Established 1978

To PSA Or Not To PSA, That Is The Question!

by Dr. Jordan Shlain

For the last 15 years, the prostate-specific antigen (PSA) test has been a mainstay of conversation in the doctor’s office, around dining tables, and in the locker rooms of country clubs.

It seems clear that all men should be screened for prostate cancer, much the same way that women are screened for breast cancer with an annual mammogram. Doesn’t it?

Before we delve into this question, a little history is in order. A few decades back, we used to give 325 milligrams of aspirin for heart attack prevention. It wasn’t until we had the perspective of hindsight that we realized the gastritis and bleeding this therapy caused were outweighing the benefits. After many medical “papers” were published, the dose was optimized at 81 milligrams (and preferably enteric-coated).

Female hormone replacement therapy was all the rage in the 1980s and 1990s. It helped with menopause and solved the short-term problems. A landmark study in the last few years, however, has shown that the doses used were causing more harm than good. Naturally, this led to significant rethinking and changing of
Remember in the early 2000s, when CT scanners were the cool new diagnostic technology? Whole body scanners and heart scans were advertised in newspapers, and patients paid $1,000 per scan. Since then, it came to light that the radiation exposure far outweighed the benefit of the scans, and furthermore, the diagnosis of incidentalomas increased greatly. (An incidentaloma is an incidental finding that leads to unnecessary invasive procedures.)

With all this, you might have an idea of where the discussion of PSA testing is going. Luckily, we have just started to gain some perspective. In short, it should not be pro-forma to have every man undergo this test. Before deciding if you’re a candidate, you should first have a cogent and thorough dialogue with a physician regarding the pros and cons in your particular case. Since a growing chorus of physicians and respected organizations are rethinking the original recommendation, it’s time to shed light on this fascinating debate.

Let’s first explore the nuance of a PSA test. The goal of any cancer-screening test is to identify cancer early, when treatment can be most effective. For men who are 75 years old and older, though, invasive treatment for a slow growing cancer might not improve outcomes, specifically quality of life and mortality. In other words, the patient might not live long enough to experience the effects of the cancer, so why put him through a test that might lead to treatment that could reduce his quality of life?

You might wonder if there is an actual downside to a little blood test, even when you factor in the negatives. Well, the rubber meets the road when you get down to the meaning of “uncertainty.” This gets to the heart of the question: is it better to do something, or is it better to do nothing, when we know that we can never know the ultimate outcome?

Considerations that can help you organize your thoughts, as you go through the machinations of deciding whether to undergo the test, are the risk factors:

• Age: after age 50, your chance of having prostate cancer increases substantially

• Ethnic background: black men have a higher risk for developing and dying of prostate cancer

• Family history: if a brother or father was diagnosed before the age of   65, your risk is greater than average

• Diet: a high fat diet and obesity could increase your risk

Official recommendations include:

American Urological Association: test, starting at age 40

American Cancer Society: consider starting testing at age 50 for average risk, younger for high risk

Centers for Disease Control: evidence insufficient to determine whether the benefits outweigh the harm

US Preventive Services Task Force: no testing if over 75; evidence insufficient for men under 75

Institute for Clinical Systems Improvement: not enough evidence to clearly determine whether early detection saves lives

Ask the Doctor: Email us at with your health related questions. We will try to answer you in our next column.

Dr. Jordan Shlain is the founder and medical director of Current Health Medical Group. He is also an assistant clinical professor at the UCSF Medical Center and a medical economics lecturer at UC Berkeley.

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