Dilemma of the PSA test to detect Prostatic Cancer

Written by Dr. Harold Gunatillake FRCS, FICS, FIACS, MB, BS, AM (Sing)-Health writer

When you are over 40, the doctors’ advice you to have a PSA test to check and record the number as your base, for future comparisons. If there is a history of prostate cancer in the family, you are advised a test yearly. If you do not have a family history and your first PSA test is low, then your doctor will advise you to get a test done every three years. If the first reading is high or subsequent readings reveal a progressive increase in the numbers, the problems arise. It is a dilemma for the patient, family doctor and the specialist to evaluate and manage such cases.

The normal PSA levels on a single blood test giving less than 4 ng/ml are considered normal, and you need to thank God or Karma for it. Recent studies, some recommend lowering the cut-off levels less than 2.5 or 3ng/ml. as normal. PSA values are low in younger people as their prostate glands are smaller. If the number is higher than 3ng/ml in a younger patient that would be a cause for concern. The doctors wouldn’t be concerned if the number is borderline or above on the first reading. But, on successive tests, if it is going up progressively over a period of years, then it would be a concern. Keep in mind that with age the prostate gland does get bigger and more Prostatic-Specific Antigen (PSA) is secreted under normal conditions. This also has to be considered in pinpointing prostatic cancer. The test is done on a sample of blood taken usually from the arm. This is called a screening test for cancer.

Now there is a difference between statistical findings and treating individuals for prostatic cancer. Statistics seem to reveal that doing PSA screening tests and treating or when the test is not done and not been treated the death rates don’t differ very much, or the difference is marginal. So why should patients go through painful biopsies of the gland with needles through the anal canal, grading the
cancers and further being treated with operation, radiotherapy, and chemotherapy respectively, if there is no difference as far as the statistics reveal without such procedures?

There also have been unnecessary operations being done on PSA values alone when prostatic cancer was not found with lab results.
The United States Prevention Services Task Force (USPSTF), a non-governmentalexpert panel that produces guidelines for primary care providers proposed new recommendations advising doctors to perform the PSA test only for older men after discussing the pros and cons and further management and intervening through consent with the patients.

It is considered important that the patient is warned in doing a PSA screening test on clinical suspicion.

In the early stages, there are no symptoms to detect prostate cancer clinically from the history of symptoms and signs. Enlarged prostate which is normally detected clinically or otherwise on per rectal (PR) examination may also give symptoms common to both situations, but in cancer, it is more likely to get pain during ejaculation and blood in urine or semen, in addition to difficulties in passing urine. Pain behind the scrotum is a sure sign of inflammation or early cancer of the prostate gland.

In 2012 USPSTF released a controversial recommendation against PSA testing at any age. It was based on a large US study showing no decrease in prostatic cancer deaths among men screened using the PSA test. Many cases were diagnosed having cancer on the PSA test alone and unnecessarily treated with surgery or radiation On the other hand, there was another large study in European men showed a small decrease in prostate cancer deaths after more than 10 years follow-up who were treated.

My view is that PSA test should be done on every patient who asks for it, and those having a family history, yearly. The younger people less than 60 diagnosed on progressive PSA tests need further surgical intervention and surgery. Those elderly people diagnosed on PSA screening could wait without any further intervention other than observation regularly. They would live for a considerable period with or without surgery.

You need to discuss with your doctor and you need to make a decision when it comes to prostate cancer diagnosis on the screening test. It is a very difficult decision for you to face.