During physical exams, men have routinely been given a PSA screening for prostate cancer. But now experts are recommending against the test for men in certain age groups. Dr. David Samadi, vice chairman of the Department of Urology and Chief of Robotics and Minimally Invasive Surgery at the Mount Sinai School of Medicine in New York City, explains the rationale behind the new PSA screening guidelines and how you should interpret them.
Prostate-specific antigen (PSA) is a protein produced in the prostate gland that is measured in a blood test. Higher levels may signal prostate cancer, but other conditions can raise PSA, including a urinary tract infection, and inflammation or enlargement of the prostate. The American Urological Association recently recommended against PSA screening for average-risk men younger than 55 and older than 70.
PSA screening has been debated for years by prostate cancer specialists because it often catches low-risk cancers that patients are over-treated for with invasive biopsies and surgical removal of the prostate, a procedure that can leave men impotent and incontinent.
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The intent of the AUA’s latest recommendation is to avoid overtreatment, but Dr. Samadi says another possible consequence is missing aggressive cancers in patients in their early 40s and early 50s.
Because of that, every patient should have a conversation about PSA with his doctor — no matter his age, he advises.
“While these guidelines are for the whole country … you want to be very careful and look at your family history,” he says. “African Americans have higher risk factors than others. And individualize the care — talk to your doctor and find out what’s best for you.”
The risk for prostate cancer increases as men age, and more aggressive prostate cancers are typically found in older men between the ages of 55 and 70, Dr. Samadi explains. Once men are beyond age 70, other medical conditions are likely to cause greater risk for them than prostate cancer, he says. So goes the rationale behind the new recommendations.
While the PSA test is effective at detecting elevations of the blood protein, follow-up diagnostic tools to determine whether cancer is actually present are lacking.
“Until we find some good testing — genetic tests, imaging, MRIs and others — to really tell us what’s in that prostate, it would be very difficult to tell men 45 [or who are] in their early 50s no screening,” he says. “I think that’s quite dangerous and it’s not really well thought out. But that’s what the data says and that’s what we’re going to follow at this point.”
If a man is told he has an elevated PSA, taking a course of antibiotics in case an infection is causing the rise, before having an invasive needle biopsy, is worth discussing with his doctor, Dr. Samadi advises. If the level is still elevated after such treatment, then a biopsy is likely in order.
But because the whole prostate cannot be biopsied, more aggressive tumors can be missed. In fact, when it comes to prostate removal, 38 percent of the time the cancer turns out to be more aggressive than its pre-operative staging, he says.
“As time goes on and as we get these genetic studies, as we get better imaging and MRIs, we’re going to really narrow down the kind of patient that needs to go for surgery and the ones that we can absolutely watch,” he says. “Until that’s part of our practice, just to tell people not to get PSAs, I think it would be a huge mistake.”
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