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Prostate Cancer Screening: The New PSA Controversy

Posted 1/2/2012

Nobody wants to deal with cancer, but unfortunately as we all get older we enter the realm of increased cancer risk. Around age 30, when we finally shed the delusion that we’re not immortal, we start taking better care of ourselves. We stop smoking, eat healthier, exercise a bit, abandon skydiving as a hobby, and go in for the occasional check-up.

As far as cancer screening goes, women get mammograms and Pap smears, and after age 40 men get a PSA blood test that screens for prostate cancer. Over the past 30 years, millions of men have had their PSA repeatedly measured and sighed with relief when their results came back normal…or found themselves referred to a urologist when they did not. Good preventive medicine, right? Sounds reasonable, right? Now the bad news: having your PSA measured causes more trouble than it’s worth.

Many years ago, scientists discovered that certain cancers produced unique chemicals that could be detected by relatively simple blood tests. The chemicals were named “tumor markers” and initially were used to follow the success (or failure) of treatment for that specific cancer. One of these tumor markers—prostate-specific antigen–normally produced in very small amounts by healthy prostate glands, begins rising if prostate cancer is developing. However, PSA also rises in the presence of prostate infection, irritation, enlargement, and even recent ejaculation. Thus it’s not all that specific to cancer.

Armed with guidelines for “normal” PSA levels versus elevated “abnormal” ones, a virtual prostate cancer industry developed. Envision please an assembly line of men with elevated PSAs, riding along buttocks skyward, first undergoing a needle biopsy (you’d rather be in Philadelphia) and then passing through a bone scanner to check for cancer spread, and if none, onto surgical removal of their prostates.

Larger medical centers acquired da Vinci robotic devices to perform this surgery. Each da Vinci costs a hospital $1.5 million, plus another $300,000 to $500,000 annually in maintenance. Having sold more than 1,000 units, the company is a super high flyer on Wall Street. You’ll help offset the high price of the da Vinci when your $60,000 hospital bill arrives, not including your urologist’s fee (average income $400,000-$600,000 a year). The website of the seven-physician urology team at Henry Ford Hospital in Detroit credits themselves with more than 5,000 prostate removals using their da Vinci.

As a primary care physician, I myself dutifully ordered PSA testing on men coming in for their check-ups and occasionally measured my own as well. I began to learn which medical centers in town would fast-track their patients for (literally) next day surgery and which took a more conservative wait-and-see-if-the-PSA-goes-down approach. I also began hearing of more and more complications from surgery: lengthy hospital stays for infection, real problems with urinary incontinence and sexual dysfunction.

Was all this PSA testing really worth it?
On October 11, 2011, the US Preventive Services Task Force (USPSTF) officially announced “no.” An analysis of all the testing, all the surgery, and all the radiation concluded that the risks of PSA testing outweighed the benefits. There were simply too many surgical complications resulting from the removal of cancers that were never destined to harm anyone in the first place. It’s well known that prostate cancer is frequently a very slow-growing tumor. In fact, many older men harbor small and likely harmless prostate cancers that will never affect their health or longevity. In addition, many men who actually did die from prostate cancer had normal PSA levels during their routine screenings or had undetected spread of their cancer at the very time their prostates were being surgically removed.

This “no more PSA” news was not taken lightly by many urologists. While acknowledging that over-diagnosing and over-treating prostate cancer were indeed major concerns, they proposed that perhaps the one-size-fits-all approach–i.e., high PSA means immediate biopsy and prostate removal–could be modified by an approach called watchful waiting (doing nothing and re-testing PSA periodically). But this suggestion met with USPSTF objection, given that watchful waiting with frequently repeated PSA testing would incur unnecessary “PSA anxiety” of little useful purpose.

Better, implied the USPSTF, to just forget the whole PSA thing. If a patient is really worried about prostate cancer and wants the PSA test, OK, but doctors should no longer offer it routinely to their patients.

What’s ironic to me is that not once in the four (!) separate articles in JAMA this week discussing PSA did anyone mention prevention.

So here’s my recommendation for keeping your prostate healthy
Get a PSA test only if indeed you actually want one, but be aware of these risk issues. If you’re a (male) WholeHealth Chicago patient coming in for a check-up, I will ask if you want the test, but will no longer order it as a matter of course. If you answer, “Why are you asking me this?” I’ll assume you haven’t read this health tip and explain the statistics to you. And unless more news comes out to the contrary, I’ll not be having any more PSAs done on myself.

Let’s wrap up with a list of lifestyle changes you can make, each of which has been proven to reduce your prostate cancer risks:
1. Have a cup or two of coffee (regular or decaf) every day.
2. Have more orgasms (talk to your partner or your hand).
3. Exercise regularly.
4. Eat more tomatoes, especially cooked tomato sauces, which are high in lycopene.
5. Eat more fish or take a fish oil supplement.
6. Eliminate junky trans-fats, found in fast foods, snacks and other processed foods, and commercially prepared baked goods (e.g., doughnuts, cookies, pies).
7. Eat more green veggies, especially broccoli.
8. Take one of the several good prostate health supplements. I use Healthy Cells Prostate, but remind you that no supplement compares to bumping up your fish, broccoli, and tomato intake.

Be well,
David Edelberg, MD

Leave a Comment

  1. Sandy Siegel Miller says:

    I just read this aloud to Jonathan. He particularly likes recommendation #2! As always, thanks for the informative, entertaining newsletter.

  2. Dace Kezbers says:

    Good article. However, I think something has been left out–or put into–paragraph 4. Line 3 has “please” in it???? Then, last line, if there is “none” the prostate is removed? It doesn’t make sense to me. Am I not getting it?

    • Dr. R says:

      Hi Dace. Dr. Edelberg is trying to have you imagine a medical “assembly line” of men with elevated PSA’s. To your second point, surgical removal of the prostate is usually not performed if metastasis has occurred. Thanks for your interest.

  3. David Tenenbaum says:

    When you adopt a vegan diet, you drastically reduce your risk of a number of soft tissue cancers including not only prostate but colon cancer as well. This is documented by T. Collin Campbell’s seminal China Study. The explosion of prostate cancers is due to bad life style choices. Prostate cancer will continue to increase as long as the population remains ignorant or defiant of the abcs of nutrition –in other words, it’s the animal fats and proteins stupid. And dont expect Obama care to come to your rescue unless you consider, as Dr. Edelberg aptly points out, incontinence and sexual dysfunction, being saved. It’s never too late to change course. Adopt a vegan and vegetable juice diet, eat natto and real wasabi, and then you will have the peace of mind knowing you will unlikely be yet another sad statisitc . By the way, Dr. Edelberg, I have taken up hang gliding in my 50s. Does this mean I’m still immortal?

  4. Cyndi driver says:

    Thanks, once again Dr. E for a good, informative article. I SO look forward to seeing you in my inbox! Wish your office was in my area…

  5. Bob Gosdick says:

    Great article – also reflects my own experience. 5 or 6 years ago I had an extremely high PSA reading, which showed up after my annual physical with you. Upon your recommendation, we waited several months and took the test again and PSA had gone down. Several months later we took the test again and PSA was approaching normal. Has been so ever since. I am now 78 and still eating my tomatoes and spinach.

  6. christine cookingham says:

    THANK YOU for giving some common sense wisdom to the crazy race to surgery or chemo treatment so many doctors take.

  7. The above article came out today and as you can tell, you were right on target with the PSA test.

  8. my p2p says:

    Do you have a Facebook fan page for your site?

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