WHAT IS THE PSA TEST?

The PSA test measures the level of PSA in the blood and is the best tool currently available for detecting prostate cancer in its earliest—and most curable—stages. Prostate Specific Antigen (PSA) is a protein produced by the prostate gland. It functions to help liquefy semen after ejaculation. The elevated PSA that is detected in the blood with prostate cancer occurs because of a disruption of the cellular architecture of the prostate cells, the loss of which permits the leakage of PSA into the circulation.

USING THE PSA AS A CANCER MARKER

PSA is widely accepted as a marker for those who have prostate cancer. For prostate cancer patients, the PSA level is extremely helpful in monitoring its status. If the PSA level begins to rise, it may be the first sign of a recurrence. In fact, a rising PSA often precedes a clinical relapse by months or years. The problem with PSA as a cancer-screening tool is that although PSA can be elevated due to prostate cancer, benign prostate conditions can elevate it as well, including prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH, an enlargement of the prostate gland).

CONTROVERSY WITH PSA

The United States Preventive Services Task Force (USPSTF) counsels against the use of PSA testing in healthy men for the early detection of prostate cancer. They claim that the test does not save lives and leads to more tests and treatments that can cause pain, incontinence, and erectile dysfunction. The USPSTF is the same organization that advised women not to undergo routine mammography, which set off a blaze of controversy.

The USPTF’s proposals were met with great resistance by many cancer organizations, women, and physicians -- many of whom continue to ignore them. I, along with many other members of the American Urological Association, disagree with claims that the PSA test provides no clear benefits. Urologists, radiation oncologists, and medical oncologists (those physicians in the know who are in the “trenches” taking care of prostate cancer on an everyday basis) understand how devastating prostate cancer can be and the importance of early detection.

WHY IS PSA TESTING IMPORTANT?

PSA testing provides vital information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. It provides a great service to those who may benefit from early prostate cancer detection. Sadly, I believe the recommendations of the USPTF ultimately does more harm than good for the many men at risk for prostate cancer. I’ve practiced urology for more than 25 years, in addition to many years of residency and fellowship training. I’ve served as a physician in both the pre-PSA era and the post-PSA era.

In my early years of training at the University of Pennsylvania School of Medicine, it was not uncommon to be called to the emergency room to treat men who could not urinate (acute urinary retention). A digital rectal exam showed rock-hard prostate glands (a classic sign of prostate cancer) and imaging studies showing advanced prostate cancer involving the bones—metastatic prostate cancer with a grim prognosis. In the post-PSA era, that scenario—fortunately—occurs on an extremely infrequent basis thanks to PSA screening. The only men who do present that way these days are those who have not undergone PSA screening as part of their annual physical exams.

Annual screening with PSA and digital rectal exams has resulted in the detection of prostate cancer in early, curable stages before prostate cancer has an opportunity to spread and become incurable. I have little doubt that PSA testing saved my own father’s life. He underwent prostate surgery for cancer 17 years ago and is now a healthy, thriving and active 83-year-old. He had no symptoms or physical findings suggestive of cancer, only an elevated PSA that had accelerated from prior years.

Prostate cancer is a remarkably variable disease with every case being unique, literally as different as snowflakes. This demands that the treatment of prostate cancer be individualized. The challenge is to distinguish between clinically significant and clinically insignificant cancer and to decide the best means of managing clinically significant disease to maintain quantity and quality of life.

Not all prostate cancers require active treatment and not all prostate cancers are life threatening. If a diagnosis of prostate cancer is made, whether active treatment is necessary or whether active surveillance (watchful waiting) may be an option is an important decision that needs to be made.

THE FACTS ABOUT PSA TESTING

• 95% of male urologists and 80% of primary care physicians older than 50 have PSA screening—clearly those in the know feel that screening is beneficial.
• USA death rates from prostate cancer have fallen 4% annually since 1992, five years after introduction of PSA testing.
• Urologists do not screen or treat men who have a life expectancy of less than 10 years for the very reason that prostate cancer rarely causes mortality in the first decade after diagnosis and that other competing medical issues will cause death before the prostate cancer has a chance to.
• Prostate cancer is a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis.

WHAT YOU SHOULD DO:

1. Discuss with your doctor the pluses and minuses of PSA screening for prostate cancer.

2. PSA testing is certainly advisable if you are in good health and have a greater than 10-year life expectancy, especially if you have a family history of prostate cancer or are African American, both of which put you at higher risk.

3. Understand that PSA blood testing, aside from requiring a needle stick, has no side effects whatsoever, but provides useful information that can help make a decision whether or not to proceed with further testing, such as prostate biopsy.

4. Learn more about prostate health at The Private Gym.

Andrew Siegel, M.D., Urologist, Cofounder of The Private Gym, and author of the highly acclaimed book, Male Pelvic Fitness, Optimizing Your Sexual and Urinary Health.