Prostate Cancer and PSA Scree... Health Article

If you could find a screening test able to detect a potentially deadly cancer, it would be hailed as a lifesaver and widely recommended, wouldn’t it? Not necessarily. The fact that the prostate-specific antigen (PSA) blood test detects prostate cancer in its early stages is undisputed. But whether it should be used as a routine screening tool is one of the most controversial issues in men’s health today.

The prostate is a walnut-sized gland located under the bladder and next to the rectum. It provides about a third of the fluid that propels sperm through the urethra and out of the penis during sex. According to the American Cancer Society, more than 215,000 American men are diagnosed with prostate cancer ieach year. That makes it the second most common cancer in men. About 27,000 men die of the disease annually, which ranks prostate cancer second only to lung cancer in cancer deaths among American men.

PSA is a protein made by the prostate cells. The PSA test measures the amount of PSA in the blood.

PSA screening has revolutionized the way doctors diagnose prostate cancer over the past decade. The PSA test can find prostate cancer earlier than the digital rectal exam, the other major test for the disease. Because of the popularity of the PSA test, the number of men diagnosed with prostate cancer has climbed dramatically, but experts disagree about whether this is beneficial.

Here’s an overview of the controversy. Prostate cancer usually grows slowly and most often affects the elderly. This means that detecting it early may not necessarily lead to a longer life. Many men will die years later of other causes, often without ever even realizing they had prostate cancer. That fact can make it difficult to choose treatment, which has side effects that include impotence, incontinence, or both. The problem is that there is no foolproof way to know if a man will suffer from the prostate cancer or not.

How Doctors Use the PSA to Find Prostate Cancer

A doctor may consider the level of PSA, how the levels change over time, and your age in deciding whether to recommend a biopsy. A biopsy is the removal of a small amount of prostate tissue. If the biopsy tests positive for cancer, the tissue is evaluated to determine how advanced the cancer is, how likely it is to spread, and which treatment is best. Although these tests provide a great deal of information, none available today can provide a definitive answer on how likely it is that a particular cancer will spread in a particular person.

For use as a screening tool, the PSA test has drawbacks. First, the test is not always accurate. It fails to find prostate cancer in 1 out of 4 men who have the disease. Plus, not all prostate cancers cause the PSA to increase. Third, higher than average results usually trigger follow-up testing and biopsies. But two-thirds of the results turn out not to be cancer. Most often, the high PSA level is due to noncancerous conditions that are common in older men. These conditions include benign prostatic enlargement (BPH) and prostatitis, an inflammation of the prostate. Because of these varied results, the test doesn’t mean a clean bill of health if it’s negative and can often cause concern if it’s positive.

What Experts Say About the PSA Test

“I have sat in a conference of cancer specialists where there has been heated debate, and afterwards a poll was taken on who would want to be screened, and the room was divided,” says Harmon Eyre, MD, chief medical officer for the American Cancer Society.

Most scientific and medical organizations such as the U.S. Preventive Services Task Force, the American College of Physicians, the National Cancer Institute, the Centers for Disease Control and Prevention, the American Association of Family Practitioners, and the American College of Preventive Medicine do not recommend routine screening for all men.

However, the American Cancer Society, the American Urological Association, and the National Comprehensive Cancer Network (NCCN) all recommend screening. The NCCN’s guidelines are the most specific. They recommend that screening be offered beginning at age 50 to men who have at least a 10-year life expectancy, and that it be offered earlier, possibly at age 45, to men with risk factors for prostate cancer.

William Catalona, MD, a professor of urology at Northwest University in Chicago, who pioneered PSA testing, believes screening should begin routinely at age 50 and be offered to men age 30 and older who have a very strong family history of the disease.

“Prostate cancer is the second leading cause of cancer death in men. And one of the main problems is detecting it too late. I would rather do a few more unnecessary biopsies to save lives,” he says.

Steven Woolf, MD, MPH, a professor of family practice at Virginia Commonwealth Universityin Fairfax and a science advisor to the US Preventative Services Task Force, disagrees.

"If treatment saves a man’s life, it’s justified. But what if the patient wasn’t going to suffer any health problems and ends up with permanent complications that affect his sexual and urinary function?”

Those in favor of regular PSA testing note that the mortality rate for prostate cancer is declining. Those against it say there is no hard evidence to attribute this to PSAscreening.

To learn if screening is saving lives, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial is underway, but results won’t be available until 2007.

How to Decide If You Should Get a PSA Test

If you’re deciding whether to have PSA screening, weigh your feelings about having the test with how you feel about the possible consequences of treatment. Don’t overlook the fact that PSAscreening is done to find prostate cancer before symptoms develop. If you have any of these symptoms, you should see your doctor.

• A change in your regular urination pattern

• Blood in your urine

• Impotence

• Pain in your pelvis, spine, hips, or ribs

These symptoms may also be present with noncancerous diseases and should be checked by a doctor.

Also weigh your risk factors to decide whether to have PSA screening. These are the risk factors for prostate cancer.

• Age. The rate of prostate cancer rises in older men. Bear in mind, though, that this doesn’t mean younger men are immune. In fact, the cancer may be more aggressive in younger men.

• Race. Men of all races must be concerned about prostate cancer, but African Americans have higher rates. And Asian men have a lower-than-average risk.

• Family history. Prostate cancer tends to run in families. Fathers, sons, and brothers of patients have twice the risk of men with no affected relatives. Men with 3 affected relatives face a risk almost 11 times greater than average. Men whose female relatives have a high incidence of breast cancer may have a higher-than-average risk of developing the disease.

How to Get the Best Results If You Get a PSA

Most PSA tests measure total PSA, which is the amount that is bound to blood proteins. In March 1998, the U.S. Food and Drug Administration (FDA) approved the free PSA test. It gives a ratio of PSA found free-floating in the blood to that which is bound with protein. Comparing results from the 2 tests helps doctors rule out cancer in men whose PSA is mildly elevated due to other causes. A 1995 study in the Journal of the American Medical Association showed that the free PSA test could reduce unnecessary prostate biopsies by 20% in men with a borderline PSA level between 4 and 10.¹ If you have a borderline PSA, you should ask your doctor about this test. Research is also being done on other ways to make the PSA test more accurate and to find other types of blood markers that could be used.

To improve the accuracy of the PSA test, many doctors recommend that men abstain from sex for 2 days before the test. Also, tell your doctor if you are taking any of these drugs, as they may affect test results.

• Proscar or Propecia (finasteride)

• Saw palmetto, an herb used by some men to treat benign prostatic enlargement

• PC-SPES, an herbal mixture containing saw palmetto

In the absence of universal agreement on screening guidelines, a man should weigh his personal views and discuss these with his doctor.