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22 Prostate-specific Antigen (PSA) testing Prostate-specific antigen (PSA) testing What is prostate cancer? There are many issues surrounding the PSA test – especially around whether men should routinely have the blood test. Each year, around 25,000 men in the UK receive a diagnosis of prostate cancer. Prostate cancer kills about 10,000 men a year. The average age at diagnosis is 75. It is rare in men under 50. It is generally a slow growing disease. Many people believe a PSA blood test finds out if a person has prostate cancer. This fact sheet disperses that myth and may help you to understand why a test should not be taken without the patient being fully informed. It explains the implications of results and on a broader scale, why PSA tests are not recommended as a screening tool for prostate cancer. We are not saying you should not have a PSA test, but that we prefer you to know everything there is to know before we take it. What is BHP? You will have been invited to attend the prostate assessment clinic for investigations into your urinary symptoms. Four out of every five men aged over 50 years will have some degree of enlargement of the prostate gland. Usually this enlargement is caused by a non-cancerous condition called Benign Prostatic Hypertrophy or BPH. The symptoms BPH can cause include increased frequency of passing urine, a sudden urge to pass urine, difficult in urinating or a weak flow of urine. Is it treatable? Treatment of BHP involves taking drugs or having an operation often known as a “rebore”. Its actual name is Trans Urethral Resection of Prostate or TURP. While BPH is by far the commonest cause of problems with the prostate gland, it does not lead to cancer, nor increase the risk of cancer developing. However, some of the symptoms of prostate cancer are often similar to those of BPH, so, one of the tests you may have at the prostate assessment clinic is a PSA test. What are the symptoms? Many men with prostate cancer are unaware they have it. It will not threaten their life, or cause any symptoms. If we had found it, we may well have subjected them to treatments with side effects such as impotence and incontinence. Unfortunately, so far, we have no way of knowing which of the prostate cancers we find are going to be aggressive, as opposed to ones that are not going to cause problems. Am I at risk of prostate cancer? You are more at risk of prostate if your father or your brother has had it. What are the advantages of finding prostate cancer? If we find prostate cancer at an early stage (confined within the prostate), we may be able to cure it. We may, even if the cancer is detected later, be able to control it and prevent it from causing problems. What are the disadvantages of finding prostate cancer? Many older men will have prostate cancer. Some believe that 80% of men over 80 years old have prostate cancer. Many of these men will die of old age with their prostate cancer rather than because of it. However, if we’d found the prostate cancer, we may well have offered treatments. These could cause side effects that could well affect a person’s quality of life. What is a PSA test? PSA stands for Prostate Specific Antigen. It is a protein produced in the cells of the prostate gland. It combines with seminal fluid to assist sperm. All men have small amounts of PSA in their bloodstream. Why do PSA levels rise? Prostate biopsies There are many reasons PSA levels in the bloodstream rise: We use a small needle to take several small biopsies form the different areas of the prostate. We send these off to our laboratory for analysis (more information will be given to you about this procedure if it is recommended). Sometimes this test can cause temporary bleeding, difficulty in passing urine and infection. To lessen the risk of infection we prescribe antibiotics. 1) Age. Men produce more PSA as they get older. Therefore the normal range used by our laboratory considers the patient’s age. 2) Benign Prostatic Hypertrophy (BHP) 3) Inflammation of the prostate gland. 4) Exercise (such as cycling because of its massaging effect on the prostate). 5) Sexual intercourse. 6) Prostate cancer. Does a high-level of PSA mean I have prostate cancer? Please note that PSA is related specifically to the prostate and not specifically to prostate cancer. A raised PSA only tells us that you might have prostate cancer. It is not by itself an accurate way of detecting the presence of prostate cancer. Not all prostate cancers are going to cause problems or become lifethreatening. PSA testing is of limited value in discovering those cancers which need treating. It is important also to recognise that prostate cancer may very occasionally be present if a PSA is normal. This is known as a ‘false negative test’. Around 20% of all men with prostate cancer have a normal PSA. What happens if my PSA level rises? If your PSA is raised we will undertake further tests to try to detect whether you have cancer in your prostate. What further tests will you perform? Probably all of these: Digital Rectal Examination (DRE) At some point we will perform a digital rectal examination. A gloved and lubricated finger is inserted into the rectum to examine the prostate. It is possible to detect some abnormalities of the prostate gland in this way. Transrectal Ultrasound Scan of the prostate A small probe will be placed in the rectum allowing us to take ultrasound images of the prostate. PSA Testing Version 1 © Chesterfield Royal Hospital NHS Foundation Trust Reviewed Date: June 2016 Next Planned Reviewed Date: June 2018 Directorate: Surgical Will all these tests tell me if I have prostate cancer? Not necessarily. If the laboratory detects prostate cancer in the biopsies we send then obviously you have prostate cancer and we can get on with treating it. However the laboratory may well report that all the biopsies we sent to them are negative. Unfortunately, while this is good news, it doesn’t mean that we can tell you that you definitely do not have prostate cancer. There may well be a small cancer hiding in the prostate that was not biopsied. So, should I have a PSA test? By now you will realise the whole issue of looking for prostate cancer is not black-and-white. The PSA test is by no means a perfect test to look for prostate cancer. An increased PSA can occur when no cancer is present; and a normal PSA does not rule out the possibility of prostate cancer. A raised PSA is the trigger for a series of other tests, in particular the prostate biopsy which carries its own problems. A negative biopsy does not necessarily mean that prostate cancer is not present, but the area we have biopsied is not cancerous. A positive biopsy, while definitely indicative of prostate cancer, may well have found a prostate cancer that will never cause you any problems and does not need treating anyway. We could then find ourselves in the position of over-treating a clinically insignificant condition. In conclusion then, a PSA test should not be taken lightly. You should look at the possible risks and benefits of the test. We are happy to spend time talking to you about the issues surrounding the dilemma. Only when you feel fully informed, should you proceed.