Updated approach to prostate cancer screenings
Should men have their PSA checked?
Not too many years ago, the answer to that question would have been a simple one: “of course!” After all, the PSA (Prostate Specific Antigen) test was an amazing breakthrough that for the first time allowed prostate cancer to be detected before it was too late.
In the days before the PSA test, by the time prostate cancer was diagnosed, it had almost always spread through the body — it was already metastatic.
The excitement over PSA testing to screen for prostate cancer was later found to have a cloud hanging over it: urologists were finding far more cases of prostate cancer than had been found in earlier times.
While patients were unquestionably being cured of prostate cancer who before would have died from it, there were other patients being diagnosed and treated who in the days before PSA would simply have lived out their lives without even knowing that they had a mild form of prostate cancer. Prostate cancer, which before was underdiagnosed, was now being over-treated.
This was well-known to urologists, but the problem was this: who needed to be treated, and who was safe to watch?
Fortunately, large studies were already underway at institutions like the Mayo Clinic and Johns Hopkins University. These research studies proved conclusively that a large percentage of men with low grade and low volume cancer could be watched closely, without needing to go through the risk and expense of major surgery or full courses of radiation therapy.
In the early 2000s, urologists began to transition rapidly into doing surveillance on a sizable number of patients who were diagnosed with prostate cancer. This has proven to be completely safe as long as patients are carefully selected by strict criteria. I estimate that at least 40 percent of the patients I have diagnosed in the last 15 years have been best served by observation — not active treatment — and this has been great for patients.
Many people have heard of PSA testing as being controversial. I’ve had patients say to me: “I’ve heard PSA is a bad test.” This is too simplistic. The official recommendation of most official medical organizations is that providers should discuss the pros and cons of PSA testing with their patients before ordering the test.
Men between the ages of 55 and 69 should be having this conversation. In practice, however, a lot of men simply aren’t being tested at all until it is too late, and as a result, I have seen more men with metastatic prostate cancer in the last five years than I had seen in the previous 15.
My recommendation? Ask your provider to do the PSA test every year starting at age 55 (at age 40 if African-American or if you have a family history) — and if it is high, then see a urologist who takes a cautious approach.
Treatment is still the safest thing for many patients, but in 2017, you want to think surveillance first — not treatment first.
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