Download PSA and Prostate Cancer

PSA and prostate cancer screening
Prostate cancer is the most common non-skin cancer and the second most common cause
of cancer-related death in men, surpassed only by lung cancer. It is estimated that
238,590 new prostate cancer cases will be diagnosed in 2013, with 29,720 men dying of
the disease during the year.
Prostate cancer screening consists of a digital rectal exam and a PSA ( prostate specific
antigen) test. PSA, a protein produced by the prostate, can be tested with a simple blood
test. It is specific to the prostate but not to prostate cancer, as other factors like infection,
inflammation of the prostate, or having a catheter in the bladder can cause an elevated
PSA. Therefore, not all men need a prostate biopsy, and the urologist considers all these
factors before recommending a prostate biopsy.
The American Urologic Association (AUA) has recently released new guidelines
regarding screening for prostate cancer with PSA. These guidelines are based on a
European clinical trial which studied patients between ages 55 and 69 and found
screening to decrease prostate cancer mortality by 29%. Patients between 40 and 54
years of age were not included in this study . The AUA states that screening is
recommended in patients age 40-54 who are at high risk of prostate cancer , those with
family history and African Americans. The AUA recommends screening in men older
than 70 years of age if they have > 10 years life expectancy.
There has been controversy regarding the usefulness of the PSA test since the United
States Preventive Services Task Force (USPSTF) issued a recommendation discouraging
its use for prostate cancer screening in October 2011. It raised the concern that having
this test “has no net benefit or the harms outweigh the benefits.”
Urologists, represented by the AUA, strongly disagree with this recommendation. While
everyone realizes the PSA test has its limitations, the fact that doctors are diagnosing
cancer at an earlier stage due to this test represents a strong argument to continue it as
part of the annual prostate cancer screening. There has been a 40 percent decrease in
deaths from prostate cancer since the PSA was introduced in the early 1990s, as patients
are being diagnosed earlier, at a more curable stage. Urologists agree that PSA has to be
used and interpreted appropriately, and not every patient may need to have the test — or
a prostate biopsy — done. Prostate cancer that is felt by rectal exam represents a higher
stage than one diagnosed by a biopsy done due to elevated PSA.
Many patients who present with prostate cancer that can be felt on rectal exam may have
an advanced stage where cure is not an option and palliation (i.e., easing symptoms
without curing) is the only treatment we offer. Going back to diagnosing patients only by
rectal exam would do a disservice for men who wish to have their cancers detected early.
The screening PSA test is particularly important since prostate cancer does not cause any
symptoms in its early stages.
There have been significant advances in treating prostate cancer in the past 10-15 years
with the availability of treatment options with less side effects. Radiation (X-ray therapy)
and surgery are the mainstay curative treatments for localized prostate cancer. Radiation
is aimed at the prostate gland from numerous directions and, with improved technology,
the X-ray machine can deliver the radiation to the prostate very precisely, minimizing any
damage to surrounding tissues. Advances in robotic surgery of the prostate have helped
surgeons perform the surgery through small incisions with less blood loss and quicker
patient recovery.
Not all men with prostate cancer will die from the disease. In some patients, the cancer
can be slow-growing and is not lethal. The decision to treat will depend on the patient’s
health and life expectancy and usually is made after extensive counseling by the
urologist. While significant research is underway to find a better test than PSA for
predicting a lethal disease, urologists will continue to recommend screening with digital
rectal exam and PSA.