I am sick of explaining PSA testing to my patients. To get out of the inevitable questions about the pros, cons, science, and politics behind the new recommendations, I made the following handout. Ironically, my laziness motivates me to do a whole bunch of stuff. It kind of feels like I'm being tricked into doing extra work, but there's nobody to blame. I'm just that way. I guess I'm a sucker that way. Anyway, here it is. Feel free to take advantage of my work to make your life easier. I don't think there's any hope for me.
PSA Testing - Pro's and Cons
What is a PSA? PSA is short for Prostate Specific Antigen and is a protein that is elevated in men who have prostate cancer. PSA levels are tested using a blood test, and have up until recently been done yearly for all men over 50. A “normal” PSA level is between 0 and 4, with numbers getting into the 100’s with prostate cancer.
What is the controversy about PSA testing? The group of researchers and doctors who recommend testing have recently changed their recommendations. In the past, all men over 50, and younger men with increased risk for prostate cancer were urged to get the test once a year. This recommendation has been reversed, now only recommending PSA testing in men who either have had prostate cancer or who are at increased risk of developing it.
Why did they change this recommendation? While PSA did reveal the presence of prostate cancer, studies have never reliably shown that average-risk men who get PSA tests live any longer than those who don’t. This is especially true in men over age 65.
How could PSA not save lives if it helps find cancer? There are several explanations for this:
- Prostate cancer is very slow-growing. Studies of men in their 80’s revealed that a very high percentage of them had cancer in their prostate. For older men it is now accepted that most men who get prostate cancer will die with it, not from it.
- Treatment for prostate cancer is not completely safe. While some men were cured of prostate cancer by getting surgery and/or radiation, other men underwent these procedures, had long-term compilations, hospitalizations, and even death from the treatment. When all of these were put together, the benefit of finding the cancer did not outweigh these negatives.
- Most elevated PSA tests are not because of cancer.
So how is prostate cancer diagnosed? Unfortunately, there is no good test to screen for prostate cancer in average-risk men, just like there is no test to screen for brain tumors, pancreas cancer, or pneumonia. Cancer is only diagnosed when it gets bad enough to give symptoms.
What are the symptoms of prostate cancer? There are no consistent symptoms for prostate cancer. Most symptoms from the prostate are from benign prostate enlargement (BPH), which doesn’t lead to cancer.
Should anyone get PSA testing? Yes, men who have an increased risk (father or brother with prostate cancer) should still get it done yearly, as should men who have already had prostate cancer. Most now agree that it’s not beneficial over age 65, but it is still controversial if average-risk men between 50 and 65 should be tested (urologists think so, but most researchers do not).
Why not just get tested “to be safe?” A negative test is a good thing, and is reassuring that there is no cancer. The problem is when the test is positive, as it really impossible to not aggressively treat it once it has been found.
Can men still get tested if they want? Yes, but they should understand that doing so may lead them to get many procedures, surgery, radiation, and/or hospitalization, as well as side effects of treatment, such as impotence and incontinence. All of these complications come without the assurance that they come with a longer life. The bottom line is that we need a better test.
I didn't say it in this handout, but I do have a theory as to who is behind the resistance to these recommendations: it's the Lexus dealers and yacht manufacturers. They have sold a bunch of cars and yachts to urologists on the income generated by PSA testing. It makes sense. It's all about the yachts.