If you’re like most men age 40+, you probably get your PSA (prostate specific antigen) test when you go for a physical that includes a blood draw. You learned either from your doctor, or a health promotion, that men should get a baseline PSA at age 45 (40 if you have known risk factors) and then track it every year. This is called screening, and it’s a cheap and easy way to monitor your prostate. But what, exactly, does PSA screen for? Well, it’s not very specific. An elevated (or rising) PSA can signal the benign gland enlargement that occurs with aging, infection, inflammation, prostate cancer, or physical stimulation of the gland such as bike riding or sexual activity. In other words, it’s not specific for any one thing.
If you’re a person who follows health news, by now you have learned that a few years ago, a U.S. task force panel of medical experts recommended against routine screening of otherwise healthy men with no known risk factors for prostate cancer. This led to an ongoing controversy over the merits of early detection vs. the risk of invasive diagnostic and treatment procedures that come with risks of side effects. At the heart of the controversy is whether screening actually saves lives. If you ask the experts, they will cite studies that failed to demonstrate a reduced prostate cancer mortality rate. If you ask patients who were diagnosed and treated for prostate cancer based on a higher-than-normal PSA that led to a biopsy that led to treatment, they will say they are glad their cancer was discovered, even if they are living with imperfect urinary, sexual or bowel function due to treatment. The problem is, there is little data on men’s awareness of the task force decision, and if their feelings about screening and treatment are affected by their recommendation.
A team of researchers at the University of Buffalo reached out to prostate cancer patients to collect information on this topic.[i] They found that just under 20% of men had accurate knowledge about the task force decision. When informed about it, their attitudes were negative, with over 85% highly supportive of annual PSA testing in men ages 50+. The researchers found the decision had no impact on treatment choices, internal conflict during decision-making, or regret after treatment. They concluded that learning about screening and overtreatment controversies has not adversely affected patients diagnosed and treated since the decision, with the majority of men still “highly supportive” of PSA screening. They noted, “As survivor anecdotes often influence people-s medical decisions, it is important to appreciate the scale of opposition to the new recommendation.”
My patients are not opposed to PSA screening, but they sure don’t want to be subjected to a blind, random biopsy which misses cancer at least a third of the time—leading to a repeat biopsy the following year. When presented with the news that their PSA is abnormally high for their age, they seek out alternatives to an immediate biopsy. They come to our Center for a 3T mpMRI of the prostate to learn if a biopsy is warranted, based on imaging. If so, they want a targeted biopsy under real-time MRI guidance in order to get an accurate diagnosis with the least amount of invasiveness and risk.
You can afford to have a positive attitude about the PSA blood test if you know that you have a choice about what comes next if the result is a red flag. Until an inexpensive cancer-specific test comes along, it’s still the easiest way to keep tabs on your prostate health.
[i] Orom H, Underwood W III, Hormish DL et al. Prostate cancer survivors’ beliefs about screening and treatment decision-making experiences in an era of controversy. Psychooncology. 2014 Nov 10. Epub ahead of print. Doi: 10.1002/pon.3721