Should you check your PSA?

December 1st, 2011 By Steven Knope, MD

Many of you have read about the recent controversial statement from the U.S. Preventive Services Task Force that ordering a PSA as a screening test for prostate cancer is a bad idea. The Task Force recommendation was so strong that it was given a D-rating, which means the Task Force believes that there is moderate or high certainty that PSA testing has no net benefit or that the harms of testing outweighs the benefits.

This statement has created a strong backlash from some urologists. It runs contrary to other groups. It has also created a great deal of confusion in patients and their families.

Why not check a PSA?
There are several arguments that can be made against ordering routine PSA levels as a screening test for prostate cancer:

  1. In most men, prostate cancer is a slow-growing, benign disease. In fact, most men die with prostate cancer, not from prostate cancer.
  2. In men who live long enough, most will develop prostate cancer and most of these cancers will never cause any problems.
  3. The PSA test cannot differentiate the relatively rare, aggressive prostate cancers that kill men from the more benign prostate cancers that cause them no harm.
  4. Treatment of most benign prostate cancers found by PSA testing is still treated aggressively, because there is no way to differentiate between benign cancers from the more malignant varieties. Treatment usually involves surgery or radiation therapy, which often leads to serious complications, such as erectile dysfunction, urinary incontinence and psychological harm associated with the label of “cancer.”

What are the potential life-saving benefits of PSA screening?
The best data that we have on the value of PSA screening comes from two large studies, one done in Europe and one done in the U.S., and the results of these studies are contradictory. The U.S. study showed that men who had regular PSA screening tests had no improvement in mortality compared to men who did not have screening PSAs.

The European study, on the other hand, showed a 20% reduction in mortality in those men who had their PSA checked compared with men who did not. Wow! That sounds pretty good. However, the 20% number is deceiving. If we ask another question of the European study, we get a different perspective.

If we look at the number of men we would need to treat to save just one life from prostate cancer, it turns out that relatively few lives are actually saved. In the European study, it was determined that 48 additional patients would need to be treated to prevent just one prostate cancer death. Think about this for a moment. To save just one life, 48 additional men would need to have unnecessary major surgery or radiation therapy – with all of the attendant complications – to prevent just one death. That is a lot of complications!

Are there some men who are at greater risk of aggressive prostate cancers?
Yes. And the argument has been made by some experts that these men should have PSA testing as opposed to the general population. For example, black males have a higher prevalence of fatal prostate cancers than other ethnic groups. Men who have a first degree relative with prostate cancer before the age of 65 tend to have more aggressive disease.

It may be that these higher-risk men should be screened with regular PSA tests, whereas lower-risk men should not. However, there is still controversy.

So you still haven’t given me the answer! Should I check my PSA, yes or no?
Fair enough. At the present time, the best advice I can give you is to speak with me and/or with your urologist if you have one during your next visit. Based on the present literature, it is my belief that men should have a frank discussion with their doctor and decide on a case-by-case basis whether or not they should have regular PSA testing.

If someone is anxious about getting prostate cancer, due to their ethnicity or a family history, it is entirely reasonable to check a PSA. If someone is just anxious in general, and is unconcerned about the downsides of surgery or radiation therapy for prostate cancer, then it is reasonable to check a PSA. However, given the current data – and our inability to identify the aggressive prostate cancers from the benign prostate cancers – it is perfectly reasonable for most men not to have an annual PSA test.

Bottom Line: Use this newsletter to better understand the basic issues of PSA screening for prostate cancer, then talk to me in person at your next visit to decide whether or not you want to continue to have annual PSA screening.


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