The PSA Test: What Men Need to Know About Prostate Cancer Screening

Dr. Sameer Baig, MD is a triple specialty physician, fellowship trained and certified in Hematology, Oncology, and Internal Medicine. Questions / Comments: Hello@SpecializedClinic.com.

Prostate cancer is the most common cancer in men (with the exception of skin cancer), and usually diagnosed later in life. Prostate cancer can often be deadly, but many cases of prostate cancer are indolent, meaning slow growing. So slow in fact that men may die from something else, i.e. another concomitant medical condition other than prostate cancer. Please note, this is not a reason to ignore prostate cancer testing! It is the fourth most commonly diagnosed cancer in the world. In the US alone, about 270,000 cases will be diagnosed this year. There is a screening test for prostate cancer called PSA (prostate-specific antigen) testing, however use of the PSA test has been mired in controversy.

So what’s the controversy? Since PSA testing became widely available in the late 1980s it significantly enhanced our ability to detect prostate cancer. Doctors were now able to find these cancers very early, which ordinarily would sound like a good thing but as I noted earlier, prostate cancer is a little unusual as many of these will be slow growing. Many of these cancers may not need treatment right away, if ever. Doctors were able to find so many men with elevated PSA levels which resulted in more biopsies, which found more cancer, which led to more treatment. Biopsies and treatment are not entirely benign things. Doctors carefully weigh the risk and benefits of all interventions before making a decision and only pursue a diagnostic and treatment course if the benefits outweigh the risks of not doing anything. Biopsies can lead to harm — complications such as infection, pain, bleeding, and urinary obstruction (~2% of all biopsies). Overtreatment can also cause a drop in quality of life, fatigue, pain, and sexual dysfunction. This led to many more questions for oncologists to ponder and answer such as — does every prostate cancer need to be identified and treated? What prostate cancers definitely need treatment? Is PSA leading to too many biopsies and complications for cancers that otherwise would not have needed treatment? What is the best way to utilize PSA testing? Does earlier detection improve survival and quality of life?

Unfortunately there is no good way to predict before a biopsy takes place as to whether a prostate cancer would have ever caused symptoms or harm to a man during his lifetime had it been left alone. The government, i.e. the USPSTF (United States Preventive Services Task Force) have changed their stance a lot over the years based on the available data. In 2002 they said that there was insufficient evidence to make recommendations for or against PSA or DRE (Digital Rectal Exam) screening. Basically saying, we have no idea, let’s wait for more data. In 2012 the USPSTF decisively recommended against PSA screening for prostate cancer. Most doctors followed suit and stopped checking PSAs. Consequently detection rates of prostate cancer started to go down — you can’t find something if you’re not looking for it!

Interestingly, as the detection rates of prostate cancers were going down in the late 2000s and 2010s, the rate of advanced stage i.e. stage III, and IV metastatic prostate cancer rose by 6% during this period of time. The drop in prostate cancer incidence observed in this period was simply because we were told to stop looking for it — it was not real. What was obvious was that cases of de novo metastatic prostate cancer were on the rise. Doctors began sounding the alarm, and some just went ahead and ignored the USPSTF guidelines altogether and started PSA testing in their male patients again. On May 8, 2018 the USPSTF made a complete U-turn, and released a final recommendation statement on PSA screening for prostate cancer where they went from recommending against any PSA testing to now advocating for testing men between certain ages after a discussion with their doctor.

Numerous data supported, and continue to support that no PSA testing is not the right answer. More recently, in a retrospective cohort study published by Bryant et al in JAMA Oncology in October 2022, evaluated 4,678,412 patients in 2005 and 5,371,701 in 2019 at Veterans Health Administration (VHA) facilities. PSA screening rates declined at the VA between 2005 and 2019 — but diagnosis of metastatic prostate cancer increased over the same time period.

There is real harm in too much testing — overdiagnosis, anxiety, complications from biopsy, reduction in quality of life from overtreatment. And clearly, there is also a risk of incurable cancer from no screening at all. So should you get screened? The final USPSTF recommendation is men ages 55–69 to discuss testing with their doctors and make an individualized decision. However for men 70 years or older, the USPSTF does not recommend routine PSA based screening.

As an oncologist, I generally recommend PSA screening based on the patient — not the patient’s age per se. I do not like guidelines based solely on age, after all it’s just a number. Why is that? Because I have patients in their 70s who are in excellent physical health, and far better off than men who are 15 or 20 years younger. There are also other considerations, i.e. risk factors to consider: Does or could the patient have Lynch syndrome? Could they be a BRCA mutation carrier? Is the patient Black or White (racial makeup is an independent risk factor)? Is this a man with a family history of prostate cancer? Are they on certain medications such as 5-alpha reductase inhibitors? — My point is that this is complicated, and that is why you need to talk to your Doctor.

Bottom line:

  • I recommend serial PSA screening for medically fit males with >10 years life expectancy as a general guideline.
  • PSA screening decisions should be made with your doctor after a detailed discussion of risks and benefits, and what your individual risk for prostate cancer is.
  • I do not recommend one-time screening PSAs — it is ineffective and a waste of time and money.

Remember, always demand to see a Medical Doctor (MD or DO after the name), it’s your right!

References:

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Dr. Sameer Baig, MD is a triple specialty physician, trained and certified in Hematology, Oncology, and Internal Medicine. Questions / Comments: Hello@SpecializedClinic.com. TL;DR — Learn about your