My brother-in-law was seemingly the healthiest person we knew. He hikes up and down steep hills as part of his daily work. He kayaks intense oceans as part of his weekend play. He never even gets a cold. So he rarely sees a doctor. Luckily he did finally go for a general checkup when he turned 50, and those simple blood tests saved his life. Turned out, he had aggressive prostate cancer. Standard screening, to find prostate cancer in people who do not have symptoms, allowed him to be treated in time.
Against a backdrop of uncertainty and controversy, the American Cancer Society recently updated their prostate screening guidelines for the first time in almost a decade. This was largely in response to the findings of a massive federal study that was published in the New England Journal of Medicine last year. This study evaluated the usefulness of a popular prostate screening test that measures the amount of prostate-specific antigen (PSA) in your blood. Basically, PSA is a protein produced by the prostate gland. PSA is present in small quantities for normal men, but it is generally elevated for men with prostate cancer or other prostate disorders.
Some recent news coverage sensationalized the results of this federal study, so here are the basics of the report. The research findings are based on 10 years of follow-up of nearly 77,000 men (ages 55-74). Half of the men received annual PSA tests for six years, and the other half received “usual care” from their own doctors (physicals that in some cases included PSA tests). After 10 years, the men that received annual screening were diagnosed with prostate cancer 17 percent more than those in the “usual care” group. However, the screening didn’t reduce the rate of death from the disease. (Various possible and plausible explanations are discussed in the report, but I’m not going to get into the gory details here.) This brings into question whether the PSA test should be used for general screening, because prostate cancer over-diagnosis leads to unnecessary treatment and potential lasting side effects such as impotence and incontinence.
So, what is a man to do? Since I work in the area of prostate cancer research, friends and family members have been asking my opinion on whether or not they should be regularly checked for prostate cancer.
To me, it seems like these new screening guidelines assume that ignorance is less stressful than having faith in your doctor. Namely, it is better to not even perform a simple PSA blood test, because patients with low PSA levels are often over-treated. I understand the issues that they are addressing, but I think the reasoning is somewhat flawed. Why not instead just change how you treat patients with low PSA levels? Such PSA test results would indicate that you probably have some non-aggressive cancer cells in your prostate but they are unlikely to harm you. Scary yes, but so are impotence and incontinence treatment side effects. So why not just repeat the blood test in 6 months or a year to see if PSA levels have risen? Is this common practice of “watchful waiting” by your doctor really more stressful than not having the blood test at all? Because, for some, that simple blood test could also indicate that you have aggressive prostate cancer that needs immediate treatment.
Based on my personal and professional experience, I recommend that men get at least one initial PSA test when they are in their early 40’s. Doctors can use this as an important baseline in the future. This agrees with the American Urological Association’s guidelines. However, I am not a medical physician and some men have higher risk for prostate cancer, so it is important to speak about your health and concerns with your physician