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No One-Size-Fits-All Prostate Test Answer

The draft recommendation by the U.S. Preventative Services Task Force on prostate cancer screening has led to renewed debate regarding the value of prostate-specific antigen testing. PSA is a blood test that is routinely given to men beginning at age 50.

Certainly, the decision to undergo any cancer screening (colonoscopy, mammogram, pap smear, PSA test) is a personal one. However, it’s important for men to understand the pros and cons of PSA screening.

First the facts: In 2010, prostate cancer was the No. 2 cause of cancer death in American men. Nationally, more than 30,000 men died of this disease – representing 11 percent of the total cancer deaths.

PSA screening does save lives. In fact, there has been a large reduction in prostate cancer mortality in the last decade (when PSA testing became more common) compared with years past. The proportion of men cured with treatment has also gone up dramatically in the era of PSA.

It is true that most men diagnosed with the disease will not die from it. However, many people do not realize that prostate cancers are not all the same. That is, some forms are aggressive and more lethal, while other forms are only rarely so.

If one harbors a slow-growing prostate cancer, it may be reasonable to avoid treatment and “watch” the cancer. I have many men in my practice doing just that.

But for the man with an aggressive prostate cancer, catching it early with a PSA test and then treating it could be truly lifesaving. These men, I believe, have the most to lose by not getting a PSA test.

Critics of PSA point to prostate cancer’s lower overall mortality rate as a reason to forgo testing. They also cite potential risks of treatment.

But as a cancer specialist, I have seen the whole spectrum of this disease, and can tell you this doesn’t tell the entire story.

Advanced prostate cancer can lead to painful and serious complications without causing death. I often see such men develop urinary retention – the inability to urinate – which usually requires surgery. Bone pain, spinal cord compression and bleeding are other potential risks that have been well documented in the medical literature. Indeed, death should not be the only measure of a cancer’s prowess.

The PLCO trial, published in the New England Journal of Medicine, is frequently used as evidence against PSA testing. However, most people are not aware of the serious flaws in how this study was conducted.

To evaluate PSA, it would make sense to compare men who undergo PSA screening versus men who do not. Instead, the authors compared more screening with slightly less screening – the majority of men in both groups had undergone PSA tests in the past!

Not surprisingly, the study couldn’t detect a difference. But another, more scientifically sound study, published in the New England Journal of Medicine, did show a survival benefit to PSA screening.

So what should men do? The answer is not as simple as the Preventative Services Task Force would make it seem. Indeed, many respected cancer organizations continue to recommend PSA testing.

Not everyone with an abnormal test needs something next. PSA is certainly not perfect, but eliminating it altogether only sends us back in time. Rather, the focus should be on improving the test and interpreting it better – such research is ongoing at the University of New Mexico and around the world.

If you believe ignorance is bliss, you probably won’t want to get a PSA test. But if you are healthy, have a good life expectancy and want to reduce your chance of dying from prostate cancer, talk to your doctor about getting a PSA test.

Dr. Satyan K. Shah is the director of robotic surgery at the University of New Mexico Cancer Center.

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