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Prostate Cancer—PSA test revisited

Nov 17, 2011

Back in December, we talked about the PSA test, a common, but controversial, blood test used to screen for prostate cancer. Now, the PSA test has been back in the news, after the United States Preventive Services Task Force (USPSTF) issued a draft recommendation that healthy men under age 75 not have the PSA test.

Background

PSA stands for prostate-specific antigen, a protein that helps liquefy semen so that sperm can travel more easily. Both cancerous and non-cancerous cells produce PSA, but cancerous cells tend to produce more of it. If your PSA levels are elevated (higher than 4.0 ng/ml), your physician might order further screening or a biopsy.

While alarming, a high PSA reading doesn’t necessarily mean you have cancer. In fact, most men with abnormal PSA readings don’t have cancer. Infection, enlarged prostate, and inflammation can make your levels rise.

The problem is that you can have cancer even if your PSA test results are normal. Cancer cells don’t always make a lot of PSA. Medicines for an enlarged prostate can also make your test results “normal.”

So there is some controversy around the PSA test. Men have been advised to start screenings around age 50. If they’re at higher risk for prostate cancer, they might start around age 40. However, it’s important for men to know the facts about the test beforehand and understand that results might not be conclusive.

The USPSTF Recommendation

The USPSTF is a panel of primary care providers who are experts in preventive medicine. The panel issues recommendations for primary care physicians and health care systems, according to its website.

The USPSTF studied five large, randomized trials of PSA testing and concluded that the PSA test does not save lives. The panel also felt that there was more harm in the test than benefit because of overdiagnosis and overtreatment.

Having a high PSA level often leads to biopsy and treatment, such as radiation therapy and surgery. For some men, treatment is more harmful than the cancer itself and the side effects of treatment, such as erectile dysfunction, incontinence, and bowel issues become bigger problems than the cancer. In some cases, “watchful waiting” – close monitoring of the situation without direct treatment – is more appropriate.

There are also emotional aspects to the test. Men who have elevated PSA levels may become anxious over the uncertainty of their condition.     

Reaction

Many in the medical community strongly disagree with the USPSTF’s recommendation.

On November 8, the American Urological Association, which represents 13,000 urologists and urological health professionals in the United States, sent a letter to the USPSTF, which stated in part:

We recognize the Task Force's concerns about over-diagnosis and treatment, and understand that overtreatment of over-diagnosed prostate cancers is common (90 percent of men with detected prostate cancer receive some form of treatment). We also recognize that, in some cases, treatment of prostate cancer can result in serious harm without any benefit for those who are over-diagnosed and over-treated. However, we stand firmly in our belief that the PSA test – when used and interpreted appropriately – provides valuable information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer, especially in younger men.

In a response dated October 10, 2011, the Prostate Cancer Foundation noted:

The PSA test still has a role to play in early detection and treatment for millions of men. It should be noted that in the pre-PSA era, approximately 80% of patients who were diagnosed with prostate cancer, were already in advanced stages of the disease with metastatic cancer. Today, the number of patients who are diagnosed with metastatic disease at time of initial diagnosis is around 20%. In the past 15 years, the death rate has been reduced from 42,000 annually to 33,000.

And on October 26, 2011 Johns Hopkins advised:

Many leading cancer and patient groups and doctors agree that there is harm with PSA screening and the treatment that follows diagnosis. But a more targeted screening approach focusing on those at greatest risk of developing prostate cancer, and active surveillance for those who don’t need immediate treatment, could shift the balance of benefit and harm toward benefit.

PSA screening is the best test available for the detection of cancer cells in the prostate. Rather than discontinuing use of the only test available to detect the disease early and treat it successfully, efforts should focus on reducing harm.

What Should You Do?

Having the PSA test is a personal decision, one best made with your urologist and/or primary care physician. Before having the test, make sure you understand what the results may – or may not – mean. And be sure to discuss any questions and concerns with your doctor.