Do You Really Need a PSA Test? (cont.)
3/30/2009 9:48:32 AM
Surgery to remove the prostate and radiation are standard; but both treatments may produce such complications as impotence and incontinence. Fortunately, newer techniques are less likely to damage the nerves essential for erections and urinary control.
For older men "watchful waiting"-now often called "active surveillance"-rather than treatment is often best. This means frequent retesting and monitoring, with an eye to beginning therapy if the localized cancer progresses. Studies comparing watchful waiting to surgery or radiation therapy have yielded conflicting results.
The upside of testing:
Despite the unknowns and drawbacks, millions of men are being tested, often because many doctors include the test in routine blood work. The good news is that death rates from prostate cancer have been gradually declining since the 1990s, and its incidence has leveled off. Some researchers attribute this improvement to PSA testing, though this is still debated. Improved treatments also deserve credit.
Last year a study in the urology journal BJU International found a big decline in prostate cancer deaths in the Austrian state of Tyrol, where PSA screening was offered free to men beginning in 1993. Almost 90% of men age 45 to 75 were screened, and by 2005 the death rate from prostate cancer dropped by 54%, compared to a 29% drop in the rest of Austria, where free screening was not available. Another recent study showed that mortality rates from prostate cancer have fallen four times more in the U.S. than in Britain, where far fewer men get PSA tests and the cancer is usually treated less aggressively.
But these were only observational studies, not clinical trials. Several major clinical trials, which should more clearly determine whether or not PSA screening saves lives, are in progress. Results are expected in a few years.
What to do:
The troubling fact is that for some men a delay in the diagnosis of prostate cancer will be fatal. Every man should discuss the PSA test with his doctor. When the pros and cons are fully described to men who have not yet made up their minds about the test, they are more likely to decide against it, according to a 2007 review article in the American Journal of Preventive Medicine.
Here is what we recommend for PSA screening:
. If you are under 50 and white and have no family history of prostate cancer, your risk is low and you need not be tested.
. If you are black or have a family history of prostate cancer (a father or brother diagnosed with prostate cancer), begin screening at age 50. Some doctors say you should begin at 45 or even at 40-especially if your father or brother was diagnosed with prostate cancer at a relatively young age.
. If you are 50 to 74, are not black, and have no family history or other risk factors, you may choose not to be screened, depending on your overall health and personal preferences.
. If you are 75 or older, or your life expectancy is less than 10 years because of ill health, screening is not recommended.
. If you get tested and are taking any drug (such as finasteride, brand name Proscar) for prostate problems, remind your doctor, since it may affect PSA levels.
. If your PSA level turns out to be high, get retested before having a biopsy and talk to your doctor about other steps that can help clarify the results. A biopsy should be done only after a complete evaluation of not only your PSA results, but also your age, race, family history, the results of a digital rectal exam, and any prior biopsy.
UC Berkeley Wellness Letter, April 2009