Who Should Get a PSA Test?
Every year, there are nearly 175,000 new cases of prostate cancer in the U.S. according to the American Cancer Society. Prostate cancer is the second most common cancer among men in the U.S., behind non-melanoma skin cancer, according to the Centers for Disease Control and Prevention. More more than 31,600 men die from prostate cancer annually, according to the cancer society. Overall, about 1 man in 9 will be diagnosed with prostate cancer in his lifetime. Prostate cancer is the second-leading cause of cancer death in men in the U.S., behind lung cancer. The risk for prostate cancer rises with age. Men on average are diagnosed with prostate cancer at age 66, according to the American Cancer Society.
What Is a PSA Test?
There are two primary methods of screening for prostate cancer, according to the Prostate Cancer Foundation. There's the digital rectal exam, in which a doctor places a gloved finger into the rectum to examine the prostate for irregularities, like a growth. Then there's the PSA test, which is a blood screening that looks for prostate specific antigens, which are proteins produced by the prostate and found in small amounts in the bloodstream.
What Is Considered a Normal PSA Level?
The test results are typically reported as nanograms of PSA per milliliter of blood, and an elevated PSA can be a sign of prostate cancer. What is considered a normal PSA level varies by age group. For example, for men in their 40s, a PSA level of 0 to 2.5 would be considered in the normal range. For men in their 50s, the normal range is 0 to 4; for men in their 60s and 70s, the normal PSA level range tops out at 4.5 and 6.5, respectively.
[See: Questions to Ask Your Doctor About Prostate Cancer.]
How Often Should Men Get One?
Years ago, most cancer organizations recommended that all men age 50 and above routinely have their PSA levels checked. But that led to unnecessary radiation treatment and unneeded surgeries to remove patients' prostate glands. The unneeded treatment, in turn, resulted in some men suffering from side effects of the treatment. For example, prostate surgery can lead to erectile dysfunction, urinary problems, internal bleeding, blood clots and infections. There's a risk of the patient having a poor reaction to anesthesia. Side effects from radiation therapy for prostate cancer include erectile dysfunction, irritation of the bladder and urinary tract and bowel symptoms.
Thanks to research suggesting that not every man should get a PSA test, cancer organizations today recommend that some but not all men, in consultation with their doctors, undergo PSA testing. The American Cancer Society recommends that men talk to their doctors about the "uncertainties, risks and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information."
At What Age Should Men Get a PSA Test?
These are the cancer society's recommendations for when men should have a discussion with their doctor about having a PSA screening:
-- Age 50 for men who are at average risk of prostate cancer and are expected to live for at least another 10 years.
-- Age 45 for men who are at high risk of developing prostate cancer. This would include African-American men (whose risk of developing prostate cancer is almost 60% higher than Caucasians, according to a study published in 2016 in the medical journal BMC Urology) and men who have a first-degree relative diagnosed with prostate cancer at an early age, younger than 65. A first-degree relative would be a father, brother or son. (The Prostate Cancer Foundation says having a mother, sister or daughter with breast or ovarian cancer puts men at high risk of getting prostate cancer. Having a first-degree male or female relative with colon cancer also raises the risk, the foundation says).
-- Age 40 for men at even higher risk. This would include men who have more than one first-degree relative who had prostate cancer at an early age.
Should Men Age 70 Get a PSA Test?
The cancer society's recommendations are similar to those issued by the U.S. Preventive Services Task Force. The USPSTF's recommendations call for men ages 55 to 69 to talk to their physicians about "the potential benefits and harms of screening" and to weigh their values and preferences in making their decision. Screening can reduce the chance of death from prostate cancer in some men, but it also carries potential drawbacks, including false positives that require additional testing, including a biopsy. Screening can also lead to over-diagnosis and over-treatment, the USPSTF says. The agency recommends against PSA-based testing for men age 70 and older. In a 2018 press statement, the American Urological Association says that "while we agree that a number of older men are not candidates for prostate screening, we believe that select older, healthier men may garner a benefit. We urge those men to talk to their doctors about whether prostate cancer testing is right for them." Men age 70 and above are less likely to benefit from the detection of low-risk cancer than younger men, according to AUA guidelines. "Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing as they are not likely to benefit," says Dr. Jonathan W. Simons, an oncologist and chief executive officer of the Prostate Cancer Foundation.
[See: 10 Things Younger Men Should Know About Prostate Cancer.]
Research on PSA Tests
Research changed the way urologists think about the need for PSA screening for prostate cancer, says Dr. Otis W. Brawley, a former chief medical officer for the American Cancer Society. He's also a Bloomberg Distinguished Professor at the Johns Hopkins University School of Medicine in Baltimore. A series of separate clinical trials published in the late 1990s and early 2000s suggested that widespread PSA screening on balance helped few men but at a great cost. For example, research suggested that out of a group of 1,000 men, four men would die of prostate cancer with PSA screening, and without it, five would perish from the disease. But increased PSA screening also meant dozens more men in the screened group of 1,000 would be diagnosed with prostate cancer. Many suffered terrible side effects -- like erectile dysfunction or incontinence -- from prostate cancer surgery or radiation treatment, he says. Research involving 162,000 men in Europe suggests that "for every life saved by PSA screening, 27 men would be diagnosed and treated for prostate cancer that wouldn't have been lethal if left undetected," according to Harvard Health.
PSA Research Advances
Advances in research over the last 20 years or so have allowed doctors to narrow down which prostate cancer patients should be treated, Brawley says. "In the 1990s we treated everybody," Brawley says. "In the 1990s we cured a lot of people with prostate cancer but they didn't need to be cured; their cancer was not going to kill them or significantly affect their lives. Today we have molecular tests that help us figure out who needs to be treated."
Thanks to the advances in research, today more than half of all men diagnosed with prostate cancer opt for active surveillance as opposed to surgery or radiation treatment, Brawley says. With active surveillance, doctors monitor men diagnosed with prostate cancer that's not believe to be aggressive enough to mandate immediate treatment. This approach cuts down on the number of patients who suffer the side effects of unnecessary prostate cancer surgery or radiation therapy, he says.
PSA Screening Options
It's important to keep in mind that having a PSA test that shows abnormal levels is not by itself the equivalent of a prostate cancer diagnosis, says Dr. Brian B. Norouzi, a urologist with St. Joseph Hospital in Orange, California. "The PSA test is only a screening test and does not definitively determine if someone has cancer," Norouzi says. In addition to cancer, other conditions, like an enlarged prostate or an infected prostate can raise PSA levels, according to the Mayo Clinic. If your initial PSA test results are abnormal, your doctor can recommend another PSA screening to confirm the results. Your doctor could, if the second PSA results are high, recommend continued PSA tests and digital rectal exams at regular intervals, according to the National Cancer Institute. If the PSA levels continue to rise or if your urologist finds a suspicious lump during a rectal exam, your doctor may recommend further tests to rule out other causes. For instance, a urine test could determine whether elevated PSA levels are caused by a urinary tract infection. The doctor may also call for imaging tests, like X-rays, a cystoscopy or a transrectal ultrasound, according to the NCI.
What Is a Prostate Biopsy?
If, based on testing, your doctor suspects prostate cancer, he or she may recommend a prostate biopsy, an invasive procedure in which hollow needles are inserted into the prostate, according to the National Cancer Institute. This allows for the collection of tissue samples that a pathologist will examine under a microscope for evidence of prostate cancer. A physician might use ultrasound to study the prostate during the biopsy. However, the ultrasound can't by itself be used to diagnose prostate cancer.
[10 Ways to Prepare for Surgery.]
Prostate Biopsy Risks
Having a prostate biopsy carries several risks, according to the Mayo Clinic. These risks include:
-- Rectal bleeding.
-- Blood in your semen.
-- Difficulty urinating.
-- Infection of the urinary tract.
