Dr. Nordquist’s Prostate Cancer Screening Recommendations:
- Discuss PSA & Prostate Cancer Screening with a physician knowledgeable in Prostate Cancer
- African American men or men with a family history of prostate cancer should obtain a baseline PSA between age 35-40 and consider yearly PSA and DRE (digital rectal exam)
- ALL other men who have at least 10 years of expected life remaining should consider a yearly PSA and DRE
- “normal” PSA values (<4 ng/ml) may still be concerning for cancer if there is a significant change from the prior year’s PSA value
- Concerning PSA results may be further evaluated with a repeat PSA, a “free PSA”, or an MRI
- Not all men diagnosed with prostate cancer require treatment. Discuss ALL of your options with a Prostate Cancer Expert
Prostate Cancer Screening: Let’s Simplify the Controversy:
- Prior to the PSA test being available in the 1990’s, 80% of men who were found to have prostate cancer after it had already spread and was not curable.
- After the PSA screening was offered, 85% of prostate cancers were detected in men that were still confined to the prostate gland and potentially curable.
- To repeat: we went from 80% of men being non-curable to 85% of men being potentially curable through the use of an inexpensive blood test!
Does PSA screening detect prostate cancer earlier and save lives. The answer may seem obviously “YES”, but some experts disagree. For several years there has been significant controversy regarding the PSA blood test and screening for prostate cancer. In 2012 the USPSTF (a government appointed “expert” panel which did not include a urologist or oncologist) which gave PSA Screening a grade D (which means they discourage men from getting PSA screening at any age). More recently the same panel revised their recommendation to a grade C for men aged 55-69 (which means PSA screening may be advised for selected patients depending on individual circumstances) and remains grade D for all other men less than age 55 and older than 70 years of age. This led to an unprecedented number of primary care physicians to stop checking PSA values in men. If you don’t screen for a cancer it doesn’t make it go away you just catch it late after it has spread. Prior to the USPSTF recommendations I used to see only few men a year who had prostate cancer spread at the time of diagnosis. Since the USPSTF recommendations I now see several men a month with prostate cancer which is non-curable. All we did is went back to pre 1990 medicine.
WHY PSA GOT A BAD RAP:
Think of the PSA as a fire detector. It has one job pick up fire. It does a good job at it. If there is a fire it will go off. However other things can also set off the detector that aren’t fire such as dust in the air. So the PSA is the detector, it has one job to pick up prostate cancer. It does a good job. If cancer is there it is most likely going to detect it. However other things can make the PSA detector alarm such as an enlarged prostate, or inflammation or infection in the prostate gland. This led to many men undergoing biopsies for concern of prostate cancer only to be found to not have cancer (a false alarm). However, if a woman undergoes a breast biopsy and it is negative we all say “Halleluiah!”. However if a man has a prostate biopsy that is negative we all say ” why did you put that man through an unnecessary biopsy?” Some of the blame falls on the physicians. In the past any man who had a diagnosis of prostate cancer despite the Gleason grade (aggressiveness) would be sent for surgery or radiation even if unnecessary. This led to over treatment and unwanted side effects.
To further evaluate PSA and screening there was a very large study in the U.S. called the PLCO study that enrolled over 75,000 men to checking PSA or NOT checking PSA in men aged 55-74. PSA screening in this study did not show a benefit so that is when the USPSTF came out with their 2012 grade D. More recently the data was re-analyzed and found that actually many men who weren’t supposed to have their PSA checked on the PLCO study actually did anyway. In fact there were more PSAs checked in the group who were not supposed to have it checked vs. the group who were supposed to have it checked. So in actuality this was a study of PSA screening vs. PSA screening = NOT VALID STUDY! So the USPSTF revised their screening recommendations to a grade C but just for men aged 55-74.
MY PERSONAL FEELINGS:
PSA is not a perfect test but until we have a perfect test we should use it wisely. We should screen any man that has a few years left in him and if a diagnosis is made then step back with the patient and cancer team and make appropriate recommendations of no treatment, medicines, surgery, or radiation.