The PSA test in “screening” for prostate cancer: yesterday, today, and tomorrow


So our good friend Howard Wolinsky has just written up his assessment on the evolution of the use of the PSA test in “screening” for prostate cancer in an article on the MedPage Today web site.

First and foremost we should congratulate Howard on his careful interviewing of a number of significant individuals (from the USPSTF, the AUA, and the AAFP) in putting together his article. Howard is nothing if not thorough. However, …

As Howard points out with care … and these are things that all of the relevant opinion-leaders now seem to agree with …

  • The widespread use of the PSA test to “screen” men at potential risk for prostate cancer remains controversial (for all sorts of reasons).
  • The critical issue is not actually having or not having the test, it is what is done with the resulting data after one has the test.
  • Factors such as genetics, race/ethnicity, age, etc., are all crucial in determining when one first needs to get a PSA test and how frequently thereafter; there is definitively not “one size fits all”.
  • It is extremely important that the doctors who offer the test and use its results in advising their male patients should apply the basic principles of “shared decision-making” in helping their patients to understand the implications of both having a PSA test and taking next steps if the PSA level appears to be “abnormal (i.e., elevated).
  • The question of who should still continue to get PSA tests for risk of prostate cancer after the age of 70 years remains unresolved. Some men certainly should; others probably shouldn’t.

In and of itself, what a PSA test does when it is used in the care of a man who does not have prostate cancer is give him information about his risk for a series of different urological conditions, of which prostate cancer is just one.

Our own perspective is that, in the not too distant future, for many men who are found to have an elevated PSA level suggesting potential risk for prostate cancer, there will be newer tests (not just MRI scans and phi tests and 4KScore tests) that can help to better define risk for prostate cancer based on a simple urine sample.

The PSA test is not going to go away, however. It is relatively cheap. And unless and until a urine test with a high level of specificity and selectivity is equally low in cost, a PSA test based on a blood sample will probably remain as the base test for assessing potential risk for prostate cancer. Again, the test itself has minimal risk. The issue is what you and your doctor think about the results.

17 Responses

  1. Testing and treatment was one of the worst mistakes I have ever made in my life. My doctor lied to me and I now have a long list of side effects. I get no help from any of my doctors. Do not get tested is my advice. Read the USPSTF recommendation vary carefully concerning the risks.

  2. W.r.t. to any discussion around PSA testing, bear in mind:

    “THE PSA TEST IS ABOUT INFORMATION NOT TREATMENT”

    With this moniker in mind, we at AnCan believe the PSA test will never get misappropriated.

  3. Can I please share my experience of PSA testing in the UK with you?

    A work colleague died from prostate cancer. He had repeatedly gone to his general practitioner (GP) with groin pains and been told to take paracetamol (acetominophen), etc. When he eventually had the PSA test it was too advanced and he died from prostate cancer. I visited him in the hospice a few months before he died and he was very bitter about his GP’s failure to diagnose his prostate cancer. His widow at his funeral service encouraged every man to have the PSA test.

    Needless to say this had an indelible effect on me. I went to the GP and had a digital rectal exam (DRE) and was told I was OK. I was not given a PSA test and was only too happy to hear that I was fine. More than 8 years later my urine flow and ejaculation changed. A social friend I knew was talking to me and others about his prostate cancer. I spent 3 to 6 months mulling it over and then I went to my GP. I felt very healthy and expected to be told I was one of the “worried well”. My GP did a DRE and told me that it felt OK but that if I wanted I could have a PSA test done. The GP was quite equivocal about whether or not I should have the test done as she explained the negative aspects of the test. False positive, false negative, other reasons for a high PSA. It was left entirely to me to decide whether to have the PSA done or not.

    The GP delayed my test a week because a DRE could cause a spike in PSA. I was very close to making the same decision I had 6 years previously. Why not accept the DRE interpretation as good news? But I thought about my dead colleague and my social friend and with mixed feelings, went ahead with it. Two days after my blood was taken my GP phoned me to tell me that my PSA was 800 ng/ml!! That was in April 2017. I was seen by a urologist a week later who considered the DRE was NOT normal and a second PSA confirmed a PSA around 800. I was put onto ADT and then six sessions of chemotherapy. My PSA dropped to 0.2 ng/ml.

    What I learned from this was that a DRE and a PSA together should be used to make a decision BUT GPs may not be exposed to enough cases or sufficiently proficient to know from a DRE that there is a problem. During and after my two systemic treatments, PSA tests have been the single biomarker used to monitor my cancer and its treatment. After about 30 months my PSA started to rise again and I was given a bone scan and an MRI scan. Both came back negative and my hospital treatment team were not proposing any further action other than repeating these scans at intervals and monitoring my PSA. I was not at all happy with the rising PSA as it rose to 1.5 ng/ml and it’s doubling time was about 5 months.

    I then went to a private healthcare company and had a Ga PSMA test which lit up in both lobes of my prostate, more in my left. I presented these results to my oncologist and was given 20 radiotherapy sessions. I am waiting to see what the outcome is next month, 8 weeks after my treatment ended. A week before my appointment I am to have a PSA test. So for me and those treating me, PSA is a very important if not the only biomarker currently and cheaply available.

  4. Dear Rick:

    “Misappropriated”? I’m not sure that’s what you mean.

    To “misappropriate” something means “to dishonestly or unfairly take (something, especially money, belonging to another) for one’s own use.”

    I think the term you are looking for is “mis-use” or perhaps “mis-apply”.

  5. Over 30,000 American men are dying each year of this disease. There are an estimated over 450,000 men on ADT. The PSA test is accurate. What to do with the result is the question. This is not hard but our medical complex continues to miss-manage prostate cancer.

  6. I actually did mean misappropriated although you may not agree with the choice of word.

    I had in mind that urologists took the PSA test and used it to their financial benefit … and that’s what generated the critical train against PSA causing over-treatment.

  7. Dear Mr. Wadsworth:

    Your statistical facts are correct. However, I am not sure what you are implying when you state that “The PSA test is accurate”. If you mean that this is an accurate assay of prostate-specific antigen in a blood sample, that is correct. However, it is NOT an accurate assay of risk for prostate cancer on its own. And there are very serious questions about how best to conduct a work-up (let alone a cost-efficient work-up) on a man with a PSA level of between 2.5 and 20.0 ng/ml (although it is certainly the case that, in general, the higher the PSA level the greater the possibility that that PSA level is cause by prostate cancer).

  8. And my advice to @John …

    Don’t blame the PSA test, and don’t discourage testing. Sounds like your anger should be directed at the urologist who “lied” to you. That was not the PSA test’s fault.

    You and your urologist did a poor job communicating and you did not educate yourself well enough before choosing to undergo the knife. The PSA test just indicated you had an issue to resolve — is that a bad thing? if you did not get this information, the alternative could have been a lot worse.

    At this point it sounds like you need a new medical team that will help you — join a peer support group. There are many good ones online.

  9. Dear Rick:

    Long before the widespread availability of the PSA test, Patrick Walsh at Johns Hopkins was taking out prostates of men with low-risk prostate cancer because he believed — at the time (c. 1982 – 1990) — that it was the right thing to do. And he was telling every urologist in America that it was the right thing to do. I don’t believe that Pat Walsh was financially motivated to do this at all.

    I will accept that when the PSA test became available, there were urologists like Bill Catalona and others who pressed hard for the use of the PSA test as a screening tool for risk of prostate cancer and still believed that every patient with any amount of prostate cancer (down to well below Gleason 6 at the time) should have their prostate removed to prevent risk for metastasis and prostate cancer-specific mortality.

    I will also accept the idea that there are urologists who see the surgical management of prostate cancer as an excellent way to make money, and that there are urologists who present data to patients in a biased manner. However, I would also point out to you that there has been a major shift in attitudes over the past 10 years, and the majority of urologists today are very willing to recommend active surveillance to appropriate patients with lower-risk forms of prostate cancer. Indeed, it is now arguable that within the VA system it is becoming rather difficult to get first-line surgery for low-risk prostate cancer, even if one wanted to have this.

    We have ALL been complicit in this to some extent. When people like Terry Herbert and I first started to suggest (in my case around 1995) that widespread, annual mass screening with the PSA test wasn’t necessarily one of the world’s best ideas, we were howled down, not by the doctors but by the patient community. When Peter Albertsen first presented data showing that the risk of prostate cancer-specific mortality was very low for men with Gleason scores of 6 or less, he was howled down by many in the academic prostate cancer research community.

    We are wasting time placing blame retrospectively all over the place. The trick is to improve knowledge and call out those who don’t act on it appropriately through shared decision-making …

  10. Dear Charles:

    I am sorry to hear your clinical history. This was a problem from the day you were first given a DRE. A DRE was well known (by 2017 and long before) to NOT be an accurate way to assess risk for prostate cancer on its own. Your GP should have known that at the time. There is really no excuse for him or her not being aware of that.

  11. Hello Mr. McGill:

    Now that you have private insurance, we hope you are seeing a specialized genitourinary medical oncologist in the UK. If not we would be happy to provide you with a couple of names.

    Have you had any type of genetic testing?

    Feel free to reach out to me at rd@ancan.org

    Onward & upwards, rick d.

  12. We’ll beg to differ, Mike! You have been pushing your arguments for as long as I have been participating on your forum … and I still find them lacking.

    I strongly opposed the USPSTF D rating back in 2012 …. I recall you were not as vocal in opposition largely because you opposed widespread testing, and still may — but that is for you to say. I believe there were fallacies in your argument and still do. But I doubt I will ever convince you, although you have softened considerably and made concessions over the years.
    See if you can’t find the posting and discussions we had in 2012. I stand to be corrected.

    And why has their been a major shift in attitude amongst urologists. Because advocates like me along with doctors like Peter Carroll, Matt Cooperberg, and Lawrence Klotz have long been vocal that AS is a viable treatment alternative and that testing should be widespread. Rather than having another go at me around urologist malfeasance, highlight the fact that USPSTF now acknowledges many urologists mistreated their patients for years:

    “Back in 2012, the data actually showed that that’s not what was being done.In fact, 90% of men with low-grade prostate cancers were getting surgery and radiation,” said Krist. “And we know today that that is overtreatment, and the treatment patterns changed between 2012 and 2018 [when USPSTF again reviewed its PSA guidelines].”

    Dr. Alex Krist, USPSTF Chair.

    I for one am not part of your “we” identified as being complicit. Please never include me in that group! And I can name a number of other prostate cancer advocates who were not complicit. Sadly many of them are not with us today because they never got tested early enough. Our “we” were vocally in opposition to the USPSTF guidance in 2012 and 2016; and we sought widespread testing! Your “we” is not my “we”!

    Personally I started getting PSA testing at age 41. Sadly I did not know enough then to pursue the results or perhaps I may have avoided the consequences of being treated for T3 disease 15 years later.

  13. Very glad I was never a Catalona patient.

  14. A “(let alone a cost-efficient work-up)”?

    So the 30K+ deaths and the near 500K men on ADT are reasonable costs and acceptable losses? mpMRIs are not an unreasonable cost and a good next investigative tool after PSA or DRE raise concerns. Yes thee out of four elevated PSAs are not from cancer. The key is to find the one that is. And yes DREs miss most early stage cancers. The medical establishment must replace the “all clear” finding with “I did not feel anything of concern but this does not mean cancer is not present”. Sitemaster your intentions with your answers confound me.

  15. Dear Sitemaster,

    Thanks for your reply. I wholeheartedly agree that a DRE and PSA test should automatically be done as one set of tests. I just think the arguments about the value of the PSA test result and its interpretations is causing confusion and being misunderstood by GPs.

    Just to correct an error that I made in my rather lengthy piece … when my PSA started rising again I was given a CT scan and a bone scan (which were negative) NOT an MRI scan and a bone scan.

    When I supplied the gallium-68 PSMA data I was then given an MRI scan to plan for the radiotherapy.

    CT and bone scans, two separate procedures, would be much better replaced with a single gallium-68 PSMA scan to investigate rising PSA levels.

  16. Dear Mr. Wadsworth:

    Please appreciate that I am NOT the person who makes decisions about the costs of medical care in this country. However, I would note that (just for example) the average cost of a pelvic MRI here in the USA is anywhere from $500 to $2500 and upwards. In places like Australia and Japan it rarely exceeds $500 to $600.

    You are missing the point that I am making, which is NOT that patients shouldn’t get appropriate work-up after an assessment of initial risk for prostate cancer. They most certainly should! My point is simply that there is no consensus (among physicians and payers, let alone patients) about what type of work-up is appropriate for whom.

  17. Dear Charles:

    If you look at places like Australia, you will find that the gallium-68 PSMA tests have pretty much already replaced initial bone scans and CT scans in the assessment of potential risk for more advanced forms of prostate cancer. My personal belief is that this will also occur in most of Europe (including the UK) and the USA within a few years. However, cost is a complicating factor (particularly in the USA).

    With regard to the appropriate education of GPs in the UK, the appropriate role of PSA testing and the initial assessment of the results of such testing is hardly complicated today. My suspicion is that there may be pressure on GPs not to refer patients with elevated PSA levels to the hospital-based urology community unless this is considered to be “essential” (a political and administrative issue as opposed to a medical one). I say this as someone who was born in and lived in England until I was well over 30 years of age and had considerable familiarity with the workings of the National Health Service.

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