Be informed – PSA screening tests

PSA stands for Prostate-Specific Antigen. It’s a blood test used to screen for prostate cancer.

Doctors used to recommend an annual PSA test for men over 40. But now we know that the PSA is not a good screening tool. It results in a high number of false positives, and not all forms of prostate cancer need to be treated.

Too many men have received unpleasant, expensive treatment they didn’t need.

In an excellent YouTube video, Dr. Mike Evans explains more:

In 2012 the United States Preventive Services Task Force (USPSTF) recommended against routine PSA screening. They gave it a D grade, which means the potential harm outweighs the benefit.

Choosing Wisely, an organization working to reduce unnecessary health care, agrees with the USPSTF:

There is no good evidence that routine screening in low-risk men saves lives. Consumer Reports agrees with the U.S. Preventive Services Task Force that screening low-risk men for prostate cancer does more harm than good.

The best advice for men at this time is to be informed about your own risk (age, family history) and really understand the limitations of the PSA screening test (false positives, false negatives, over diagnosis).

Related article from the New York Times: The Great Prostate Mistake

The PSA might be useful for men who have a high risk of prostate cancer.

On its website, the American Cancer Society (ACS) says:

The decision [to be screened] should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. The discussion about screening should take place at:

  • Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
  • Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).
  • Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).

After this discussion, those men who want to be screened should be tested with the prostate-specific antigen (PSA) blood test.

I think the ACS is a bit out of touch with reality about the level of patient education and “shared decision making” happening in most doctors’ offices.

In my experience, it’s the patients who have to initiate these discussions, because honestly most physicians aren’t going to make the time.

As Dr. Evans says in his video, the decision to screen, and what to do with that information afterwards, can be very complicated—in other words, time consuming.

One more thing to be aware of: While most primary care physicians have heeded the USPSTF recommendation to limit use of the PSA, urologists haven’t. If you see a urologist, he or she will be much more likely to order a PSA screening test.

If your physician does recommend a PSA, take time to ask questions, be fully informed, and really understand the pros and cons of the test.

Bottom line: For most men, the cons will outweigh the pros.

Sláinte,

Frugal Nurse

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Comments

Be informed – PSA screening tests — 5 Comments

  1. I sometimes wonder if the healthcare system avoids pragmatism. By encouraging the PSA, in the name of best practice, a doctor/hospital has the potential to make a lot of money. This video highlights that statistically speaking, there is very little benefit outside of the highest risk population. Pushing a slew of tests on a patient may just increase the amount of follow up care whether it is required or not. I agree with your response to Ray, knowing what tests are being performed and what you may want to do with the data is the key to taking control of your health care!

    • Hi Nathan, there is no doubt in my mind that many less-than-helpful screening tests are being ordered because they generate more income. Doctors don’t get paid much to just talk to a patient. They get paid to “do” something; the bigger the better. That’s why urologists are still dependent on the PSA as treating prostate cancer pays their bills. Our system is not practical, and it is full of perverse incentives and conflicts of interest. Thanks for your comment! FN

  2. Every year, a PSA screen, at this point I don’t think it’s going to change in my lifetime. Seems to be a “package deal” for routine blood analyses. The only thing that has changed is how I would respond to a PSA increase beyond that due to BPH for a man my age.

    • Hi Ray, you’re right. A lot of unnecessary screening blood tests are routinely bundled together and the patient bears the burden of knowing what is being ordered, asking why, and saying no. Sometimes the physician doesn’t even know every test that is being done–he or she just orders a pre-designed package for your gender and age. I’ve learned to ask for a printed out list of ordered lab work before going to the lab so I can strike off the tests I don’t want.

      Thanks for the comment! FN