Just One PSA Test in Midlife Can Predict Future Risk of Prostate Cancer

For generations, men have dreaded prostate cancer screenings.

The old fashioned method of prostate cancer testing was the digital rectal examination, or DREC. This is a nicer way of describing the process by which a doctor inserts a gloved and lubricated index finger's into a man's anus to feel the prostate. Many men underwent this test every year until testing for prostate specific antigen, also known as PSA, became more widely available.

Digital Rectal Exam Is Notoriously Unreliable

The problem with the "finger exam" is that it is extremely non-specific. A man's prostate will feel different to different doctors, and it will feel different to the same doctor on different days. In a study published in the New England Journal of Medicine in which 9440 men were given digital rectal examinations, 1977 men had "enlarged" prostate, but only 113 had elevated levels of PSA. There are other reasons to do a digital rectal exam, detecting anal cancer, for example, but over 90 percent of the time what the doctor feels is not a cancer or even prostate inflammation.

PSA is not actually a measurement of prostate cancer. It's a measurement of prostate inflammation, which is, ironically, in a few cases caused by the digital rectal exam itself. PSA can also be elevated after prostate infection or a UTI. Both doctors and the men they treated often erroneously assumed that a certain number had to mean the man had prostate cancer and prostate cancer, radiation, and hormone therapy were necessarily in the man's future. However, the proof of prostate cancer depends on biopsy.

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Prostate Biopsy Doesn't Necessarily Mean Prostate Cancer

Prostate cancer isn't diagnosed by either digital rectal exam or PSA alone. The next step in the diagnostic process is a biopsy. This involves using tiny needles to take tiny samples, about a millimeter (1/25 of an inch) long, from the prostate gland. A prostate biopsy can an intense "pain in the ass" for a few minutes, although most doctors inject the prostate with the painkiller lidocaine (this is not a pleasant procedure, either) and use needles that are coated with lidocaine to take the samples. 

When all of this is done, only about 25 percent of men who get a prostate biopsy actually have prostate cancer. That means that 75 percent of men who undergo biopsies don't have cancer. The biopsy itself can cause problems. There can be infections. (Author's note: My own father died of complications from a urinary tract infection after having a prostate biopsy that didn't find cancer, at the insistence of his sister, a nurse, who thought his PSA was dangerously high.) And even when there is a finding of prostate cancer, the best approach may be watchful waiting rather than treatment itself.

A Single PSA Test May Be All the Screening a Man Needs

Wouldn't it be nice to have just one PSA test and be done with it? Men have to make their own decisions with their doctors, but some of the latest research finds that one PSA test may be enough. Dr. Mark A. Preston from Brigham and Women's Hospital in Boston and co-investigators have analyzed data from the Physicians Health Study and found that:

• One in every 12 men who has a PSA of 2.1 or higher before the age of 55 will die of prostate cancer in the next 30 years.
• One in every 7 men who has a PSA of 3.9 or higher before the age of 59 will die of prostate cancer in the next 30 years.

Is a High PSA a Reason to Panic?

It is comforting to take a second, closer look at the findings from the Physicians Health Study. The study looked at deaths over a period of 30 years. Another way of stating the results of the data analysis is that 11 out of 12 men who have a PSA of 2.1 or higher before age 55 won't get prostate cancer and die of it before age 80. Also, six out of seven men who have a PSA of 3.9 or higher before the age of 59 won't get prostate cancer and die of it before the age of 85.

Prostate cancer is more often a disease men live with rather than die from. Because prostate cancer is seldom fatal, more and more doctors are advising watchful waiting rather than removing the prostate at the first sign of cancer. Once a man has his prostate removed, there is never again going to be an ejaculation. More often than not men who have radical prostatectomy lose erectile function and have to start wearing what are often called "man diapers" to deal with urinary and/or fecal incontinence. Other treatments may keep prostate cancer in check without the removal of the gland.

All of this being said, there are some aggressive forms of prostate cancer that require aggressive treatment. Men need to find doctors they can trust and work with them. Signs that there may be a need for a second opinion include:

• Pushing for treatment when your PSA is stable or declining.
• If your doctor recommends cancer-sensitive tests such as PHI or PCA3, make sure you are not part of a research study. You may be randomized to a treatment not optimal for your health for the sake of the study.
• If your doctor recommends annual prostate biopsies, also make sure you are not part of a research study. Annual prostate biopsies, which, as previously mentioned, are not without risks of their own, are often for the sake of research rather than for the treatment of the men who undergo them.

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The American Academy of Family Physicians has issued a statement that says "There is convincing evidence that PSA-based screening leads to substantial overdiagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients."

Look for a doctor who can maintain a long-term relationship with you in treating prostate cancer. Expect an explanation of why your prostate cancer has to be treated now and not later. Don't get it a hurry to have prostate cancer removed, and explore every option for staying as healthy as possible for as long as possible without surgery and radiation.