Patient Handout: PSA Testing

I am sick of explaining PSA testing to my patients.  To get out of the inevitable questions about the pros, cons, science, and politics behind the new recommendations, I made the following handout.  Ironically, my laziness motivates me to do a whole bunch of stuff.  It kind of feels like I\’m being tricked into doing extra work, but there\’s nobody to blame.  I\’m just that way.  I guess I\’m a sucker that way.
Anyway, here it is.  Feel free to take advantage of my work to make your life easier.  I don\’t think there\’s any hope for me.

PSA Testing – Pro\’s and Cons

What is a PSA?  PSA is short for Prostate Specific Antigen and is a protein that is elevated in men who have prostate cancer.  PSA levels are tested using a blood test, and have up until recently been done yearly for all men over 50.  A “normal” PSA level is between 0 and 4, with numbers getting into the 100’s with prostate cancer.

What is the controversy about PSA testing?  The group of researchers and doctors who recommend testing have recently changed their recommendations.  In the past, all men over 50, and younger men with increased risk for prostate cancer were urged to get the test once a year.  This recommendation has been reversed, now only recommending PSA testing in men who either have had prostate cancer or who are at increased risk of developing it.

Why did they change this recommendation?  While PSA did reveal the presence of prostate cancer, studies have never reliably shown that average-risk men who get PSA tests live any longer than those who don’t.  This is especially true in men over age 65.

How could PSA not save lives if it helps find cancer?  There are several explanations for this:

  1. Prostate cancer is very slow-growing.  Studies of men in their 80’s revealed that a very high percentage of them had cancer in their prostate.  For older men it is now accepted that most men who get prostate cancer will die with it, not from it.
  2. Treatment for prostate cancer is not completely safe.  While some men were cured of prostate cancer by getting surgery and/or radiation, other men underwent these procedures, had long-term compilations, hospitalizations, and even death from the treatment.  When all of these were put together, the benefit of finding the cancer did not outweigh these negatives.
  3. Most elevated PSA tests are not because of cancer.

So how is prostate cancer diagnosed?  Unfortunately, there is no good test to screen for prostate cancer in average-risk men, just like there is no test to screen for brain tumors, pancreas cancer, or pneumonia.  Cancer is only diagnosed when it gets bad enough to give symptoms.

What are the symptoms of prostate cancer?  There are no consistent symptoms for prostate cancer.  Most symptoms from the prostate are from benign prostate enlargement (BPH), which doesn’t lead to cancer.

Should anyone get PSA testing?  Yes, men who have an increased risk (father or brother with prostate cancer) should still get it done yearly, as should men who have already had prostate cancer.  Most now agree that it’s not beneficial over age 65, but it is still controversial if average-risk men between 50 and 65 should be tested (urologists think so, but most researchers do not).

Why not just get tested “to be safe?”  A negative test is a good thing, and is reassuring that there is no cancer.  The problem is when the test is positive, as it really impossible to not aggressively treat it once it has been found.

Can men still get tested if they want?  Yes, but they should understand that doing so may lead them to get many procedures, surgery, radiation, and/or hospitalization, as well as side effects of treatment, such as impotence and incontinence.  All of these complications come without the assurance that they come with a longer life.  The bottom line is that we need a better test.

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I didn\’t say it in this handout, but I do have a theory as to who is behind the resistance to these recommendations:  it\’s the Lexus dealers and yacht manufacturers.  They have sold a bunch of cars and yachts to urologists on the income generated by PSA testing.  It makes sense.  It\’s all about the yachts.

8 thoughts on “Patient Handout: PSA Testing”

  1. I am torn on this because my father has a history of prostate cancer, but one that was discovered later in life. “Officially” I am at increased risk, so a positive test would have more likelihood to be a true positive, so for now I will still get them.

  2. What about getting the test and then deciding that I don’t want to do anything when I see an increase?  My PSA has always been below 1 and I’m 66.

  3. It’s something I wouldn’t personally do.  I generally feel that I have to act on information I have.  It gives a sense of “what if” should you go on to develop significant prostate cancer.  Once you look for something, there is an obligation (at least as a doctor) to act on it.  The suggestion is to not test PSA in the 1st place, not to ignore high ones.  It is, however, anyone’s right to forego further testing after a positive result.  Not testing will avoid a lose-lose situation

  4. I was more thinking about not doing anything if it went from .5 to 2.  I wouldn’t make the same decision if it went to 50.  But, I see what you mean.  It might be best just not to test.  Of course my PCP’s business will loose a little bit of money.  If I die early from an aggressive prostate cancer, I guess I’ll just have to accept it.  In any case it will probably be easier.

    What is the advise on the digital exam.  I wouldn’t mind eliminating that.  I do have BPH.

  5. I agree that 0.5 to 2.0 is just enough to make pause.  Still, not straightforward decision.  That’s the problem with this kind of test.  Regarding digital exam, I am pleased to say, from perspectives of both glover an glovee that there is no evidence of anything profitable coming out of this exam.  I have given it up.  BPH is only relevant as it causes symptoms, so a doctor feeling it and telling you what you already know is not worth it.

  6. Rob,I just skimmed through the official USPSTF recommendation again. Regarding screening for men with increased risk for prostate cancer (family hx and black patients), they say this:
    ” It is not known whether an alternative approach to screening and management of screen-detected disease could achieve the same or greater benefits while reducing the harms. Focusing screening on men at increased risk for prostate cancer mortality may improve the balance of benefits and harms, but existing studies do not allow conclusions about a greater absolute or relative benefit from screening in these populations.”
    and this:
    “Additional research is needed to determine whether the balance of benefits and harms of prostate cancer screening differs in men at higher risk of developing or dying of prostate cancer, including black men and those with a family history of the disease.”
    It seems that they do not make a distinction between high risk and normal risk regarding benefits and harms of screening.

  7. I’m a family doctor in MA. I’m so sick of the conversation as well. This is helpful! I will use it and credit you. Thank you!

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