Tests for prostate-specific antigen may not be perfect but in my case, results helped identify my prostate cancer. A sudden rise in my PSA levels was the first alarm to indicate that further testing was required.
All kinds of things affect PSA results: age, ethnicity, medications, inflammation, benign enlargement of the prostate gland, lab variability, and body mass index.
Despite being flawed, PSA results are worth paying attention to. That’s not the message that men have been getting because over-reliance on the tests can result in over-treatment. The United States Preventive Services Task Force came out against testing for PSA in 2012.
The Canadian Task Force on Preventive Health Care followed in 2014 with similar concerns that the PSA tests were too unreliable and heightened the risk of overdiagnosis, unnecessary follow-up, and treatment.
The warnings never made sense to me. We are told that early detection leads to the best treatment for cancer. Yet, the advisory groups said that such screening was unlikely to save many lives and would lead many men to undergo harmful surgery or radiation that could make them impotent or incontinent.
That may be true when PSA tests are the only indicator. Too many men, and their doctors, rely on PSA tests as conclusive. I think that’s especially true in the U.S. because health is a marketable commodity, not a universal right. If you can pay for treatment and if there are doctors looking for patients, supply and demand will dictate treatment. In a market-driven health care system, treatment is preferable to doing nothing.
Yet, doing nothing is a reasonable option. It’s called “watchful waiting” and it was offered to me by my doctor as an option. Doing nothing is more likely to happen in Canada where the opposite market conditions exist: doctor supply is low and the demand in our universal system is high.
I was encouraged by a study in the Canadian Medical Association Journal where the response to PSA tests is more nuanced. Dr. Rodney Breau, senior author of the study and surgical oncologist at a Ottawa Hospital, says the PSA test is a valuable tool and that the potential risks overtreatment can be managed.
“Instead of throwing the baby out with the bathwater and just scrapping screening altogether, many people believe if we screen smarter and treat patients more appropriately…then we’re going to keep all those benefits of screening and really significantly reduce potential harms that might be associated with it,” Dr. Breau told the Globe and Mail.
In my case, watchful waiting was not an option. For one thing, my PSA levels were high and rising quickly. A rectal exam revealed my prostate was large and asymmetrical. The Gleason score on my biopsy was high (a test of how aggressive the cancer is). The good news was that the cancer had not metastasized; it was contained in my prostate.
Unlike me, for most men who receive PSA tests watchful waiting is the best option. The CMAJ study showed that only 30 per cent of the subjects who monitored results required treatment. It’s worth paying attention but not as a sole indicator.