No convincing evidence PSA test saves lives in men over 50

As a physician who began practicing medicine before the advent of the PSA (prostatic specific antigen) test, as it became available I was delighted to find that there was now a test offered that could aid in the early diagnosis and treatment of prostate cancer and help save the lives of my male patients who were destined to develop prostate cancer.

It was not long before national authoritative groups began issuing guidelines for physicians to follow in screening their male patients for prostate cancer. Entities such as the American Urological Association and the United States Preventative Services Task Force recommended screening all males age 50 or more for prostate cancer with the PSA blood test annually. This was based on the premise that if we had a test that could help us find prostate cancer early, then we could provide aggressive therapy for the cancer at an early stage and prevent the patient from dying of prostate cancer.

This aggressive treatment included surgically removing the prostate gland itself, or radiation therapy (including brachytherapy with radioactive “seeds”) or hormone suppressive therapy. This recommendation for such screening was issued with similar conviction for the benefit of the patient as that for mammography in women for breast cancer screening.

The United States preventative services task force has issued updated guidelines as of October 2011 and after further review of the scientific evidence regarding the benefits of the PSA test used to screen for prostate cancer, the newest recommendation is not to use the PSA test for the routine screening of men at any risk for prostate cancer without physician – patient discussion as to its limitations.

This surprising about-face of recommendations is due to a number of factors that include the biological activity of prostate cancer itself. It is a slow growing cancer found in many men who die from other causes but who never knew they had prostate cancer.

The aggressive therapies described above have many side effects including erectile dysfunction, bowel and bladder incontinence as well as surgical complications themselves. Radiation therapy can cause severe inflammation and scarring of the surrounding tissues near the prostate and rectum and can cause its own complications. Biopsies of the prostate performed as additional investigations for an elevated PSA test can cause life-threatening infections or bleeding.

The scientific studies have indicated that aggressively treating or removing this type of cancer did not convincingly prolong or improve the life of the majority of these men who were found to have prostate cancer by use of the PSA screening test. The PSA test was helpful in finding cases of prostate cancer but interventions undertaken as a result of the elevated PSA were not convincingly benefiting the patient and as a result of this type of screening, patient harm was occurring.

What to do now? The PSA test still has its uses but physicians should not order the test for prostate cancer screening without first having a thorough discussion of the implications and limitations of this test with the patient being screened (shared decision making). There are many men who would still want to have the PSA test perhaps because of family history or a close friend who has developed prostate cancer and prefer an aggressive approach to prostate cancer screening and treatment despite the risks and limitations.

The take home message is do not let your physician order a PSA test on you for prostate cancer screening until after discussing with you these new guidelines.