To Test or Not to Test: The PSA and You

Editor’s Note: Dr. Sean Cavanaugh is Director of the Genitourinary Center for Advanced Oncology at the Atlanta-area location of Cancer Treatment Centers of America®.  The opinions are those of the author and they appear in our newsletter as an educational resource for readers.

For men seeking clarity on whether to undergo routine prostate cancer screening, two recent studies in the Journal of the American Medical Association (JAMA) may raise new questions.  Since 2012, there has been a drop in the routine use of the blood test known as the PSA, short for prostate-specific antigen, according to the studies published on Nov. 17, 2015.  Meanwhile, fewer prostate cancers are being diagnosed.  The changes come after the U.S. Preventive Services Task Force gave the PSA test its lowest grade, arguing that its use contributed to over-treatment in men without a family history or elevated prostate cancer risk.

I remind men that the routine testing recommendations haven’t changed for people at higher risk.  That includes African American men, who are 60 percent more likely to get prostate cancer and 2.5 times more likely to die of the disease than white men.  It’s important to make sure that African American men are routinely getting screened.  However, there is more to the story.

Three key groups, The American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN) and the American Urological Association, have urged family physicians to discuss the value and risks of routine testing with all male patients, taking into consideration their unique medical history.  I agree. Our advice to the community is no change for anyone at elevated risk.  In fact, for those patients at normal or low risk should have a discussion with their primary care doctor about what level of PSA screening is appropriate for them.

Although cancer of the prostate gland is common, striking 1 in 6 men in their lifetime, the majority of tumors grow slowly and cause no symptoms.  Simply waiting for symptoms to develop isn’t an optimal approach for early detection, doctors say.  Difficulty urinating, painful ejaculation or blood in semen may not appear until the cancer has progressed into the later stages.  That’s why oncologists value the PSA test.  When considered along with medical history and a biopsy if warranted, the screens can identify a tumor and its likely course early, when it’s easier to treat.

“In the old days, the first symptom would be bone pain for probably the majority of men,” explains Dr. Christian Hyde, Radiation Oncologist at our Georgia hospital.  “If prostate cancer spreads, it will often spread to the bones.  And this can show up as a dull, aching pain that is often worse toward the end of the day and is relieved by rest.  It requires aggressive treatment, often in the form of chemotherapy and hormone therapy and radiation.”

One of the JAMA reports, led by Ahmedin Jemal of ACS in Atlanta, found prostate screening rates fell 18 percent from 2010 to 2013 among men 50 and older.  The number of diagnoses fell, too.  In 2012, 180,043 men were diagnosed with prostate cancer—16 percent fewer than the year before.  The other JAMA report, led by Dr. Jesse D. Sammon, found that prostate cancer screenings fell most sharply in men under 75, especially in those between 60 and 64.

A separate study, by Matthew David Hall and colleagues, found that the proportion of men diagnosed with intermediate- and high-risk prostate cancers grew by 3 percent each year between 2011 and 2013.  That means about 14,000 additional men out of 233,000 newly diagnosed heard their cancer was more advanced.

Catching aggressive prostate cancer early can improve the chances of beating it.  The five-year survival rate for localized and regional prostate cancer is nearly 100 percent, for example, but that rate falls to 28 percent once the cancer has spread to the bones and lymph nodes.  Scientists are watching to see whether the task force’s recommendation against routine testing could eventually affect survival rates.

What is the takeaway for men who have concerns?  Individualized health care is good health care.  This is something to talk about.  If you have a good physician and a good health care team, then you can be confident that the decision you reach is the right one for you.

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