New article says PSA (Prostate Specific Antigen) Saves Lives in men by a whopping 13 % as advanced prostate cancer rates are on the rise.
What is PSA or Prostate Screening Antigen?
PSA (Prostate Specific Antigen) is a protein made by the prostate gland in men that is measured by a blood test. Its levels rise as we age with higher levels associated with cancer. It is a screening test for prostate cancer but due to lack of consistent evidence that it saves lives the guidelines on testing are not as well defined as other screening test, like colonoscopy that screens for colon cancer.
A new study in NEJM (New England Journal of Medicine) says screening men with PSA reduces the risk of dying from prostate cancer by 13 % maybe more. This is the first study that shows a clear benefit of PSA screening with outcomes in mortality similar to that of having a colonoscopy to prevent colon cancer.
Prostate cancer is the #1 cancer in men. Prostate cancer deaths are expected to double over the next 20 years due to an aging population and men living longer. The wide-spread belief is that most men will die with prostate cancer not because of prostate cancer so testing and screening is more relaxed.
The current guidelines by the American Urology Society suggests PSA as a screening test in men ages 45 to 50 and to offer every 2 to 4 years up to the age of 70 or if life expectancy is 15 years or more. It may be offered to younger men at age 40 who are at higher risk for prostate cancer including those with genetic mutations (BRCA gene), black race, or 2 or more family members with a history of prostate cancer. The decision to screen for prostate cancer is a shared decision with your doctor understanding the risks and benefits of screening.
Why is PSA testing for prostate cancer so important?
The new study, “European Randomized Trial of Screening for Prostate Cancer,” looked at over 160,000 men ages 55 to 69 in 8 European countries over a 20-year period and asked the question: Does the benefit of testing with PSA (Prostate Specific Antigen) impact mortality or the risk of men of dying from prostate cancer given the controversy surrounding the benefit of screening for prostate cancer in men.
Studies have reported a 20 % reduction in prostate cancer deaths using PSA testing however the benefits are often offset by overtreatment or overdiagnosis of an indolent type of prostate cancer that is slow to progress especially with the potential negative side effects of treatment. Side effects of treatment include difficulty control peeing (leakage), sexual problems, and bowel control.
Although the study did not screen men above the age of 70 it did show clear cut survival benefit of screening that was not offset by harm with the average age of screening at age 60. The authors argue that a 13 % improved survival rate may have been higher if screening started at the age of 50.
The 3 big takeaways from the study: PSA-based screening lowers prostate cancer deaths, over diagnosis and over treatment still remain key challenges, and targeted and standardized screening may optimize benefits including testing at earlier ages and with high-risk groups.
Why is screening for prostate cancer using PSA controversial?
Even though prostate cancer is the #1 cancer of men accounting for 35,000 deaths each year in the U.S. there is controversy about PSA screening in the medical community. The reason for the debate is the assumption many prostate cancers grow so slowly that would never threaten a patient’s life, but the new study argues that PSA screening can save 1 in every 12 men’s life by identifying aggressive cancers sooner.
It is important that if the initial PSA is elevated the American Society of Urology recommends repeating in a few weeks to be sure is a “true,” positive. PSA can be artificially high due to infection or prostatitis, long-distance bike riding and ejaculation if done within 48 hours of testing.
The guidelines say if your PSA is within the normal range for age but increasing from the prior year’s it may be concerning for cancer. Your doctor may consider if PSA is rising or elevated to perform a DRE or digital rectal exam to see if he or she can feel a hard nodule or signs of cancer. A prostate ultrasound or MRI may be helpful in checking the size or “prostate density,” or areas that are suspicious for cancer. Other blood tests like a “free,” PSA may be helpful along with a prostate PET scan where areas of cancer may “light up.”
Symptoms of prostate cancer are usually absent but may start with blood in the urine or difficulty peeing and in advanced cases weight loss and bone pain as prostate cancer spreads to bone. Treatment of prostate cancer is complex so important to distinguish between aggressive forms compared to more indolent or slow growing forms as treatment can lead to life altering including erectile dysfunction, and bladder and bowel issues.
Any last advice about PSA screening?
PSA screening in younger men ages 45 to 69 is important. It is the #1 cause of cancer in men and the #2 cause of cancer deaths in the U.S. The American Cancer Society estimates that in 2026, there will be 330,000 new cases affecting 1 out of every 8 men.
There are conflicting reports on the benefits of PSA screening as many men with prostate cancer will be indolent and slow growing and can be followed conservatively. This coupled with side effects of treatment including the inability to sustain an erection makes screening and treatment options more challenging as quality of life needs to be considered.
That said, the new Study out of Europe is one of the largest and most robust studies and says screening with PSA saves lives by a whopping 13 % and implies higher if started at ages 45 or 50. Currently, in the U.S. PSA testing among younger men is low and high in men over the age of 70 leaving little opportunity to prevent deaths by early screening. It is important based on this study that we make PSA a critical part of our routine labs and annual wellness visit. It’s a diagnosis that should not be missed as the number of new cases of advanced prostate cancers continues to climb.
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