Should men get a PSA test for prostate cancer? The same federal panel that recommended that women in their 40s not get routine mammograms has now come forth with the statement that PSA testing men for detection of prostate cancer should be stopped.
I think it is not that simple and I still believe in PSA testing, just with changes in how it is done.
As many of you know, I’m a prostate cancer survivor and now patient advocate, having been diagnosed with a relatively high grade prostate cancer. I’m nearly two years out and doing well so far, having learned some valuable lessons from my cancer despite the horror of the experience. Of course, I don’t know what the future holds, but knock on wood I’m optimistic.
How was my prostate cancer detected? PSA testing at age 42.
It’s hard for me not to be a believer. My cancer was no “watchful waiting” type of cancer.
Why might studies of tens of thousands of men seemingly show that PSA testing doesn’t help save lives?
Let me explain.
First, the average age of diagnosis for prostate cancer, usually based on elevated PSA, is around age 70. Whether a man who is 70 gets treatment for prostate cancer or not, his overall mortality rate is relatively high at that age. The window for surgery or other treatments for prostate cancer to increase his life expectancy is relatively narrow.
Second, doctors will tell you if you are in the cancer field (probably not if you are an average patient) that for many patients by the time an elevated PSA is detected, some of the time the cancer has already spread yet such spread is not detectable at the time of diagnosis. That metastatic cancer will not be cured by removing the prostate or irradiating the heck out of it, and it is that metastatic cancer that kills patients. If the cancer is still local, then removing the prostate has the potential to cure.
Third, paradoxically it is young men who may be helped the most by PSA testing. What doctors now recommend is PSA testing after age 50, but I believe it is really far more logical to test at age 40. This establishes a baseline and provides guidance for future testing plans. If the test is low at age 40, then perhaps testing every 5 years makes more sense. If the PSA test is high for that age, yearly testing could be done for a period of time. If no increase is evident, the testing interval could be shifted to longer.
Fourth, dump the arbitrary cutoff of 4.0 ng/ml. It is basically meaningless if you do not take into account the man’s age. Men who are around age 40 typically have a PSA around 1.0 or less. When doing PSA testing for men, use an age-based scale. What is normal for a 50 year old is not the same as for a 70 year old, etc.
Fifth, don’t discourage men from get tested no matter their age. Even though the average 70 year old man has fewer years to live than say a 60 year old, we are all different. Many 70 year olds are otherwise healthy and want to actively manage their health.
Finally, if scientists studied only those patients for whom an elevated PSA led to the detection of a high-grade (say greater than or equal to 7 on the Gleason scale), I am 100% convinced they would find that PSA testing saves the lives of men, particularly young men.
So I say keep on doing PSA testing, but do the testing not globally and blindly, but in an intelligent, directed manner based on scientifically rigorous criteria. This is a way to save lives but avoid putting men who have low odds of any benefit through unnecessary treatments.
Patients and physicians need more information about how probability works and what positive false or otherwise mean to make informed choices. Screening breast/prostate/bowel make medical personnel more aware of what to look for. It is interesting that historically decisions not to screen appear to be aligned with bad economies.
It is complex looking at lead time,sojourn time, changing of diagnostic bars all of these influence population stats. Sadly insurance reforms can make someone needing screening in anti screening climate ineligible.
This happened to a close family member the sequlae was 10 of thousands of uninsured care the alternative was certain death as a fast growing phyloddes tumor was discovered . She wasn’t covered because she was under 40…
Looking t population stats cancer death at older ages rather than younger are consistent with screening
I am a prostate cancer survivor who brought a statistical bent to the processes of making decisions.
In my view, of course you should have PSA testing. The test is not invasive and has no unpleasant side effects. The issue is how you make use of the information gained.
It is always better to make decisions in your life based on information, for any purpose but particularly when it involves potentially life threatening conditions (medical conditions, hazardous activities you may engage in, etc.). When you find that you have an elevated PSA that has been accelerating, you need to know the conditional probabilities and odds of various outcomes given your PSA level (e.g., your likelihood of having cancer, of an early death from cancer). You also need to know what information will be gained if you have further procedures (such as a biopsy), and how more information gained about your situation changes the conditional probabilities. Obtaining this information from your urologist (and can be found using on-line nomograms) enables you to make informed decisions. Then you can decide what course you will take. Removing what is often the first information source (PSA) makes no sense. What is needed is having an understanding of how this information puts you in charge in making a series of decisions based on the experiences of many others who have the same situation (e.g., PSA level, Gleason scores, percent of cancer in needle biopsy, etc.).
I ended up having surgery and have no side effects or detectable PSA after 5 years. Will I ever know if this would have been the case if I had instead done nothing? Of course not. Was the process I went through traumatic? Yes. Was it worth it? For me it was.
Thanks, John. I feel mostly similarly as you about this but am so far only 2.5 years out from surgery. Best wishes to you!
Paul
One interesting tidbit I learned while studying urology yesterday: In men with 2 to 10 ng of PSA in blood, it’s useful to measure the ammount of it that is free vs bound to proteins (In tumors, free PSA is higher) to decide whether to do a biopsy or not.
I’ve watched a best friend in his 70’s try to treat his prostate cancer with alternative methods even though his urologist brother and I both said, “Get it out of there!” in the beginning when he was in his 60’s.
He has now moved on to seeds and radiation but it’s now an up-hill struggle.
The main reasons he refused the early surgery? Incontinence and impotence.
The reason I’m writing this is to tell anyone it might help that
1- Incontinence is NO BIG DEAL. Six years post radical and still leaking a bit, I treat it the way every woman does her period. I deal with it; it’s part of my life.
2- Drugs did nothing for erection although my surgeon had clearly spared the nerves. Orgasm was possible, just not erection. It took me some years to find the SOLUTION. A three-part implant that has made me and my partner happy enough that “ecstatic.”
(Remember when staying erect long enough was the biggest worry in your life? When you first became sexually active? The inflatable doesn’t go away until you tell it to. What a gift to an older man and woman.)
Should you have PSA/biopsy/etc.?
I can’t say. But to not do treatment because of possible consequences… that’s foolish.
Based on my history I think you’re probably headed in the right direction: at age 56 PSA had gone from 2 to 7 in 2 years (+/-), Gleason 6/7(different scores from different pathologists – which tells you something), surgery followed 9 months later (PSA returned) by radiation and 6 months of Lupron, PSA non-detectable for last 6 years, erectile dysfunction only side effect. I would make the same decision today.
I was glad to come across a link to this post on the NYT Well blog, and I largely agree with your arguments. Somewhere in my late 40s I began to have PSA tests and the results were well below the “4.0” threshold. Then in my early sixties my PSA rose sufficiently that my urologist suggested a biopsy. Negative for cancer. A few years later another rise in PSA, this time more significant, and another biopsy. Still negative. At that point I began taking tamsulosin and finasteride to treat BPH, and after a few months my PSA was back down in the low range — and my symptoms were under control. During these years my older brother developed prostate cancer and had a radical prostatectomy.
Had either biopsy shown prostate cancer I would probably elected treatment of some kind — watchful waiting is not appealing to a man in his sixties who, based on family history, has a good chance of living well into his nineties (my father died at 96). Even now, at 70, if my PSA were to jump I would have a biopsy and probably elect treatment if the Gleason score were high. I would gladly trade my sex life and the trouble of incontinence if it would improve my life span.
I plan to continue having a PSA, given family history and my own previous experiences. I hope others in their 40s and 50s also continue to get tested. As you suggest, used carefully and in combination with other pertinent facts about a patient’s life expectancy, family history, and medical condition, the PSA test will save lives.
Thanks for developing a thoughtful and reasoned perspective on this issue.
At my university there was controversy between the prev medicine and urology departments (the former being against PSA testing, the latter for it). Myself, I am not sure. At the moment it’s the only thing resembling an operative screening test we have. And, while the costs (and secondary damage and side-effects) are certainly something to consider, it’s undeniable that prostate cancer mortality has plummeted in the last few decades. Granted, PSA tests aren’t the only factor in this (improvement in chemotherapy and radio and brachitherapy can’t be disdained), but at least part of the effect is likely due to it. I wonder, if, like the recommendwtion against mammogrwphy screeening in forty years old women, it isn’t as much due to it not being benefittial as for it not being cost effective. I don’t know for certain. I haven’t looked imto the original sources for this (I’m preparing the MIR exam atm -sort of like the USMLE-, and for it’s purposes I just answer by rote that “as of today, psa is not recommended by the USPTF” if it comes up). For what it’s worth, though, during hospital rotqtions in med schoolI saw people getting referrals for it quite often, practically on a routine basis. I’m trying to convince my father to get it checked.