When the U.S. Preventive Services Task Force recommended in October 2011 that men not get routine PSA screening for prostate cancer, many men were surprised and angry—similar to the way women felt two years earlier when new mammogram guidelines were released. PSA stands for prostate specific antigen, a protein produced by prostate cells and released into the blood.
Even though the PSA blood test can detect cancer early, it saves few, if any, lives and often leads to treatments causing serious complications, according to the draft guidelines from the Task Force. It concluded that the substantial risks of screening outweigh the benefits, which are small at most, and thus the PSA test should be discouraged. Note: The guidelines focus only on routine screening, not the use of PSA in men with symptoms or signs of prostate cancer or for its use to monitor cancer treatment. Also, the financial costs of testing and treatment were not considerations in the analysis.
For most American men who have had PSA tests—and especially the two million who have been told they have cancer based on results of screening and subsequent biopsies—this was probably a shock. But actually it wasn’t something out of the blue. Three years ago, the Task Force advised against routine PSA tests for men over 75 for the same reasons and, reportedly, it was ready to recommend against routine screening for all men, period. But fears of a backlash (from patients, urologists and politicians) led it to call for more analysis of the data and to postpone the release of the new guidelines.
The value of PSA screening has actually always been questioned. The Task Force has never recommended it, though until now it just said there was insufficient evidence to recommend for or against it for men age 50 to 75. In 2010 the American Cancer Society stopped advising routine screening and urged more caution; it now simply tells men to talk to their doctors about it. Urological and prostate cancer advocacy groups, which have been boosters of screening, are most vocal in disagreeing with the Task Force’s recommendations.
How can a simple early-detection test for cancer not automatically be a great thing?
ABCs of PSA
The prostate, a gland between the bladder and rectum in men, produces seminal fluid. Cancer of the prostate is the second most commonly diagnosed cancer in men (after skin cancer) and the second leading cause of cancer deaths in men (after lung cancer).
The unusual thing about prostate cancer is that the great majority of tumors—especially in older men—remain small, develop very slowly or not at all, do not spread and cause no symptoms. It’s estimated that 1 in 6 American men will be diagnosed with prostate cancer, and 1 in 36 will die from it—meaning that it is fatal in about 15 percent of diagnosed cases. Thus, far more men die with prostate cancer than from it. In fact, autopsy studies reveal that one-third of men in their forties and fifties and three-quarters of those over 85 had prostate cancer—usually small and harmless—and never knew they had it (they died from something else).
Age greatly increases the risk of prostate cancer—about 85 percent of cases are diagnosed in men over 60, and 70 percent of deaths occur after age 75. Having a brother or father with prostate cancer more than doubles the risk. Black men are 60 percent more likely to develop it than whites, and twice as likely to die from it. Nevertheless, the Task Force did not recommend screening for black men or those with a family history, for lack of evidence of benefit.