The PSA Test Controversy

 

The Prostate Specific Antigen, commonly known as the PSA, is a protein made only by the prostate gland. It was found that patients with prostate cancer had significantly elevated PSA levels. This PSA test was developed in the late ’80s and has been a standard lab test to obtain since then. Many men, including Joe Torre, Rudy Guiliani, Nelson Mandela and Colin Powell, had their prostate cancer cured because they found their disease early. Former Mayor Guiliani claims the PSA test saved his life. Prostate cancer is among the second most common cause of death by cancer in men, so screening for it just makes sense… right?

Earlier this fall, The United States Preventative Task Force (an influential US government sponsored panel that reviews medical data and makes recommendations that guide healthcare providers and insurance companies) stated that the PSA test should no longer be performed on healthy, asymptomatic men.

Why? The test seems like it has little downsides at first glance, but scratch the surface and he head scratching begins. It is simple to administer and sensitive, almost everyone with prostate cancer has an elevated PSA. The test’s specificity, on the other hand, leaves much to be desired, as many as 7 out of 10 men with an elevated PSA do not have cancer.

Prostate cancer is a bit unusual as cancers go, so screening for it is tricky. It is incredibly common, usually slow growing and usually not aggressive. While incredibly common, only 3% of men die from prostate cancer and many never have any symptoms. The fact of the matter is prostate cancer is usually such a slow moving disease that many men who do have it die from an unrelated cause, never knowing they were affected. Despite this fact, most men treat their prostate cancer once they find out they have it. Could you sleep at night knowing you had cancer and you were doing nothing about it?

Cancer is among the most terrible diseases to plague humans, partly because it’s treatment involves invasive biopsies, radiation, difficult surgery and toxic medicines. The prostate is in crowded real estate, with many delicate nerves, blood vessels and other structures surrounding it. Complications from surgery and radiation can lead to erectile dysfunction, incontinence, and pain. These side effects can devastate patients’ quality of life and rarely, lead to death. If the cancer would never cause symptoms, it seems silly to treat it and risk these terrible unintended consequences.

Unfortunately, it is not so simple. Some prostate cancers are more aggressive than others, and many men have fantastic outcomes after receiving treatment. The golfer Arnold Palmer was back on the green 2 months after his prostate was removed. Many men owe their lives to the PSA test. It’s easy to say only 3% of men in our population die from this disease. It is much harder to swallow that your father, brother, or husband died form this disease when a simple blood test could have found it before it was too late. Despite all of the evidence, there is this nagging gut feeling that throwing this test to the curb seems wrong. So what should doctors and patients make of this quagmire?

First of all, more research is needed. There is likely a role for the PSA test in high-risk individuals, those with symptoms and an abnormality found on physical exam. Also, looking at the PSA in context, for example, how fast it rose from the previous measurement (the PSA velocity) or examining conditions that could have raised the PSA, could also be used to help improve the test. Studies looking at these techniques or others could lead to effective screening techniques. But what about right now?

We have to balance the risks and benefits with the information we have. Ultimately, it is a personal decision you should make with your doctor’s guidance.

Be well,

Dr. Bruce Feinberg