Men are confused, partners are concerned and patients with prostate cancer and those who treat them have been outspoken in the last few weeks about a recommendation that men no longer be screened for prostate cancer with a PSA test.
The confusion and outcry created by the recommendation by the U.S. Preventive Services Task Force are understandable. We are talking about a disease that claims the lives of more than 32,000 men a year. A death from prostate cancer, which tends to spread to the bones, can be a painful death. So physicians who treat men with prostate cancer want to do everything in our power to detect the disease early, when it is treatable, in an effort to prevent the pain, suffering and deaths of our patients and many others.
For years, that has included testing men for levels of a protein associated with prostate cancer, among other prostate conditions, with a simple blood test done during their routine, yearly check-ups.
One problem is that the PSA test, which measures the level of a protein called prostate specific antigen, is not a perfect test. It is easy for men to be tested, but much harder to know what to make of the results. The test can reveal elevated levels of PSA, but it doesn’t reveal whether those elevated levels absolutely mean that a man has cancer.
The second problem is that not all prostate cancers behave similarly. A small fraction are extremely aggressive, but the majority are not. Prostate cancer is a major killer, but more often the cancer is slow-growing. Right now, there is no blood test used in clinical practice that can distinguish between prostate cancer that will kill and prostate cancer that won’t.
A prostate biopsy often can detect poorly differentiated cancers, which can pose a threat to a person’s life, versus well-differentiated, small-volume cancers, which generally do not pose such a threat. The fact remains that when prostate cancer cells are aggressive and do metastasize, it’s a burdensome disease for which there is no cure. We have a long way to go in treating it.
Because prostate cancer is sometimes very aggressive, we do all that we can to treat it to prevent death from prostate cancer, which is characterized by bone pain, urinary obstruction and bleeding. That has included a PSA test. The challenge for men and their physicians is in knowing what to do when a PSA blood test reveals elevated PSA.
Told they may have cancer because of elevated PSA levels, many men have undergone biopsies, surgeries, radiation and other treatments that have changed their lives irrevocably. The blood test itself hasn’t harmed men, but the resulting biopsies and further treatment sometimes create side effects that markedly decrease quality of life. That’s why the task force recommended that men no longer be tested for PSA.
According to the task force panel, one million men from 1986 through 2005 received surgery, radiation therapy, or both, who never would have been treated had they not had a PSA test. Of those, more than 5,000 died soon after surgery, 10,000 to 70,000 suffered serious complications, and 200,000 to 300,000 suffered impotence, incontinence or both.
It is thus easy to understand the panel’s rationale, even if you do not agree with their ultimate recommendation.
That said, a data-supported, reasonable recommendation is that men at average risk should receive information, including a PSA test if they want it, at an appropriate middle age, although African American men or men with a family history of prostate cancer should receive information at an earlier age, such as 40 or 45 years. The American Urological Association recommends a PSA test at age 40, and if the value is low, a re-test can be deferred for some years.
Dr. Viraj Master is a urologic oncologist and associate professor and Director of Clinical Research in the Department of Urology at Emory University and member of the Winship Cancer Institute.
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