October 25, 2020

The Niche

Knoepfler lab stem cell blog

Should men get a PSA test for prostate cancer? Yes, but…..

PSA testing, cancer zodiacShould 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.

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