Now that the government panels and medical associations no longer recommend PSA testing, consider this: in the 1980s, before PSA testing, 50,000 men died annually from prostate cancer. In the 1990s, with PSA testing, 30,000 died annually. PSA testing saved 20,000 men each year (about 25,000 now) from slow, painful deaths from prostate cancer. And they are telling us to stop doing this test?
Prostate cancer is the second leading cause of cancer death in men. PSA testing, which measures the level of prostate-specific antigen in the blood, is our only reliable early-warning method. A PSA level above 4 ng/ml is considered high and may be a sign of prostate cancer. The problem is, PSA is nonspecific. Yet doctors often rush men with an elevated PSA to prostate biopsy. If the biopsy shows cancer, even a low-grade one, many doctors recommend aggressive surgery or radiation, with their serious long-term side effects, even when treatment isn’t really needed.
Consider: 50,000 prostatectomies are performed each year for prostate cancer, yet 40,000 of these surgeries are unnecessary. The numbers are similar for radiation therapy.
This is why mainstream medicine has retreated from routine PSA testing. Retreating into the past, meaning 25,000 additional prostate cancer deaths a year, isn’t the answer. Here is what you can do to protect yourself from undiagnosed prostate cancer as well as from overzealous doctors recommending unnecessary treatment.
1. Men over 50 should continue to get annual PSA testing. Men at greatest risk are African-Americans or those with a blood relative with prostate cancer. Begin PSA testing at 40.
2. Always get a repeat PSA. An elevated PSA does not always mean prostate cancer. Common causes of elevated PSA include an enlarged prostate or prostate infection. Orgasm within 48 hours before PSA testing can cause an elevated result. So can pressure on the prostate caused by biking or an exercise bike. Laboratory error can occur. Many doctors aren’t aware of these factors.
3. Make sure you really need a biopsy. Biopsies are important to verify that you actually have prostate cancer and to identify the aggressiveness. However, of the 1.2 million biopsies done annually in the US, half aren’t necessary. And biopsies can cause problems: 4 percent of men biopsied require hospitalization for infection or bleeding.
4. Learn about new technologies, which can help you avoid a biopsy you don’t need. The multiparametric, 3.0 Tesla MRI, now available at a handful of top medical centers, can identify suspicious areas that might warrant a biopsy. If none exist, a biopsy can be avoided. Some institutions are now using MRI to direct biopsy needles, providing a “targeted biopsy,” far more accurate than the random biopsies we do now. Color doppler ultrasound is another technique that can see into the prostate. A couple dozen doctors in the US use this method to identify areas of concern and to guide biopsy needles.
5. Educate yourself on new treatments. These diagnostic methods facilitate a spectrum of new treatments. Previously, our choices were to cut out or fry the entire prostate, or just wait and see. Now, with MRI guidance, new treatments such as cryosurgery (freezing), high-intensity focused ultrasound (heat), and focal laser ablation can be used to remove half of the prostate or to perform local treatment, like the lumpectomy some women get for localized breast cancer. The new tests also make active surveillance an effective and attractive choice for some men.
Rather than retreating from PSA testing and causing 25,000 additional deaths from prostate cancer each year, we can keep PSA testing for early warning — and also apply the new technologies we already have to avoid biopsies, surgery, and radiation treatment when they are not really needed.
By Jay S. Cohen MD