The word cancer strikes at least some fear in everyone. One thing that makes cancer so intimidating is that there is still so much we do not know about it. As doctors and patients, we do not like the unknown. We like specific outlines and rules that tell us exactly what to do. Unfortunately, these guidelines are not always so clear cut when it comes to cancer. This is especially the case with prostate cancer.
Although it seems like it should make cancer seem less frightening, cancer screening sometimes can make things seem even more intimidating. Patients often hear different opinions on certain cancer screenings and are often unsure if they are doing all that they can do to detect cancer early.
Unfortunately, with prostate cancer the guidelines and screening protocols seem to be ever-changing. While this means that more knowledge about the disease is being obtained (which is a good thing), it also makes it difficult for patients and even doctors to stay up to date (not so good). This is especially true when it comes to the use of Prostate Specific Antigen, known widely as “PSA.”
PSA is a protein released by the prostate gland into the bloodstream. Although all men have PSA, an abnormally high PSA level may indicate prostate cancer. However, it can also be elevated because of non-cancerous causes such as prostatitis or an enlarged prostate. It is also common for PSA to gradually become more elevated as men get older. Therefore, unlike most labs, there is not a clear cut “normal range.” You must include multiple factors such as patient age and other health history to decide if a PSA level is a concern regarding possible prostate cancer. So, a lot of people wonder, “why can’t there be a better test to screen for prostate cancer?” The answer is, “We’re working on it.” Although there are new tests that may be more specific towards prostate cancer, they either require more research or they are too expensive to use for mass screening.
PSA has been used for prostate cancer screening since 1994. Although widely used, urologists early on were still trying to figure out which patient populations it most benefitted and the ranges where the PSA level should be considered as “high” or “normal.” These urologists potentially erred on the side of conservatism and in these early years there may have been too many people getting screened and determinations of a “high” PSA level that may have led to unnecessary biopsies and potentially even cancer treatment in some patients. Since prostate cancer is often a slow-growing disease, people with shorter life expectancies often do not benefit from screening or treatment. This led to some of the initial research questioning the overall benefit of PSA screening. In reviewing some of this research the U.S. Preventive Services Task Force a few years ago actually did not recommend PSA screening. Urologists strongly disagreed as they felt the data the task force used was already out dated and new research showed that in the proper demographics, PSA screening was very beneficial.
Fortunately, with the encouragement of multiple health agencies including the American Urologic Association, the USPSTF reviewed newer research and realized that PSA screening could be very beneficial in certain demographics. They recommended screening for men ages 55-69. They also felt that African American men and men with a family history of prostate cancer are at an increased risk of developing prostate cancer and should discuss the possibility of even earlier PSA screening. The USPSTF felt there was more limited evidence in the over age 70 demographics, but agree that many older men will not benefit from the test, except in selected healthy older men with a long life expectancy.
I consider many factors when determining the appropriateness of a PSA. It is a shared decision with the patient and I explain some of the weakness with PSA screening. In general, I recommend annual screening for patients who are in their 50s and 60s.
In higher-risk patients, specifically those of African-American heritage or those with a family history, there is good data that they may benefit from an earlier screening protocol, possibly as early as age 45.
PSA screening is just the beginning. When PSA is elevated you must make the decision of whether you want to do a prostate biopsy. Depending on how aggressive the disease looks under the microscope you may be able to simply keep an eye on it, while on the opposite spectrum you may get results that confirm the cancer is aggressive and may have already spread.
I feel that there is more shared decisionmaking between patients and urologists when it comes to prostate cancer relative to most other cancers. There are many questions to be answered along the way, such as: “When to screen?” “When to perform a prostate biopsy?” “When to watch and when to treat?” “What treatment options are there?” Many of these answers depend on patients’ goals, priorities and life expectancy.
Nothing about prostate cancer is straightforward. Shared decision making is important throughout the entire process. I do feel that from a PSA screening standpoint, all men in their 50s and 60s should be getting annual screening. If you are extremely healthy you may continue screening into your 70s. If you are at higher risk you may consider as early as age 45. The digital rectal exam should be used as a supplement to PSA screening, especially in equivocal cases looking for nodules.
Not all prostate cancers are the same. Some may not need to be treated. Some may need aggressive treatment, but be assured that with technology like robotic surgery and IMRT (intensity-modulated radiotherapy, a type of radiation treatment), treatment has become significantly better with less side effects.
At the end of the day, we hope to screen the appropriate people and treat the appropriate people to prevent advanced metastatic disease that is lethal. I feel that if patients and doctors stick to the newest recommended guidelines that the number of men dying of advance prostate cancer will decrease significantly. That is why until an even better test comes along, I am strongly advocating for appropriate PSA screening.