PSA Screening

By Claus G. Roehrborn, M.D.
Professor and Chair of the UT Southwestern Department of Urology

Each year, millions of men over the age of 40 have prostate specific antigen – PSA – blood tests as part of routine physical exams to test for cancer in their prostate. But the utility of these tests in detecting cancer at an early stage – and ultimately in preventing death from the disease – has long been debated.

And the picture is, unfortunately, not getting any clearer. Two studies recently published in the New England Journal of Medicine – in the same issue – contained somewhat different results. If the medical world cannot draw a firm conclusion, what in the world is a patient to do?

The two independent studies were conducted, one in the United States and one in Europe. The American study concluded that PSA screening had no significant effect on reducing deaths due to prostate cancer. The European study, however, indicated that screening reduced the rate of deaths by 20 percent. But the absolute number of deaths prevented was small – seven men saved for every 10,000 screened over the course of a decade – and 48 men were misdiagnosed and treated needlessly for every life saved.

The studies did agree in one area: Relying heavily on PSA tests can lead to unnecessary procedures with serious side effects such as incontinence, impotence, and bowel disturbances that may be worse than the disease they are attempting to cure – if it even exists in the first place.

Three Questions

The inconclusiveness of the studies keeps alive three important questions facing physicians and patients alike:

First, and most basically, should a PSA test be part of the prostate examination?

The answer, in my opinion, is “yes,” but the results should be considered in the context of important health history information, the patient’s age and life expectancy, and other tests. Many men may have had several PSA tests, and in such cases the trend of the PSA reading must also be considered: is it stable, or increasing, and if so, how fast? In some cases a biopsy of the prostate might be the next step.

This leads to the second question: If a biopsy is negative, but the PSA level continues to be high – and what constitutes “high” is itself debatable in the medical community – what do you do? Keep checking the PSA level? Have another biopsy? Go to another doctor?

Each patient needs to work with his doctor to find his own solution to this question, so it’s important to have a doctor who specializes in prostate health, usually a urologist, with an independent and open mind.

If a biopsy is done and comes back with an indication of prostate cancer, the third question then is: Do you treat it?

The answer to this question may seem obvious, but it’s not. There is a growing body of evidence that certain kinds of prostate cancer do not require active treatment because they are small, slow-growing, and unlikely to be fatal. In fact, it’s estimated that 85 percent of men diagnosed with prostate cancer each year in the United States will likely succumb to something other than this cancer.

Thus, for many, a period of watchful waiting, rather than instant and aggressive treatment, may be appropriate. This decision is based on patient- and cancer-specific factors.

For example, it does make a differences if only a single one or all of the biopsy cores are affected with the cancer, and, to what degree the samples are involved: just a little or in their entirety. This allows the physician to estimate the extent and size of the cancer in the prostate.

Further, how aggressive does the cancer look under the microscope? There is a grading system, and a grade of 3 is better than a grade of 4 or even 5. And even the same size and grade cancer may be treated differently depending on whether the patient is 55, 65, or 75 years old.

And – to complicate things even more – if the 65-year-old man has many other health issues such as diabetes, heart disease, hypertension, obesity versus if he is a picture of health!

Moving Forward

The controversies over PSA tests are likely to linger. But until clarity develops, men (and their spouses, partners, or other loved ones) can increase their odds of getting an accurate diagnosis and the most appropriate treatment by taking this important step: At each of the three decision points – whether to test; whether to follow-up with additional exploratory tests; whether to treat – see a doctor who is knowledgeable, but is not biased or predisposed toward certain procedures or courses of action.

In my view, academic research and medical centers such as UT Southwestern are well-suited to offer patients objective analysis and treatment. We do not have economic interests in the surgical and radiation facilities that treat our patients – those are owned by the State of Texas. And yet, we offer patients some of the most advanced facilities in the world, along with access to some of the finest medical minds available for diagnosis, consultation, and treatment.

Whomever you choose to address prostate issues, develop a relationship with your doctor. Discuss your medical test results with him or her. Keep follow-up appointments. And proceed on a course of treatment only if and when you and your urologist agree that the risk is justified.