PSA screening is a routine blood test usually performed in conjunction with an annual physical checkup.
Testing has rapidly increased worldwide, and the number of men over 50 diagnosed with prostate cancer has since skyrocketed.
Contrary to the myths and beliefs of many vulnerable men, the PSA test is not cancer-specific.
It is simply a measurement of a specific chemical released by the male prostate gland that might become elevated in the presence of prostate cancer.
For many years, evidence regarding a PSA blood test and public perception has firmly linked it to prostate cancer.
However, while the link is viable, the test does not specifically indicate either the presence or absence of prostate cancer.
Nevertheless, it has resulted in significant overdiagnosis as well as overtreatment for the disease.
This questions whether or not such intense screening for prostate cancer actually saves lives or causes more problems.
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What is Prostate Specific Antigen (PSA)?
Prostate specific antigen (PSA) is a protein released only by the male prostate gland. Its primary function is to help keep semen liquid.
The prostate cells that produce PSA can be both benign and malignant. Malignant cells (cancer) tend to make more PSA than benign cells, hence its potential value as a cancer marker.
PSA is a screening test currently used by urologists to monitor or detect prostatic cancer, as well as to monitor the response of known prostate cancer patients during treatment.
However, it is essential to understand that the PSA test lacks specificity. There are multiple conditions unrelated to prostate cancer that can be responsible for an out-of-range PSA reading.
Deciding to get tested
Many clinical practices routinely order PSA testing as part of an annual physical. Since its inclusion in routine blood work for men over fifty, the quantity of prostate biopsies has increased substantially. Likewise, the number of men diagnosed with prostate cancer has also increased.
Recent studies suggest most of the cancers found by this combination of tests appear to be slow-growing. These are indolent cancers. They are slow-growing prostate cancers that may remain in a man′s body for years without causing severe problems.
Fortunately, they comprise the majority of prostate cancers found today. Unfortunately, perception sometimes has more weight than science. Both patient and clinician often perceive a prostate cancer diagnosis as something they need to treat, no matter what. Thus, getting tested may lead a man and his partner down a path dangerous to his quality of life.
Normal and Abnormal Results
PSA test results between 4 and 10 are most likely related to benign prostatic hyperplasia (BPH) or prostatitis. BPH is a nonmalignant enlargement of the prostate, common in men over 40 years of age. Prostatitis is an inflammation of the prostate.
In addition, almost any strenuous physical activity can cause a temporary rise in PSA.
Generally, the accepted guideline for a normal PSA lab test is 0-4 nanograms. A PSA blood test reading at or above four is usually a red flag for most urologists. However, many typical factors can influence the reading and cause a high PSA level.
When a PSA is Recommended
In May 2018, the United States Preventive Services Task Force (USPSTF) recommended against PSA-based screening for prostate cancer in men 70 years and older.
On the other hand, the CDC recommends that men between 55 to 69 years old should make individual decisions about screening for prostate cancer with the PSA test. Quoting the CDC – “Before making a decision, men should talk to their doctor about the benefits and harms of screening for prostate cancer, including the benefits and harms of other tests and treatment.”
There are several problems with this recommendation:
- Almost every urologist is a surgeon with extensive surgical training. Thus, it is nearly a given that any positive diagnosis will result in a recommendation of surgery.
- If the PSA screening indicates a possibility of prostate cancer, the pressure on a man to accept further testing or treatment is intensive. I have documented cases where my clients felt pressured into agreeing to surgery against the firm advice of other practitioners.
- Finally, the social bias a man encounters following a cancer diagnosis can be overwhelming. The general opinion regarding cancer has been to treat it early and cure it. Doctors are part of our social fabric, but finding a progressive doctor that will recommend against aggressive treatment of a diagnosed cancer is not an easy task.
The problems of blanket screening are already apparent worldwide. In recent years, the incidence of men treated for prostate cancer has increased dramatically. But the incidence of prostate cancer deaths has not seen a corresponding reduction.
Avoiding Activities That Might Alter the Test Result
There are many activities and conditions you should avoid before a PSA test to prevent a temporary increase in the result.
- Strenuous exercise. Bicycle riding is particularly notable for this. Other strenuous exercises, including sexual activity, may also raise PSA levels.
- Prostatitis: an infection and swelling of the prostate gland.
- Any urinary or bladder infection.
- Digital Rectal Exam. Manual examination of the prostate should happen after the blood sample draw for a PSA test.
If your PSA test result shows you have an elevated PSA level, you should have a repeat test a few weeks later to confirm the high result before planning any subsequent tests or treatment.
Meaning of Abnormal PSA Blood Test Results
PSA levels in the blood may vary over time in the same man. Often they correspond to the man′s daily physical activity or diet. Are there any foods to avoid before PSA test?
While there is no specific abnormal level, most doctors consider PSA levels of up to 4.0 ng/mL normal. For elevated PSA levels that exceed 4.0 ng/mL, doctors tend to recommend a biopsy to determine whether prostate cancer was present.
However, more recent studies have shown that some men with a PSA result greater than 4.0 ng/mL do not always have prostate cancer.
But instead, they may have an enlarged prostate (BPH), prostatitis, or a urinary tract infection. When faced with an out-of-range value, previous history of PSA levels is incredibly invaluable for deciding about the possibility of prostate cancer.
A red flag is when a man′s PSA suddenly rises to a level above 10 and remains there. A slow, continuous rise in PSA level over time may be highly indicative of BPH.
Diagnosing Prostate Cancer
For many years the PSA test followed by a prostate biopsy has been a primary mover in the progression to diagnose prostate cancer.
However, we can use other indicators to aid with a cancer diagnosis.
- Free PSA – The amount of PSA in the blood that is “free” (not bound to other proteins). Higher percentages of free PSA are more associated with BPH.
- PSA density – The blood level of PSA compared to the overall size of the prostate.
- Age-specific PSA ranges – PSA levels tend to increase with age.
- PSA velocity – The rate of change in a man’s PSA level over time.
- PSA doubling time – The period over which a man’s PSA level doubles. Faster times seem to indicate prostate cancer growth or progression.
Many markers associated with prostate cancer are currently studied. The PSA test itself is not a conclusive and specific indicator upon which to base further diagnosis or treatment of prostate cancer.
However, in past years, doctors have used it in this manner, thus subjecting many men to the unnecessary side effects of treatment for prostate cancer.
Our society has morphed cancer into a terrifying word.
Virtually every man has heard stories about a colleague that had treatment for prostate cancer, with the result being a wholly destroyed sex life as well as urinary incontinence for the remainder of his life.
The sad part about stories like this is that the devastating results the person is experiencing are most likely the result of aggressive treatment rather than the disease.
Prostate cancer was, in many cases, discovered as a side effect. An abnormal PSA reading in a routine annual blood test indicated additional testing and treatment.
Prostate cancer often produces few bothersome symptoms. Studies show the incidence of undetected indolent prostate cancer, when spread across the aging male population, is approximately proportional to age.
In other words, a 65-year-old man has about a 65 percent chance of having undetected prostate cancer. And, if it continues to go undetected, he has a pretty good chance of dying with it, not from it!
Nevertheless, many clinicians think they need to eliminate prostate cancer, usually by surgically removing the entire prostate gland. Unfortunately, this is far worse than the disease.
The most important take-away from this discussion is that, contrary to folklore, the PSA test is not a specific indicator that a man has prostate cancer. And the myth that a high PSA is an impending death sentence is untrue.
Any man that finds himself with a high PSA reading should have, at minimum, a repeat PSA test taken at least four to six weeks after the initial over-limit result.
A man considering PSA testing should acquaint himself with the pros and cons of testing before making any decision – especially any decision that involves further testing or treatment.