The PSA test is a bit like Winona Ryder these days.
They’re both early ’90s icons whose most influential days are quite likely behind them, although we can all agree they’ve earned rightful places in their industries.
They just aren’t getting the respect they deserve.
When the medical industry began using the PSA test in earnest 25 years ago, it was heralded as a game-changer in the early detection of prostate cancer.
Pre-PSA days, a fella perturbed about his prostate could only undergo a physical exam wherein a doctor inserts a gloved, lubricated finger into the anus, feeling around for abnormalities on the prostate gland. It’s somewhat effective, and entirely unpleasant.
“If the doctor felt an abnormal nodule, that’s what you’d be worried about,” said Brian Lane, MD, PhD, a Spectrum Health Medical Group urologist.
The digital rectal exam remains an option, but over the years the PSA test has become the preferred tool to detect possible prostate cancer. It’s an important tool, too, given that 15% of men will be diagnosed with the disease at some point in their lives.
Statistics over the past two decades tell of the test’s contribution to the battle.
In 1993, the mortality rate from prostate cancer peaked at about 39 deaths per 100,000 men, according to the National Cancer Institute’s Surveillance, Epidemiology and End Results program. In 2011, 21 in 100,000 men died from the disease.
Also beginning in the 1990s, doctors began diagnosing more cases than ever before.
This isn’t necessarily always a good thing because it can lead to overtreatment—nearly everyone agrees it did—but it’s not wholly bad, either, as it can also lead to life-saving treatment.
“Finding a test that could predict the likelihood of cancer was a huge thing when it was found more than 20 years ago,” Dr. Lane said. “It’s not the best test, but at the time it was a great one. Now we’re left with an imperfect test that everybody uses.”
And, Dr. Lane said, we’re left with this all-important question: “What do you do with the results?”
Test the test
Fundamentally, the test involves a doctor measuring the PSA level in a man’s blood. If the reading is low—anything at or below 1 nanogram per milliliter—the patient is in good shape and annual screening might be overkill. For slightly higher values of 1 to 3 nanograms per milliliter, a screening every other year is Spectrum Health’s recommendation.
“If the PSA is high, that’s where things get interesting,” Dr. Lane said. “Different physicians will make different recommendations.”
The next thing that could happen in all this: A physician sees a high reading and immediately orders a biopsy. But what is a high reading? A PSA above 3? A reading between 4 and 8? Greater than 10?
A man’s PSA level can be 10, 20, 50, or even 100 nanograms per milliliter or greater.
“If you have over 100, you’ve likely got cancer,” Dr. Lane said.
“A biopsy is the only way to know for sure if you have cancer,” Dr. Lane said, “but there are about five other things you can do before doing a biopsy to estimate your risk.”
For starters, retest the PSA level in the blood.
“With a single high value, what are the chances of a lab error?” Dr. Lane said. “A value that’s high today might be low tomorrow. So repeat the test. It’s not rocket science, but not every provider does that.”
About 50% of patients will see a high reading normalize after a second blood test.
Even so, “Not everyone who has high PSA readings has cancer,” Dr. Lane said. “About 30 to 50% do, and 50 to 70% don’t.”
How to winnow out the false-positives, or even the false-negatives? Additional tests, which take into account PSA levels and adjunct elements, such as a man’s prior PSA readings or the size of his prostate, can help.
“We most commonly use the PHI test, which can give a more accurate percent that a prostate biopsy will reveal cancer in a given man,” Dr. Lane said, “but there are other commercially-available tests as well.”
The right steps
The reality is, a high PSA reading can lead to procedures that in some cases do more harm than good, such as a biopsy, Dr. Lane said. It’s incumbent on a man and his doctor to decide what to do with information gleaned from a blood test.
“The concern is the biopsy,” Dr. Lane said. “If you’re going to biopsy everybody, you’re going to expose them unnecessarily to that risk.”
To illustrate: If a biopsy is performed on 100 men who have high PSA readings, 50 of them may learn they’re cancer-free, one of them may see complications from the biopsy, and the remaining 49 may find out they have cancer.
“Take your 49 who have cancer,” Dr. Lane said. “Have you done them good or harm? I’d say you’ve done them good, especially if you have counseled them appropriately about the risks of treatment and surveillance.”
Some would disagree.
“Some people will say those 49 guys who have prostate cancer, you may have hurt them because they can get complications from the treatment,” Dr. Lane said.
Surgery can adversely affect urinary and sexual function, and radiation can impact bodily functions as well.
“That’s where the controversy is,” Dr. Lane said. “The controversy over PSA is really a controversy about prostate cancer care. Who should be getting treated and who might be better served without rushing into a treatment decision they might later regret.”
Active surveillance is a safe approach for many men who have only favorable-risk prostate cancer.
He emphasized this: “The concerns about PSA should be minimized. We can use the test better, if we make sure to advise those who are found to have cancer that both surveillance and treatment are options.”
Men are increasingly opting for active surveillance, according to a study by the Michigan Urological Surgery Improvement Collaborative (MUSIC), of which Spectrum Health Medical Group is a participant. The MUSIC program is also working to identify better ways to reduce infections resulting from prostate biopsies.
Given the host of variables, meanwhile, it’s not difficult to see why the PSA test has drawn scrutiny from medical and scientific organizations that, in recent years, have been drastically altering their recommendations on the PSA test.
Some organizations no longer recommend routine screening for all men, although the bulk of these organizations do not advocate for a complete abolition of the PSA test.
Up until recently, the doom and gloom came from the U.S. Preventive Task Force, which six years ago issued a blanket statement that men should not undergo the PSA test.
In spring 2017, however, the U.S. Preventive Task Force eased up on that stance and instead issued a draft ruling that said, in effect, much of what Dr. Lane and his colleagues have been saying: A man and his doctor should discuss the potential benefits and risks of PSA screening for prostate cancer before making a decision.
“Any discussion that ‘PSA is bad, we should stop testing PSA,’ is overly simplistic,” Dr. Lane said. “Prostate cancer deaths continue to fall year after year, and PSA has much to do with it.”
Who, when, what?
Rather than asking if the PSA test is still useful, it’s better to ask: Who should get the PSA test, and when?
The answer? Men at elevated risk for prostate cancer, which include African-Americans and those with a family history of the disease.
“These two groups are at greater lifetime risk of prostate cancer,” Dr. Lane said.
Beyond that, a man should explore his options with his doctor.
“My thought is you have it fit in with the rest of your health care behavior,” Dr. Lane said. “If you exercise three days a week, eat healthy, watch your blood pressure, and manage diabetes well, then you are the kind of guy who’s saying, ‘Check my PSA, I want to do everything possible.’”
Men younger than 40 should not get the test, according to the American Cancer Society.
For those older than 40, it’s truly a bit of a paradox: Physicians prefer to test in healthier men and simply forego testing in unhealthy men or the elderly.
For those with limited life expectancy, “the chance that a man will die of anything other than prostate cancer is much higher,” Dr. Lane said.
If a man in his late 70s has heart disease, kidney disease or lung disease, for instance, he’s far more likely to die of those than of prostate cancer, Dr. Lane said. A very small percentage of men will actually die of prostate cancer.
“For men in their 80s, I would never recommend PSA screenings,” Dr. Lane said. “It would be pointless to test unless they have clinical concerns.”
What should you do with an abnormal PSA reading? Consult your doctor and educate yourself on your many options.
“Use the test more wisely, rather than abandon it completely,” Dr. Lane said. “Uniform testing is what’s gotten us into trouble.”