PSA test is rec­om­mended only for men of cer­tain age

Daily Freeman (Kingston, NY) - - YOUR DAILY BREAK - An­thony Ko­maroff AskDr.K

I’ve heard so many con­flict­ing opin­ions about whether or not to get screened for prostate can­cer. Are there of­fi­cial guide­lines? What do they rec­om­mend?

To say that prostate can­cer screen­ing has been con­tro­ver­sial is an un­der­state­ment. I spoke to my col­league Dr. Marc Gar­nick, clin­i­cal pro­fes­sor of medicine at Har­vard Med­i­cal School, to hear his thoughts.

The two ways to screen for prostate can­cer are the dig­i­tal rec­tal exam (DRE) and the prostate-spe­cific anti­gen (PSA) blood test. PSA lev­els rise when the prostate has turned can­cer­ous, but they also rise when the prostate is just ir­ri­tated or dam­aged. To­gether, PSA test­ing and DRE may nearly dou­ble the de­tec­tion rate for early-stage prostate can­cer.

But there’s a catch. Be­cause other prostate con­di­tions be­sides can­cer can raise the blood lev­els of PSA, an el­e­vated PSA does not al­ways mean a man has can­cer. We call a high blood level of PSA in a man without prostate can­cer a “false pos­i­tive” re­sult.

False pos­i­tive re­sults can cause need­less worry. And they may lead to in­va­sive pro­ce­dures, such as biop­sies, to de­ter­mine if can­cer is present. No test is per­fect: There is al­ways the chance of a false pos­i­tive re­sult. But it hap­pens pretty often with the PSA test.

The big­ger prob­lem, how­ever, is this: As strange as this may sound, not all can­cers are bad for your health. Some prostate can­cers are so small and slow-grow­ing that they will never spread and cause prob­lems: You’ll die of some­thing else. You’ll die with prostate can­cer, but not from prostate can­cer.

Of course, some prostate can­cers are ag­gres­sive and very def­i­nitely a threat to a man’s health. So what we re­ally want to have is a screen­ing test that de­tects th­ese ag­gres­sive prostate can­cers. Un­for­tu­nately, the PSA test can­not dis­tin­guish well be­tween ag­gres­sive and slow-grow­ing tu­mors. The for­mer may re­quire im­me­di­ate treat­ment, while the lat­ter may need no ac­tive treat­ment at all.

A fi­nal weak­ness of the PSA test is that it does not de­tect all can­cers. In other words, just as the test can be falsely pos­i­tive, it can also be falsely neg­a­tive: It comes back nor­mal (“neg­a­tive”), but you re­ally do have prostate can­cer. In such cases, a PSA test of­fers a false sense of se­cu­rity.

In 2013, the Amer­i­can Uro­log­i­cal As­so­ci­a­tion came out with new guide­lines that are more or less in line with those of other groups. Th­ese guide­lines ad­vise against rou­tine screen­ing for men at av­er­age risk who are un­der age 55 or over age 70. For men aged 55 to 69, the guide­lines ad­vise that doc­tor and pa­tient make the de­ci­sion to­gether, based on a man’s in­di­vid­ual risks, pref­er­ences and val­ues.

I or­der PSA tests in many men aged 55 to 70. But like many doc­tors, what I’m wait­ing for is a bet­ter test that de­tects ag­gres­sive prostate can­cers ac­cu­rately and ig­nores the slow-grow­ing ones.

Dr. Ko­maroff is a physi­cian and pro­fes­sor at Har­vard Med­i­cal School.)

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