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