Why Doctors Don't like the PSA Test for Prostate Cancer

Over the years, there's been a large amount of debate over whether, and when, men should get the PSA screening test for prostate cancer. When I was a medical student, the PSA test seemed to make a lot of sense. After all, if prevention is worth more than cure, especially when it comes to a deadly disease such as prostate cancer, then doesn't it make sense to have this information?

A preceptor in the internal medicine clinic told me that this view point wasn't share by many doctors who see adult patients. In their minds, and his mind, the test could be doing more harm than good in a large number of patients.

For example, if a man has the PSA test, and it is abnormal but he doesn't have prostate cancer, then he could be subjected to unnecessary tests and biopsies. This could in some men lead to urinary incontinence problems and impotence. In addition, a man with a positive PSA test and who does have prostate cancer, may be more likely to die from another disease than their prostate cancer, or at least so the thinking went.

So a lot of doctors were reluctant to recommend the test to patients. And the general consensus was that the jury was still out. Researchers have been steadily working to find other markers besides PSA which could be used to predict if a person has prostate cancer, and even how aggressive the cancer will be so that they can better tailor their treatment to their lifestyle. A new biomarker, called PCA3, could be used to determine who should receive a biopsy after an abnormal PSA test.

An article I wrote for associated content discuss is this test in more detail, to see my article about the PCA3 test, click here. In addition there is a PCA3 website which discusses issues surrounding this test, www.pca3.org In the future this test may be used in combination with the PSA test in order to more effectively screen who need further evaluation and treatment, and thus could possibly avoid over treatment based on high PSA levels.

Now, a timely recent article in the Lancet Oncology Journal, a respected medical journal, discussed a study in which men between the ages of 50 and 69 years of age were screened using the PSA test, and this resulted in an approximately 50% reduction in prostate cancer mortality over the next 14 years. This result was believed to be even more impressive than reductions in colon cancer brought about by preventive colonoscopy screenings.

As routine PSA testing in men is controversial, this study will add fire to the debate, and may convince some doctors to start recommending that men between the ages of 50 and 69 have regular PSA blood levels measured, if they are not already doing so.

For men over the age of 70, the researchers would not recommend regular annual PSA screenings, as the prostate cancer in these men may be more likely to be non-curable when diagnosed, and they may be much more likely to die of another medical condition than prostate cancer. A new study out in September 2010 in the Journal BMJ found that for men above the age of 75, a PSA test did not decrease mortality from prostate cancer, although the test was able to identify some men with prostate cancer.

A number of controversies regarding a variety of cancer screening tests, such as mammography for breast cancer and the PSA test for prostate cancer, have divided the medical community for decades. But why are some doctors very opposed to these tests?

It may be something else beyond using a test with ambiguous results, but with the time required to explain, and discussed, the tests and the results with patients. For example, a family practice physician may see 20 are 30 patients a day in the clinic, and their salary and productivity is determined by how many patients they can see. Many older physicians lament that they often have only 15 minutes to examine and talk with each patient.

Newer trained physicians, since the 1990's, have developed a much quicker patient interaction styles which may not put a lot of emphasis on taking the time to discuss cancer screening tests with patients. Many doctors may view such discussions as excessively time intensive, and they most likely will not be reimbursed for this time with patients. Some doctors may decide to wait until a more accurate prostate cancer screening test is developed.

What should patients do? As the decision to have a mammogram, or PSA test is ultimately up to the patient, concerned people should ask to discuss these screening tests with their doctor. The PSA test can detect prostate cancer in some men who have a normal digital rectal exam, meaning that the test can save lives, and this recent research study provides strong evidence that it does do this. However, an abnormally elevated PSA test results still only means that a man has an approximately 33 to 25% chance of having prostate cancer.

Nonetheless, the American Cancer Society in May of this year issues new guidelines which recommend against yearly digital rectal examinations for prostate cancer as there is no evidence that they work, and the society has stopped supporting use of the PSA test to screen for prostate cancer since the 1990s. With this new research change the American Cancer Society guidelines on prostate cancer? Possibly, though clinical practices patterns are hard to change once they are set.

As always, being proactive regarding your health care is important, and patients should stay informed about the risks and benefits of different cancer screening tests. The recent cloud of controversy surrounding cancer screening tests could sadly lead some patients to forgo these tests which might be able to save their lives.

So what do doctor recommend? Currently because of the controversy different doctor group are recommending different approaches. The American Cancer Society recommends discussing PSA screening with your doctor when a man turns 50, while the American Urological Society recommends having PSA screenings annually beginning at the age of 40. With differing expert opinions it is extremely important that men discuss this important issue with their doctor.

Sources:

http://www.associatedcontent.com/article/5448668/what_is_the_pca3_test_for_prostate_pg2.html?cat=70

http://www.medscape.com/viewarticle/724467

http://www.bidmc.org/YourHealth/TherapeuticCenters/ProstateCancer.aspx?ChunkID=14154

http://www.usatoday.com/news/health/2010-03-03-prostate-cancer_N.htm

http://www.foxnews.com/story/0,2933,595790,00.html

http://www.reuters.com/article/idUSTRE68E65W20100915