biopsies and point physicians toward the men who most need further work-up.

For veterans, these refinements are more than academic. An elevated PSA can bring weeks of fear, and a biopsy is not just another test—it is pain, risk, and often uncertainty. Every tool that reduces unnecessary procedures without missing aggressive disease is a step toward dignity. Screening should never be a lottery; it should be a careful, informed path.

Biopsies – From Blunt Force to Precision

When I trained, an elevated PSA often meant one thing: a biopsy. The procedure was blunt. A probe was placed in the rectum, and eight to twelve needles were fired into the prostate. No MRI guidance, no targeting—just random cores taken in the hope of hitting a hidden cancer. Half the men came away with “no cancer found,” which was reassuring, but only after enduring the pain, the bleeding, and the indignity. Infection was a constant risk—about one in ten developed fevers or needed antibiotics afterward. We knew it was a crude tool, but it was all we had.

That was the old day. The new day shows us we can do better. MRI scans can often be done before biopsy, highlighting suspicious areas. Instead of firing blindly, we can now guide the needle into the spot that looks dangerous. And the route of the biopsy itself has changed: many centers now perform transperineal  biopsies, passing through the skin between the scrotum and anus, rather than the rectum. The difference is profound—far fewer infections, better access to hidden parts of the prostate, and greater accuracy when paired with MRI targeting.

The biopsy will never be pleasant, but it no longer needs to be barbaric. For veterans who already face greater risks of cancer from toxic exposures, this shift from blunt force to precision is more than a medical advance—it is respect. It means fewer needles, fewer infections, and a greater chance of finding what matters while sparing what doesn’t.

Race, Access, and the VA

In the general population, prostate cancer has long carried a cruel statistic: Black men are more likely to be diagnosed, and more likely to die from it, than their White counterparts. The numbers are not subtle—they are stark. For years this disparity was chalked up to biology, as if being born Black somehow destined a man to a shorter life. But the deeper truth is harder to swallow: much of this gap reflects the failures of our medical system. Limited access to care, later diagnoses, and fewer treatment options have stacked the deck against Black men for decades. It is a shameful measure of inequality.

The story shifts inside the Veterans Administration. In a system where access is more equal—where a Black veteran and a White veteran walk through the same door and see the same providers—the mortality gap shrinks or disappears. Outcomes level, not because biology changed, but because the system did. It proves what we should have known all along: equity in access produces equity in survival.

There is another layer to consider. Among younger men diagnosed with prostate cancer, the proportion who are Black is even higher. And in younger patients, the disease tends to be more aggressive. That double weight—youth and race—underscores the urgency of smarter screening strategies. For veterans, especially those already carrying toxic exposures, ignoring these patterns is not medicine, it is neglect.

Family History and Genetics

Prostate cancer is not only about age, race, or exposure—it is also about family. A man whose father or brother had prostate cancer carries a higher risk himself. And the genetic ties go beyond the prostate. The BRCA genes, best known for breast and ovarian cancer in women, also matter in men. BRCA2, in particular, raises the risk of aggressive prostate cancer, sometimes by five to eight times.

For veterans, this means history matters. A family tree dotted with breast, ovarian, or prostate cancers is not just a record of illness—it is a warning sign. In such cases, earlier and more aggressive screening may be warranted, and genetic counseling may help families understand the risks that extend across generations. Cancer does not respect gender or service record; it follows the code written in DNA.

Understanding the Gleason Score

The Gleason scoring system guides much of prostate cancer treatment. Pathologists examine two of the most common cancer patterns under the microscope, assign each a grade from 1 to 5, and then add them together. The sum becomes the Gleason score. Lower numbers signal cancers that look more like normal prostate tissue and tend to grow slowly. A score of 6 often leads to watchful waiting rather than immediate intervention. At the other end, scores of 9 or 10 indicate highly aggressive disease, where treatment must be pursued without delay. Between these extremes lies the art of balancing benefit with risk, always shaped by the patient’s age, health, and goals.

A Veteran-Centric Pathway Forward

 For veterans, prostate cancer cannot be approached with “average risk” rules. Toxic exposures, family history, race, and genetics all tilt the odds. Screening must reflect that reality. The pathway begins with the PSA, but it should never end there. When results fall into the gray zone, percent free PSA and newer biomarkers such as the Prostate Health Index, 4Kscore, or PCA3 can help separate false alarms from true risk. If concern remains, an MRI should precede any biopsy, highlighting suspicious areas and sparing men from blind sampling. When biopsy is necessary, the transperineal route, ideally with MRI targeting, reduces infection risk and improves accuracy. And if cancer is found but proves low-risk, active surveillance is often safer than rushing to treatment. Veterans must press for this modern approach, because too often the system defaults to outdated pathways. Screening done right saves lives—but only when it is tailored to those who have already paid the price of service.

Conclusion – Smarter, Not Louder

Prostate cancer is not the quiet disease it was once thought to be. It strikes earlier, it strikes harder, and it strikes veterans who already carry the weight of toxic exposures. PSA was a step forward, but it also created confusion and unnecessary suffering. Now we stand in a new era, with better tools—free PSA, modern biomarkers, MRI guidance, and safer biopsy techniques—that can bring clarity where once there was only uncertainty. The hope for the future is simple: that veterans will not be left behind, that they will be offered the same precision, dignity, and access as anyone else, and that our medical system will continue to move from blunt instruments to thoughtful care. To those who have read this far, thank you for giving time and attention to a subject too often ignored. For veterans and their families, your awareness is part of the healing. For clinicians, your willingness to listen and adapt is the path forward.

We remain grateful—for the service given, for the progress medicine has made, and for the chance to keep learning together.

The test, the number, not the man,

A clue, a spark, a fragile plan.

Too young, too soon, the risk is clear,

Exposure’s shadow still draws near.

But guided hands can change the end,

With sharper tools, the truth we send.

For those who served, who bore the cost,

Smarter care must not be lost.

—Dr. Howard Friedman, M.D.

—Dr. Howard Friedman MD

Board-Certified | Internal Medicine | Veteran | U.S. Army Medical Corps

Founder of Howard’s House of Medicine (HHOM LLC)

https://www.hhomllc.com

Frequently Asked Questions:

Q: : Why is prostate cancer risk higher for veterans compared to the general population?

A: Veterans face additional risks because of exposures during service. Agent Orange, burn pits, oil fires, and other toxins increase the baseline chance of developing prostate cancer. These exposures are well documented, and they mean veterans cannot be judged by “average” population risk.

Q: What makes PSA testing controversial?

A: PSA can detect prostate cancer early, but it is not specific. Enlarged prostates or inflammation can also raise PSA levels, leading to unnecessary biopsies and anxiety. The controversy is not about whether cancer matters, but about how to avoid overtreating men who may never be harmed by their disease while still catching aggressive cancers early.

Q: What are safer, more accurate options for veterans today?

A: Modern strategies include free PSA testing, advanced biomarkers like the 4Kscore or Prostate Health Index, MRI scans before biopsy, and transperineal biopsy techniques. These tools reduce unnecessary procedures, lower infection risk, and focus attention on cancers that truly matter. Veterans deserve these updated approaches, not outdated one-size-fits-all screening.