Testing for Prostate Cancer Has Come Under Fire

The prostate specific antigen (or PSA) test for prostate cancer can lead to over-testing and over-treatment for non-aggressive cancers, with serious side effects.

When the PSA (prostate-specific antigen) test became widely available in the late 1980s and early 1990s, millions of middle-aged men in the U.S. who had no signs of prostate cancer were soon being tested for the disease. In fact, the PSA test, which measures the level of a protein produced in the prostate by both normal and cancerous cells, quickly became the standard in doctors’ offices for testing men for prostate cancer.

There were several reasons why the simple blood test became so popular. There’s no doubt cancer is one of the most dreaded diseases. Early diagnosis and treatment are considered the best ways to find a cure and avoid a potentially fatal outcome. Ads for the PSA test echoed the success of campaigns to encourage women to have mammograms to find breast cancer at its earliest, most treatable stages. “Get tested. Save Lives” was a common theme that was quickly adopted to encourage men to get PSA tests.

It’s no surprise the PSA test quickly resulted in millions of men being tested (many with no prostate cancer symptoms, such as trouble urinating or blood in semen) and more cases of prostate cancer than ever before were diagnosed. While that meant prostate cancer was being found in men who needed aggressive, life-saving treatment for a malignancy, however, it also meant the malignancy was also found in men who had prostate cancer that was never going to cause symptoms or death.

Many of these prostate cancer patients went on to receive treatments that had serious side effects. That raised questions about whether all adult men should have the PSA screening.

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The PSA controversy

In 2014, the scientist who discovered the prostate specific antigen in 1970, Richard J.  Albin, PhD, co-authored a book, “The Great Prostate Hoax.” In it, he claimed the pharmaceutical industry hijacked the PSA test and turned it into a multibillion-dollar business. He also pointed out that measuring PSA levels was never intended for screening prostate cancer. In the book, he wrote: “For more than 25 years I have denounced mass PSA screening as a public health disaster.”

Since the test was introduced, the U.S. has seen more than a 50 percent drop in deaths from prostate cancer. The PSA test isn’t owed all the credit, however. Treatments for serious, fast spreading forms of prostate cancer have improved dramatically in recent years.

While it’s true that finding and treating aggressive prostate cancer early is important for the best outcome, the PSA test isn’t reliable when it comes to identifying the difference between slow-growing prostate cancers that pose little or no risk to life and cancers that are likely to be deadly without treatment, according to University of Michigan Medicine prostate cancer experts.

The result is men with harmless cancers may undergo biopsies and receive treatments that can result in many undesirable side effects, including impotence, bowel dysfunction, and incontinence. Screening for cancer is generally a good thing, but the PSA test may do far more harm than good if the risks outweigh the benefits.

Who needs a PSA test?

Prostate cancer is the most common cancer and the second leading cause of cancer deaths of American men. No one is suggesting that PSA tests should not be used or that prostate cancer screening isn’t beneficial. But the emphasis is now on men making an informed decision, with their doctors, about whether they need a PSA or "watchful waiting," to see if any possible symptoms develop or increase.   

The United States Preventive Services Task Force (USPSTF) recommends that men between the ages of 55 to 69 at average risk of developing prostate cancer discuss the benefits and harms of screening with their healthcare provider. That will help them make the best choice based on their individual circumstances and medical history. After age 70, the USPSTF recommends against routinely screening for prostate cancer.

Other groups disagree somewhat with those specifics. The American Cancer Society says it’s not just age but overall health status that’s important when making decisions about prostate cancer screening, recommending men at average risk have a talk about PSA screening with their doctors at age 50. Men at higher risk (including African American men and men with a strong family history of the disease) should discuss pros and cons of a PSA test at age 40 or 45.

“Every man who has a life expectancy estimated to be greater than 10 years should at least have the conversation with their physician about the pros and cons of checking their PSA levels,” University of Chicago urologist Scott Eggener says. “Not every man needs a PSA, not every man with an elevated PSA needs a biopsy, and not every man with cancer necessarily needs immediate treatment.”

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