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Should you skip your PSA test?

The science is uncertain for now, so arm yourself with deep knowledge of the pros and cons of prostate cancer screening.

In May 2012, the United States Preventive Services Task Force (USPSTF) issued its final report concerning screening for prostate cancer using the prostate-specific antigen (PSA) test. After weighing the evidence, the expert panel concluded that PSA screening for prostate cancer should not be offered routinely to men—typically as part of a regular physical exam. Screening means testing a seemingly healthy person for signs of a hidden disease, like prostate cancer.

This voluntary recommendation, aimed at physicians, triggered numerous media reports that presented men with conflicting expert opinions and raised serious questions without offering clear answers. Should you get a PSA test? If so, when and how often? If you follow the USPSTF advice and decline PSA testing, do you risk being diagnosed someday with advanced disease that might have been treated earlier and, possibly, cured?

Right now, experts do not all agree on the answers to these questions. Amidst the uncertainty, the best strategy is deeply informed decision making.

“Before making any final choice about PSA tests, men first need to understand what is involved before and after they receive the results—whether it’s good news or bad,” says Dr. Marc Garnick, an expert on prostate cancer and a clinical professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center. “Only then can they have a thorough discussion with their doctors to determine whether or not a test is in their best interests.”

What is a PSA test?

The PSA test measures the level of prostate-specific antigen protein in your blood. The test was introduced in the 1980s to monitor the recurrence or progression of prostate cancer. At that time, prostate cancer was often diagnosed at an advanced stage, when the cancer already caused symptoms of pelvic pain or discomfort, difficulty urinating, or blood in the urine. So doctors started using PSA testing to check for hidden prostate cancer. This offered the hope of detecting prostate cancer at an earlier stage, when it is hypothetically more treatable.

But PSA has some limitations. For one thing, it is not really that specific to cancer. An elevated PSA may indicate prostate cancer, but it may also indicate a noncancerous cause, like an enlarged prostate or a prostate infection. As a result, PSA alone cannot tell you whether you have cancer; nor can it assure you that you are cancer-free. Only a biopsy can definitely diagnose prostate cancer.

The PSA dilemma

Cancers detected as the result of PSA screening and biopsy include both fast-growing “aggressive” tumors that kill and slow-growing “indolent” tumors that never cause symptoms or shorten a man’s lifespan. Lacking a reliable way to identify the truly dangerous cancers, men have usually opted for prompt treatment.

Fast forward to 2012, when the USPSTF officially recommended that men and their doctors rethink PSA testing. After reviewing the best research data available, the panel concluded that PSA screening only slightly reduces the number of men who die from prostate cancer.

How does PSA harm?

To fully understand the pros and cons of PSA screening, you have to think beyond the test itself. The PSA test is just the first step in a process to screen for, diagnose, and treat prostate cancer. There can be many potential problems along the way.

If your PSA level is high, your doctor may recommend a biopsy. In roughly one-third of men, biopsy causes bleeding, urinary obstruction, or infection, and one out of 100 men are hospitalized. Post-biopsy, the next step could be treatment. The risks of treatment include impotence and urinary incontinence (in 20% to 30% of men) and bowel problems.

Because PSA screening so often leads to biopsy and treatment—and their associated risks—it is not “just a test.” It is a gateway to unpredictable outcomes, so stepping through it is a serious decision. “It’s not that we are ‘overtesting,’ Dr. Garnick says. “We are opening a door to a possible long, expensive, and potentially painful path with no viable long-term benefit or outcome, from a statistical perspective.”

What should you ask your doctor about PSA?

Here are five questions to ask your physician about a PSA test:

1 Do I really need this? A doctor may suggest a PSA test if he or she considers you at high risk. But some may recommend it routinely to protect themselves from potential lawsuits from men who are not tested, but are later diagnosed with prostate cancer. Make sure you know whether and why you are being tested.

2 Can I choose the test even if I am not at high-risk? You may want the test for peace of mind despite the fact you are considered a low risk, and a doctor will not deny you the test. But if your PSA test indicates possible cancer, and if it turns out to be a false alarm upon further testing, your peace of mind will be disrupted for no reason.

3 How is the test conducted? A PSA test is simple and inexpensive. Blood is drawn for analysis. The cost is approximately $60 to $80.

4 What will the test show? The test measures the amount of PSA protein in your blood. A reading of 4.0 to 10 nanograms per milliliter (ng/ml) is often considered a worrisome number, and anything above 10 is even more of a concern. Keep in mind a low number does not indicate you are cancer-free, nor does a higher number guarantee you have cancer. The test indicates your probability of having prostate cancer—nothing more.

5 Can the test be “wrong?” Yes. Elevated PSA levels can occur for reasons other than cancer, such as non-cancerous enlargement of the prostate gland, infection, or recent sexual activity. Numbers in the so-called gray area of 4.0 to 10 ng/ml should be rechecked and confirmed before deciding whether to follow up with a biopsy.

Who can benefit from testing?

This does not mean you should never consider having a PSA test. It still provides valuable information that can help you make sound medical decisions. A PSA test is a data point, but not a decision point.

Also, the USPSTF recommendation is just that—a recommendation. The final decision is up to you and your doctor. PSA screening offers the most potential benefit to men at high risk. Here are the key risk factors:

  • Age: The risk of prostate cancer rises with age. Most men with prostate cancer are diagnosed in their 70s.

  • Family history: You are at higher risk if your father, brother, uncle, and/or grandfather died of prostate cancer younger than 70. You are at average risk if they didn’t.

  • Race: African American men are at higher risk than Caucasians.

The USPSTF recommends that healthy men should not undergo PSA testing as part of a medical checkup. But no doctor will prevent you from having the test if you so choose, although some may decide to stop suggesting it to their patients.

All men need to grasp the potential costs that may follow a PSA test and not treat it like just another blood test you get at every physical. Armed with this knowledge, you can then have an informed conversation with your doctor and make a decision that best meets your health status and concerns.

Screening & diagnosis (over 10 years)

Lives saved (over 10 years)

96

Number of men diagnosed with prostate cancer out of 1,000 screened.

60

Number of men diagnosed with prostate cancer out of 1,000 not screened.

4 in 1,000

Number of men who die of prostate cancer after being screened.

5 in 1,000

Number of men who die of prostate cancer without being screened.

Result

36 additional cancers diagnosed for every 1,000 men screened with the PSA test.

Result

Screening 1,000 men prevents 1 cancer death, but results in 36 additional cancers being diagnosed (and potential side effects of treatment).

Posted by: Dr.Health

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