When the PSA (prostate-specific antigen) test became available more than two decades ago, it quickly became the standard in doctors’ offices for testing men’s risk for prostate cancer.
Millions of tests later, there is a chorus of concern that it has led to over-diagnosis and overtreatment. In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA testing for prostate cancer because two studies found it did not substantially lower death rates.
At the same time, complaints were increasing over PSA screening leading to harm from biopsies to test for prostate cancer. Those, in turn led to what some experts decried as unnecessary prostate-removal surgeries that created more problems than they solved, including incontinence and impotence.
In 2014, the doctor who discovered the test, Richard Albin, MD, co-authored a book, “The Great Prostate Hoax.” In it, he claims the pharmaceutical industry hijacked the test and turned it into a multibillion-dollar business. He also claims the test was never intended for screening prostate cancer.
In the book, he writes: “For more than 25 years I have denounced mass PSA screening as a public health disaster.”
Since the test was introduced, it has been used along with a digital (finger) rectal exam (which is no longer recommended) to screen for prostate cancer. The PSA test is a blood test that measures a protein released in the blood by the prostate gland. The prostate’s function is to make seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.
PSA is a protein made primarily by the prostate gland. The test can reveal higher than normal levels in the blood, which can be one indicator of prostate cancer, benign prostate gland enlargement, or infection.
Controversy has centered on use of the PSA test to check for prostate cancer in men who have no symptoms of the disease. “Although the PSA test has been shown to lower death rates from prostate cancer by finding prostate cancer earlier, it also has increased the number of unnecessary prostate biopsies and treatments,” says the American Society of Clinical Oncologists (ASCO).
Fueling that controversy is the knowledge that prostate cancer grows slowly in many men, so slowly that in some men “it would not threaten their life, even if not treated,” the ASCO adds.
Further, experts debate over whether the PSA test has actually decreased death rates from prostate cancer. “While use of the test has led to more prostate cancer diagnoses, it has done little to nothing to actually cut the death rate,” writes Randolph Howes, MD, on the website "I Will Find The Cure."
Still, many oncologists and urologists support the use of the PSA test, partly because it remains the best screening tool available. The Seattle Cancer Care Alliance (SCCA) supports its use, for example, because it does help detect early disease. The SCCA also says screening and treatment can be done selectively, on a case-by-case basis.
The USPSTF conclusions were based on studies that had “limited follow-up and a lower death rate than expected in the absence of screening,” the SCCA adds. The USPSTF “almost certainly” understated the lives saved over the long term and “produced an overly negative assessment of the screening benefit,” the SCCA says. “Screening works,” the group adds, as shown by a 40 percent decrease in prostate cancer deaths since PSA screening began in the 1980s.
This split among professionals leaves patients confused. First, you should know that the decision to have a PSA test is yours. You should make that decision after speaking with your doctor about the benefits and risks. The decision over whether to have a biopsy also is yours.
You should also know that, although many men are diagnosed with prostate cancer and prostate cancer is a leading cause of death in men, most of the time tumors grow slowly. Most men with prostate cancer will eventually die of some other condition, such as “old age,” not from prostate cancer. There’s a common saying: “All men develop prostate cancer, if they live long enough, but few men die from it.”
In 2013, the American Urological Association released new PSA screening guidelines that are broken down according to men’s age, health, and risk profile. Among those who support the use of PSA screening, the urological association guidelines are now the golden rule.
What the guidelines say: No PSA screening for men under age 40; no routine PSA screening for men age 40 to 54 who are at average risk; PSA screening only after talking with your doctor about risks and benefits for men age 55 to 69; no routine PSA screening in men age 70 and older who are healthy (with the caveat that your should talk to your doctor about benefits and risks); no routine screening in men age 70 or older with poor health and a life expectancy of less than 10 to15 years and consultation with your doctor about the risks and benefits for PSA screening.
Urologist Justin Albini, MD, of North Kansas City Hospital, puts a period on the AUA guidelines by noting that “risk stratification has been in practice for years, allowing physicians to counsel patients on what treatment, or non-treatment may be most appropriate.”
“Active surveillance for prostate cancer is a common practice,” he says, “and urologists now recognize that some prostate cancer is (very slow to progress) and unlikely to present a problem in a patient’s lifetime. The question should be whether to treat, not whether to screen.”
One final note: think for yourself, never be the passive recipient of medical tests or treatment, and always ask questions that generate answers. To help you decide on whether to get a PSA test, ASCO offers a decision making tool. If you’re not comfortable with a recommendation, get a second opinion. While you do want aggressive prostate cancer to be detected early and treated, you don’t want the complications that some men have had to endure after unnecessary biopsies or unnecessary treatment of slow-growing cancer.
(Interestingly, dogs are being trained to sniff out prostate cancer with some success.)
April 14, 2015
Christopher Nystuen, MD, MBA