PSA Testing - When to Start, Is it Necessary, and Questionable Recommendations

A recent article in the Journal of the American Medical Association questioned whether the routine practice of checking PSA in every man over 50 makes sense. The authors pointed out that PSA testing does identify more men with prostate cancer but it does not save lives. Here is why.

Prior to PSA introduction in 1980s, most men with prostate cancer did not know that they had it. But that did not stop them from living a normal life and eventually dying from heart disease or another cause, but not from prostate cancer.

That happens because almost all prostate cancers are not aggressive. They do not spread, but stay inside the prostate gland and in the long run they do not affect man's health in any way.
But before PSA, as now, there were cases of aggressive prostate cancers that grew quickly, spread rapidly and eventually killed. The number of such cases was usually between 25,000 and 30,000 a year, just like today.

For example, according to the Centers for Disease Control and Prevention (CDC), 185,895 men developed prostate cancer in the year 2005 and 28,905 men died from it. It is clear to see that the vast majority did not die. And, despite PSA, about the same number of men dies every year.

Men who lived before PSA testing were lucky, because they did not know that they had a problem and they did not do anything to solve it. But these days, if a man has high PSA (more than 4), he will have a prostate biopsy, an invasive procedure. If no cancer is found, he may have another biopsy 6 to 12 months later. He may also get an ultrasound or a CT scan.

If a cancer is found, doctors definitely recommend some kind of treatment, from radical prostatectomy (complete surgical removal of the prostate), to radiation or seed implantation. Some men get hormonal treatment, which is known as "chemical castration" because it suppresses the production of testosterone, which is the most important "male" hormone.

And these are the men who previously would not have had any treatment at all.

Tens of billions are spent on treating the men who do not need treatment. But money is not even the worst of it. Many of these men develop complications, such as bleeding, problems with ejaculation, impotence and incontinence. Imagine having to wear a diaper for the rest of your life, just because your PSA was a little high.

The authors of the JAMA article also pointed out that there is no routine PSA testing in Great Britain, yet their mortality is just about the same as in the US. The authors have suggested revising the existing policy.

The American Urological Association (AUA) has done just that (urologists are doctors who usually deal with prostate cancer). They have issued new recommendations in the Journal of Urology. Did they recommend postponing the age of testing to, say 60 or older? Did they suggest avoiding PSA testing at all, except when prostate cancer is definitely suspected, the way it is done in Great Britain?

No, they now recommend PSA testing in men starting at age 40! This flies in the face of all the available evidence and the only reason for this proposal is to increase the workload of urologist, who will now diagnose even more prostate cancer and treat even more men who do not need treatment.