Men. PSA screening or not?

In 2012, the US Preventive Services Task Force (USPSTF) recommended against routine PSA screening in men. Fast forward to 2018 and a new recommendation:

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)–based screening for prostate cancer should be an individual one.

The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.

US Preventive Services Task Force (USPSTF)

To understand why the task force changed its mind and to provide additional information about the test, I talked to Dr. Gregory Adey, a urologist at Fore River Urology in South Portland, Maine

Why did the task force change the recommendation?

In 2012, they recommended against routine screening because they said the risks outweighed the benefits. They changed the recommendation due to the fact that there may be risks to screening, but there may also be benefits and it should be a shared decision between the patient and his doctor. I would strongly support that. I’ve seen a lot of people with bad outcomes from missing PSA screenings. You can also run the risk of being overtreated by having one. Technology is definitely a double-edged sword.

Gregory Adey, MD

What exactly is PSA?

PSA stands for prostate specific antigen, which is a protein that is responsible for helping to liquefy the ejaculate. When the sperm are trying to conceive that they’re able to get what they need from the ejaculate to help with conception. All of the cells in the prostate gland make PSA.

If your PSA is too high, it could mean you have prostate cancer but are there are other things that can elevate PSA? For instance, don’t men produce more as they age? Why?

As men get older, their prostate gland gets bigger. The cells become more numerous and they make more PSA, so levels will rise with aging. We use age-appropriate PSA levels for screening purposes rather than just a simple cutoff number. So a man’s PSA at age 70 should be very different than a man’s PSA at age 50. PSA levels may also fluctuate in the same man over time.

I tell patients that:

~At age 50 the PSA should be less than or equal to 2.5 nanograms per milliliter.

~At age 60 it should be less than or equal to 3.5.

~By age 70 5.5 is an acceptable threshold.

If you’re going to have a PSA test are the things that you might be doing the week or day before that could interfere somehow?

It’s interesting. In large studies that have looked at that it really hasn’t seemed to make a difference, but what I tell men is that this is a screening test and what we’re looking for is a really clean test. So without any real pelvic stimulation. You really don’t want to be ill in any way. You don’t want to have had severe constipation or any recent hemorrhoid or rectal procedures, a colonoscopy, things like that. I usually tell men to go three days without ejaculation or three days without any bicycle riding. If you’re riding on a road bike for 45 minutes or an hour and a half, the seat is pressing directly against your prostate. Some people would say don’t draw your PSA after a digital rectal exam, but I’m not as concerned about that unless someone’s had an extended digital rectal exam.

When should you worry about a high PSA level?

One of the real risks of PSA screening, and I think most providers in 2019 are aware of this, is overreacting to one value. One high value does not, in my mind, make a high PSA value. Does it create caution and require follow up? Absolutely. But from the standpoint of that one value, would that lead directly to a prostate biopsy? It’s extremely unlikely. There might be some clinical reason for that, but a mild elevation with no abnormality on rectal exam typically requires a repeat blood test.

I also really drill down on things that could have been going on at the time of the testing. I’ll see some men, particularly healthy men in their 50s and 60s who haven’t had an annual physical but are seeing their doctor for an upper respiratory infection or for what they think is a bladder infection and the provider will look at the chart and say, oh, you haven’t had a PSA in three years. The next thing you know, they’re going to the lab anyway and the provider will say we should also get a PSA because you’re due or overdue for one. I make note of that when I’m seeing them for the elevated value — that this wasn’t a “clean day” in their life.

Getting a PSA when you’re seeing the doctor for something else is better than not getting one, but I think there’s real value in having a yearly physical exam. You, know, they’ve got a 10-year history of values and all of a sudden in the last 18 months, there’s a change going on. That’s a powerful, powerful way to use the test.

What do you think is the most important thing men should understand about PSA testing?

Making sure that men are discussing the risks and benefits of a PSA test with their physician. I see lots and lots of men who are referred to me for one elevated value. I think that’s a very reasonable referral and we spend a lot of time talking about the value and where it comes from and why it’s high and that we’re not going to overreact to that.

Twenty-five to 30 percent of men diagnosed with prostate cancer in 2018 and 2019 are eligible for surveillance. They don’t actually appear to have the type of cancer that needs surgery or radiation or some form of therapy.

But there’s nothing worse, and I’ve seen a number of them recently, than men with urinary symptoms who haven’t had a PSA in five or 10 years and their first PSA is dramatically elevated. And they’re young men. Their symptoms aren’t from an enlarged prostate. They’re from advanced prostate cancer.

It’s all a statistics game, but you have to temper that against people who may be screened and potentially unnecessarily biopsied. If someone has high value, we recheck and if it’s still high and they’re a young, otherwise healthy person, a prostate biopsy may be indicated in that man. If that comes back normal, to me, that’s a relief. From my standpoint, it’s all about having a discussion about the risks and benefits with either your primary care doctor or a urologist.