Dr. Mitchell on PSA Testing For Men

PSA stands for Prostate Specific Antigen. An antigen is a foreign substance or molecule that triggers your immune system to produce antibodies. In this case, the antigens trigger an attack on the prostate. The PSA is a protein, which responds to inflammation, cancer or infection. The recommendation against routine screening with the PSA test comes from the US Preventive Services Task Force (USPSTF), and was supposed to be published October 11, 2011 in the Annals of Internal Medicine. The entire draft of the paper was leaked and posted October 6, 2011 on the CancerLetter.com website. As a result, many interpretations of the story have spread like wildfire across the Internet.

The New York Times reported that the PSA test is akin to a Ponzi scheme analysis, in that people who were screened actually had increased mortality. This notion is based on the analysis that more men with higher PSA levels opted for cancer treatment and may not have needed it. Those fortunate to live into their 80’s will find that four out of five men will have some kind of cancerous prostate condition. Prostate cancer is typically thought to be slow growing. However, I have a Patient with Prostate cancer that was originally diagnosed in his 60’s which has now metastasized to his bones 10 years later. Unfortunately, in this person’s case, the cancer did not grow slowly enough.

The USPSTF had already recommended against routine PSA screening in men older than 75 years. The newest recommendation now extends to all men, and comes out against routine screening in men younger than 75 years on the basis that there is “moderate or high certainty that the service has no benefit or that the harms outweigh the benefit”.

Could this be considered “rationing” of healthcare? I personally think so. Is the PSA test the end-all-be-all? Of course not. Do you have a right to have a prostate assessment at any age? Of course you do! I personally believe that all men should continue to have their PSA levels checked. An increase in the PSA number tells me that inflammation probably exists. Inflammation is not a good thing, so if we know about it, we can do something about it. From a preventive standpoint, we can work on decreasing the inflammation naturally over time.

Some of the current controversy surrounding the PSA Test stems from the recommended treatments after finding an elevated PSA level. Many Physicians err on the side of caution, so they may order a biopsy on the Prostate, which is not always necessary. A PSA test is a valuable tool but should probably not be relied on exclusively. A Digital rectal exam should be performed annually which allows for masses to be found. A mass can be present on the prostate with a normal PSA level. If a digital rectal exam reveals a mass or enlargement of the prostate gland, an ultrasound of the prostate could be ordered to visualize the gland. At this time, a biopsy may be recommended to determine your “Gleason score.”

Is all of this necessary?

My answer is you should always have the right to make an informed decision and to arm yourself with as much information as possible. While I would not rely on the PSA test as a solitary means for prostate cancer screening, I do recommend it as an assessment of overall prostate health. A patient’s care should be customized to fit their needs. For example a man with family history of prostate cancer will need earlier PSA tasting than a man without such history. No authority should be able to tell you what test you can or cannot have your Doctor order for you. Men with changes in their PSA levels should know about them and be able to make informed decisions as to what the next step should be.