A Urologist Makes the Case for PSA Testing
HealthReach, Fall 2012 | Page 5
Earlier this year, a U.S. Preventive Services Task Force issued a recommendation against the use of PSA testing as a screening measure for prostate cancer. We asked urologist Robert Mordkin, MD, FACS of Washington Urology about the value of PSA testing and what he recommends to his patients.
What is PSA?
PSA stands for prostate-specific antigen, a substance produced in the prostate. Elevated PSA levels may suggest the presence of prostate cancer; however, elevated levels do not always indicate cancer. PSA levels are determined through a simple blood test.
When should men have the PSA test?
For men who are not at increased risk for prostate cancer, the American Urology Association recommends baseline PSA screenings at 40 and 45, followed by annual screenings starting at age 50. Men with a family history of prostate cancer (father, grandfather, brother or uncle) should be screened every year starting at 40. The same recommendation goes for African American men, who are at higher risk for prostate cancer. Establishing a baseline early on is important, as each man’s “normal” PSA levels are different. Having annual PSA tests allows us to track PSA levels over time and note any changes that may indicate a need for further intervention.
Why is the PSA test controversial?
Some studies suggest that PSA testing may lead to unnecessary treatment in some patients. Urologists understand that the PSA test has its limitations, but value the opportunity for early detection that PSA may provide. Until better testing and treatments for prostate cancer are developed, the answer is not to do away with PSA testing altogether but rather to be balanced and cautious in who and how we screen, diagnose and treat.
How is prostate cancer treated?
Prostate cancer is typically slow growing. Many men will likely have some amount of cancer in the prostate if they live long enough. Fortunately, for the majority of these individuals, the cancer will remain non-life threatening. Every patient is unique, and there are many variables that factor into treatment decisions. Those include the size and aggressiveness of the cancer; the patient’s age, overall health status and family history; and the potential side effects. In many men, the recommendation actually should be to not treat the disease at all, but simply follow the cancer for some time to see if it will remain indolent rather than progress. This approach, which we call expectant management or watchful waiting, involves annual physical exams, repeat biopsies and ongoing monitoring of PSA levels, but no direct intervention. It allows patients to avoid the potential side effects from treatment for a disease that can often remain slow growing and nonlife threatening.
What are the possible side effects of treatment?
The side effects with the most impact on quality of life are the possibility of impotence and incontinence.
What is your concern with the recommendation of the U.S. Preventive Services Task Force?
As a physician who deals daily with both the side effects of treatment as well as the devastating late stages of prostate cancer, I fear that the Task Force recommendation will result in some men ignoring prostate disease until it is too late.
In your opinion, why is PSA testing important?
Prostate cancer continues to be the most commonly diagnosed non-skin malignancy in men—and it is the number two cancer killer of men in this country. Prior to the advent of PSA testing, the vast majority of men with prostate cancer were diagnosed only when they presented with widely metastatic disease into their bones, causing terrible pain and pathological fractures. PSA has dramatically reversed this trend, allowing for most men to be diagnosed years earlier than previously possible.
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