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The PSA Testing Debate: To Screen or Not to Screen

January 05, 2015

Should you or shouldn’t you? That’s the question many men over the age of 40 often face in regards to PSA testing.

The PSA test is a prostate cancer screening test that evaluates a man’s level of prostate-specific antigen (PSA), a protein that both malignant and benign prostate tissues produce. Malignant cells typically cause PSA levels in the blood to increase. However, men with benign but enlarged prostate glands often have elevated PSA levels as well, which can make evaluating a PSA test more difficult.

As a hematologist and oncologist, patients often ask me to order a blood test that can detect all cancers. Unfortunately, I always have to inform them that no such blood test exists. Cancer screening tests are difficult to use in day-to-day practice for many reasons, particularly because they are sometimes unreliable and misleading. For these reasons, we rarely send these tests away for results unless we suspect that someone already may have one of these conditions.

The PSA test became widely available in the 1990s and has led to a significant increase in the number of men diagnosed with prostate cancer. But for various reasons this test is still controversial, and many men waver about whether to take it. Conflicting debates in the medical community about who should take the test and when, and whether it’s necessary to begin with, also make things more complicated.

That’s understandable, because sometimes these tests are non-specific. There are several factors that can elevate a PSA aside from prostate cancer. Activities that force the prostate to contract, such as sex and ejaculation, can raise the PSA. Any activity that puts direct pressure on the prostate, such as riding a bike, also can raise it.

PSA Test Results and Age

Another significant issue with PSA screening is the question of what to do with the results. In some studies, offering PSA screening has helped men live longer. However, other studies have not confirmed this. This discrepancy may exist because most prostate cancers are slow-growing. Older men with prostate cancer often succumb to other health issues, even though they may still have the disease. Yet, men in this age group have often had PSA testing. PSA screening in men 75 and older is unlikely to help them live longer, but may be associated with increased anxiety, unnecessary biopsies and other unwarranted procedures. Most cancer groups and urologists don’t recommend PSA screening in this age group.

For younger men, it’s a bit more complicated. Doctors will offer most men who have an elevated PSA a prostate biopsy, which later can lead to surgeries or radiation; both of which have potential side effects that include incontinence and erectile dysfunction.

A recently published trial indicated that nearly 100 men would need screening to prevent one death. This likely is because prostate cancer is slow-growing. However, older trials do show reduced mortality in men diagnosed with early-stage prostate cancer, since early detection allows them to receive primary treatment before the disease spreads.

So, Should You or Shouldn’t You Have a PSA Test?

In general, we still advocate PSA screening in men age 50-70 with a life expectancy of more than 10 years. However, men need to understand the implications of the test before they do a screening. Even if your PSA is elevated and you do a biopsy to determine if you have prostate cancer, observation may be the best course of treatment. Not all men diagnosed with prostate cancer need surgery or radiation, especially if the cancer is low-grade and localized.

Depending on your risk factors and medical history, a PSA test may or may not be the best option for you. If you’re debating whether to take a PSA test, talk to your doctor. He or she can give you details on the benefits and challenges of getting screened, so you can make the best decision for your health.

Do you have questions about prostate cancer screening?

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