Many doctors still recommend PSA testing to screen for prostate cancer

Like many men his age, Marlin Zook began getting prostate screenings about 15 years ago even though he had no risk factors for prostate cancer. When his PSA level turned up elevated, his doctor began watching it more closely.

A biopsy in 2000 showed abnormal cells deemed moderately aggressive. Zook underwent radiation and today, at age 76, he calls that screening test “a lifesaver.”

“My urologist told me recently that if they hadn’t found cancer when they did and hadn’t treated it as we did, ‘you would no longer be with us,’” the Upper Allen Twp. man said. “I’m very thankful.”

Zook’s is a dissenting voice in a growing chorus of naysayers on the need for routine prostate screening.

“For most men, doctors will say ‘you’re going to die with it; you’re not going to die from it.’ But you don’t know if you don’t have the screen,” Zook said. “I would say get a baseline PSA for sure; it’s very important.”

The PSA test measures the blood level of prostate specific antigen, a protein that is produced by the prostate gland. The higher a man’s PSA level, the more likely it is that he has prostate cancer. Doctors also do a digital rectal exam to feel for size and abnormal growths.

However, the PSA test can uncover small tumors that would not grow fast enough to threaten life, whereas side effects of treatment for the tumors might threaten quality of life through incontinence and sexual dysfunction, said Dr. Jay Raman, urologic surgeon at Penn State Milton S. Hershey Medical Center.

“Is PSA screening rampant? Yes. Is it necessarily used properly? No. But it is of benefit when it is used properly,” Raman said. “I am hard pressed to look at a 44-year-old man with a family history of prostate cancer and treat him the same as a 70-year-old man with heart disease.”

Recently, the U.S. Preventive Services Task Force recommended that healthy men should no longer receive PSA screening. The American Cancer Society and the U.S. Centers for Disease Control also say there is insufficient evidence to recommend it.

More recently, the American Society of Clinical Oncology said, “For men with a shorter life expectancy, harms appear to outweigh benefits, while for men with a longer life expectancy the balance is less clear.”

On the other hand, prostate cancer remains the second-leading cause of male cancer deaths.

All of this can leave a man feeling confused — should he have PSA screenings or not?

Dr. Scott Owens, urologist with Urology of Central PA Inc., strongly disagrees with the recommendations against screenings. He says he’s particularly dismayed that the U.S. Preventive Service Task Force did not include one urologist or oncologist in the panel making the recommendation.

“The bottom line is with PSA testing, you don’t see the value in it until after 10 years,” he said, citing an 11-year, European study recently published in the New England Journal of Medicine that reported a 21 percent reduction of death in men who had PSA screening vs. those who did not.

“The PSA blood test is the only way we can pick up the disease in asymptomatic men. For men with aggressive prostate cancer, which is 20 to 30 percent, it will go completely undetected and develop into metastatic disease that can be fatal,” he said.

By detecting cancer early and doing a biopsy, doctors can evaluate whether it is slow growing or more aggressive and whether to wait and watch or actively treat it.

However, Hanover oncologist Dr. Marc Hirsh said that even if doctors explain to patients that prostate cancer can lie dormant in the body without causing harm, most men, upon hearing cancer is present, will go ahead with therapy rather than live with the anxiety.

Indeed, 90 percent of men who find out they have prostate cancer elect for active therapy, Raman said.

When Palmyra resident Gary Young found out his PSA was elevated and a biopsy showed cancer cells, he didn’t hesitate to get treated.

“I was not interested in waiting and watching when told I have cancer,” said the 63-year-old car salesman. “If I would have waited, who knows what may have happened.”

He elected to have his prostate removed last December with robotic surgery done by Raman. He said the procedure was painless and he was back to work within a week. His only side effect was temporary incontinence for about three months. He will be monitored with blood work every three months for the next five years.

Young, whose father had prostate cancer, said he would have gotten screened even without the family history.

Since his experience, he’s become an ambassador for PSA screening. “This is something that really needs to be talked about,” he said. “I think men should get a physical every year and it should include a PSA every year.”

Still, some doctors, including Hirsh, said that’s excessive. “While screening may have saved some lives, in a large percentage of men, it leads to a lot of unnecessary treatment with side effects such as incontinence, impotence and bowel and urological problems,” he said. “Many doctors are still ordering the PSA test and I don’t think patients are really informed. All men at age 50, or sooner if they are at high risk, should become informed about the limitations and risks of taking the test and then make a decision.”

Owens said he recommends men have a baseline PSA at age 45, the results of which will determine how frequently further testing is needed. Men at high risk for prostate cancer should have their baseline PSA at age 40 and every year thereafter, he said. (Risk factors for prostate cancer include having a first-degree relative diagnosed with prostate cancer before age 65 and being African-American, according to the American Cancer Society.)

“Men get intimidated by sound bites about risks,” Owens said. “Robotic surgery and newer forms of radiation lower those risks. Sure, there are still risks, but the alternative is to miss it and not treat and then have a mortality.”

Raman said he’s concerned that the new guidelines give men the wrong message.

“I think the message they’re getting is that they shouldn’t worry about prostate cancer, and that’s not accurate. The fine print after these recommendations says that men should have a discussion with their clinician about what’s right for them, but I don’t think people get to a lot of the fine print,” he said.

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