Prostate Cancer Screening: Navigating the PSA Debate

Few cancer screening tests generate as much debate and confusion as the PSA test for prostate cancer. Unlike mammography or colonoscopy, where there's general agreement about screening recommendations, PSA testing remains controversial among medical experts.

Understanding this controversy and the nuances of PSA testing can help you make an informed decision about screening that aligns with your personal values and health priorities.

What Is PSA?

PSA stands for prostate-specific antigen, a protein produced by both normal and cancerous cells in the prostate gland. The PSA test measures the level of this protein in your blood. While PSA is primarily used for prostate cancer screening, elevated levels don't necessarily mean cancer is present.

Understanding PSA Numbers

PSA is measured in nanograms per milliliter (ng/mL). There's no single "normal" PSA level that applies to all men, as PSA naturally increases with age and prostate size. However, some general guidelines include:

• Below 4 ng/mL is generally considered normal, though this varies by age
• 4 to 10 ng/mL is considered moderately elevated
• Above 10 ng/mL is considered high

However, these are rough guidelines. Some men with PSA levels below 4 have prostate cancer, while many men with levels above 4 do not. Context matters significantly when interpreting PSA results.

Why PSA Testing Is Controversial

The debate around PSA screening centers on a fundamental question: does routine screening in men without symptoms save lives, or does it lead to more harm than good?

The Case for Screening

Proponents of PSA screening point out that prostate cancer is common and can be deadly. It's the second leading cause of cancer death in American men. When prostate cancer is found early through screening, it's more treatable.

Some large studies have shown that PSA screening can reduce deaths from prostate cancer, particularly when men are screened regularly over many years.

The Case Against Routine Screening

Critics of routine PSA screening emphasize that many prostate cancers grow so slowly they would never cause health problems during a man's lifetime. Detecting these slow-growing cancers through screening can lead to overdiagnosis and overtreatment.

Treatment for prostate cancer, including surgery and radiation, can cause significant side effects such as urinary incontinence and erectile dysfunction. When men are treated for cancers that would never have harmed them, they experience treatment side effects without any real benefit.

Additionally, the PSA test produces many false positives, leading to anxiety and unnecessary biopsies in men who don't have cancer.

Current Screening Recommendations

Because of these complexities, current guidelines emphasize individualized decision-making rather than routine screening for all men.

U.S. Preventive Services Task Force

The USPSTF recommends that men aged 55 to 69 make an individual decision about PSA screening after discussing the potential benefits and harms with their healthcare provider. For men 70 and older, they recommend against routine screening, as potential harms outweigh benefits in this age group.

American Cancer Society

The ACS recommends that men have the opportunity to make an informed decision with their healthcare provider about screening. They suggest these discussions begin at:

• Age 50 for men at average risk who are expected to live at least 10 more years
• Age 45 for men at high risk, including African American men and men with a first-degree relative diagnosed with prostate cancer before age 65
• Age 40 for men at even higher risk, such as those with multiple family members diagnosed with prostate cancer at an early age

Factors That Can Affect PSA Levels

Many things besides cancer can cause elevated PSA levels:

• Benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate
• Prostatitis (inflammation or infection of the prostate)
• Recent ejaculation
• Vigorous exercise, especially cycling
• Recent digital rectal exam
• Certain medications
• Urinary tract infections

This is why an elevated PSA doesn't mean you have cancer. It means further evaluation is needed to understand what's causing the elevation.

Beyond the Basic PSA Test

To improve the accuracy of PSA testing, several variations and additional tests have been developed:

PSA Velocity and Doubling Time

Rather than looking at a single PSA value, these measures track how quickly PSA levels rise over time. Rapidly rising PSA may be more concerning than a stable but elevated level.

Free vs. Total PSA

PSA exists in different forms in the blood. The ratio of free PSA to total PSA can help distinguish between benign conditions and cancer. A lower percentage of free PSA is more associated with cancer.

PSA Density

This calculation divides PSA level by prostate volume (measured by ultrasound). It accounts for the fact that larger prostates naturally produce more PSA.

Newer Tests

Several newer tests, including the 4Kscore test, Prostate Health Index (PHI), and blood or urine tests for specific genetic markers, aim to better distinguish between aggressive cancers that need treatment and slow-growing cancers that may not.

What Happens If PSA Is Elevated?

An elevated PSA doesn't automatically mean you need a biopsy. Your healthcare provider will consider multiple factors:

• How elevated is the PSA?
• Has your PSA increased from previous tests?
• What's your age and overall health?
• What did the digital rectal exam reveal?
• Are there other explanations for the elevation?

Sometimes the approach is to repeat the PSA test in a few weeks or months. If the level remains elevated and concerning, a prostate biopsy may be recommended. Some men may have an MRI before biopsy to better identify areas of concern.

Understanding Your Risk Factors

Certain factors increase your risk of developing prostate cancer:

Age

Risk increases significantly after age 50. Nearly 60% of prostate cancers are diagnosed in men over 65.

Race

African American men have the highest risk of developing prostate cancer and are more likely to develop aggressive forms of the disease at younger ages.

Family History

Having a father, brother, or son with prostate cancer more than doubles your risk. Risk is even higher if multiple family members have been affected or if they were diagnosed before age 65.

Genetic Factors

Inherited mutations in certain genes, including BRCA1 and BRCA2, increase prostate cancer risk.

Making Your Decision

When deciding about PSA screening, consider these questions:

What Are Your Risk Factors?

Men at higher risk may benefit more from screening than those at average risk.

What Are Your Values?

How do you feel about the possibility of finding and treating a cancer that might never have caused problems? Some men prefer to know and treat any cancer found, while others are comfortable with active surveillance for low-risk cancers.

How Long Do You Expect to Live?

Since many prostate cancers grow slowly, screening makes most sense for men expected to live at least 10 more years, as they're most likely to benefit from early detection.

How Would You Handle an Abnormal Result?

Would you be comfortable with active surveillance for a low-risk cancer, or would you want immediate treatment? Understanding your preferences can help guide screening decisions.

Questions to Ask Your Healthcare Provider

• Based on my age and risk factors, do you recommend PSA testing for me?
• What are the chances that screening would find a cancer that would actually harm me?
• What would happen if my PSA is elevated?
• What are the risks and benefits of prostate biopsy?
• If cancer is found, what are my treatment options?
• What are the side effects of different treatments?