PSA Testing Guidelines Raise Questions Over Benefits

In May of 2012, the U.S. Preventative Services Task Force (PSTF) triggered a firestorm of debate by recommending against routine prostate-specific antigen (PSA) testing as a screen for prostate cancer. Since then, many medical professionals have taken the political view that this recommendation is an attempt by the government to get between the patient and his doctor, but the truth is that excessive testing causes considerable harm.

PSA screening is used in the United States more than it is any other country. Since its inception, the number of prostate cancer cases detected has increased substantially, resulting in it being the most commonly diagnosed cancer in American men. By discouraging routine screening of asymptomatic men, the aim of the PSTF is to diminish harm caused by over-treatment. While most prostate cancer is relatively slow growing and non-aggressive, elimination of routine testing can allow some cases of aggressive cancer to slip through, thus delaying diagnosis of a serious condition. The individual decision of whether or not to routinely test PSA is a two-edged sword that many men will need to face as they age.

Most doctors routinely include a PSA test with a man’s annual physical. PSA is a blood protein that is produced only by the human prostate gland. When it falls outside a normal range, additional testing and a biopsy often follows. An elevated level may mean that the man has prostate cancer, but there are many other unrelated conditions that can cause a man’s PSA to rise temporarily. But, if any cancer is found, the man is usually doomed to a regimen of aggressive treatment and debilitating side effects, even though the cancer may be insignificant.

Almost every article about prostate cancer begins with a recital of the statistics of the number of deaths it causes. While scary numbers make strong media headlines, what is rarely mentioned are statistics about the number of men found to have low levels of non-aggressive prostate cancer. Often these men are treated aggressively with surgery, radiation, or hormone deprivation therapy, and suffer afterward from treatment side effects that seriously deteriorate their quality of life.

Researchers at the University of Cambridge in the United Kingdom that analyzed data from the Prostate Testing for Cancer and Treatment trial found that only about 10 percent of prostate cancers detected by screening may be aggressive enough to post a danger to a man’s life. The other 90 percent are not likely to ever cause any serious symptoms, and may go unnoticed for decades without ever posing a significant risk.

Thus, the strategy espoused by many clinicians—that early detection is critical for a cure—does not work well for non-aggressive cancers that can lay dormant and symptomless for decades.

The caveat here is that PSA testing is still valuable, providing that both doctors and men—aware of both its value and its limitations—use it intelligently. Before testing, a thorough examination and discussion of the pros and cons should take place between doctor and patient. Many men with prostate cancer have normal PSA levels, and many men with elevated levels do not! Thus, the test is, at best, a very unreliable indicator, and treatment decisions need to be made wisely after gathering more information.  Unfortunately, in the U.S. today, an out-of-range PSA value is often the main basis for a urologist to recommend aggressive treatment, much of which may be unnecessary!

Many benign conditions, particularly prostate infections (prostatitis) and enlargement (BPH) can cause an elevated PSA, and higher than normal levels. Depending on the doctor’s approach, this may or may not result in more tests or aggressive treatment. Discussing this in advance gives a man the chance to evaluate his doctor’s thinking, and if needed, find a doctor that is more in line with him. Some doctors are willing to take a “wait and see” approach and retest several times over a few months before making recommendations. Others insist an immediate biopsy is mandatory. While a blood test is rather benign, a prostate biopsy is not!

A high PSA value coupled with an overly aggressive doctor can cause anxiety and result in additional—and unneeded—medical treatment.

All men over fifty should consider the PSA test as one important tool to be used as a basic indicator for monitoring the prostate health, with the knowledge that an abnormal result should only be a warning flag that something may be wrong.

There are many other resources that should be used wisely to determine if an out-of-range PSA value is a real problem and further analysis is needed or not.