PSA Screening—The Controversy?

PSA, prostate specific antigen, is a screening test for prostate cancer which detects the level of PSA in the bloodstream.  PSA is a serum protease (an enzyme), that helps in the liquefaction of semen.  A normal PSA for somebody 70 years or less of age is 2.5 ng/dl.  A PSA higher than that, in this age group, carries a 25 to 30 percent risk of prostate cancer.   Additionally, a man’s PSA can be screened and followed up over time, as a rising PSA elevates the risk of prostate cancer.  A man’s PSA can be elevated due to other conditions as well, such as benign enlargement of the prostate, inflammation of the prostate or urinary retention.  Although it is not a perfect test, it has greatly increased the detection of prostate cancer and lowered mortality due to the disease.

On May 21, 2012 the U.S. Preventive Services Task Force (USPSTF) released a recommendation against prostate-specific antigen (PSA) testing.  As stated earlier, PSA testing is used for the early detection of prostate cancer; it involves a simple blood test to measure the level of a prostate specific protein in the bloodstream.  When elevated, PSA tests can help identify prostate cancers while they are localized within the prostate and thereby still curable.  The USPSTF recommendation was in part influenced by European studies that suggested that prostate cancer caught by PSA testing was overtreated. These studies have been strongly criticized as they do not represent the screening patterns or populations of the United States. Nevertheless, the USPSTF recommendation carries great significance and could lead to PSA testing no longer being a covered benefit for Medicare beneficiaries.

Numerous patient and physician organizations have spoken out against the recommendation including the American Urologic Association (AUA). The AUA asserts that the PSA test “provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients. But not all prostate cancers are life-threatening. The decision to proceed to active treatment or use surveillance for a patient’s prostate cancer is one that men should discuss in detail with their urologists.”[1]  The use of surveillance has become much more common, in an attempt to treat only those cancers that are life-threatening.  The AUA asserts that the recommendation is a great disservice to men around the country, particularly those with a higher risk of the disease (i.e., African American men, those with a family history of the disease, those who are underinsured and those who live in rural areas with limited healthcare access). If such individuals are denied the opportunity for prostate cancer screening with PSA testing, many fear that prostate cancer mortality rates will skyrocket. Presently prostate cancer is the most commonly diagnosed cancer of men in American and the second leading cause of cancer death among American men. 

Patient advocacy groups argue that the decision to be tested for prostate cancer is an individual decision; one that men should discuss with their physicians. These organizations profess that PSA testing provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. In the absence of a suitable alternative for prostate cancer screening, these organizations contend that eliminating PSA testing would risk a return to the prostate cancer death rates of the 1980′s. Following that era, mortality rates from prostate cancer dropped by 40%, a reduction attributed to the institution of PSA testing.  Drs. Thomas Hildreth, James Hendricks and Herkanwal Khaira of Napa Valley Urology Associates (NVUA) issued a statement in response to the USPSTF recommendation earlier this year.  The Urologists at NVUA stressed that early detection of cancer has been a mainstay of modern medicine, and that although PSA testing is imperfect, its elimination would create a tremendous void in the early detection of prostate cancer.  They encourage patients to speak up both to their physicians and congressmen as to their feelings regarding prostate cancer screening.

Written and Edited By: Harjit Khaira, Dr. James Hendricks, Dr. Herkanwal Khaira, and Dr. Thomas Hildreth