Based on my more than 35 years of experience in urologic oncology, and having treated more than 10,000 men with prostate cancer, I recommend that if you are a male between 40 and 70 years old, you should get an annual prostate-specific antigen (PSA) blood screening test and a digital rectal exam (DRE).
If either of these tests is abnormal, consult a urologist you can trust. Further testing, which might include a CT scan, an MRI, and a bone scan, as well as a review of your medical condition—taking into account any problems such as hypertension, diabetes, or coronary artery disease; lifestyle; sexual activity; anxiety level; and accessibility to a center of excellence for the treatment of prostate cancer—must be weighed and considered.
If you have a positive family history for prostate cancer (a male relative with prostate cancer) and/or you are an African-American male over the age of 40, it is even more imperative that you get a PSA screening test, as the incidence of aggressive and potentially curable prostate cancer is far greater in these groups.
In addition, if you have already been diagnosed with prostate cancer or are being treated, regular PSA testing is essential and can help your physician determine if the cancer is under control or if it is progressing and requires further treatment.
The US Preventive Services Task Force was blatantly wrong when it recommended that healthy men should no longer receive PSA blood tests as part of routine cancer screening. The reality is that PSA screening, when properly interpreted and integrated into a comprehensive prostate cancer screening protocol, saves lives.
The argument against PSA screening is that it cannot tell the difference between fast-growing and potentially lethal prostate cancer and slow-growing, innocuous prostate cancer. However, no other test at present can do this more effectively. The PSA test is the best that we have and must be used, along with other data, to determine if and when treatment is indicated if a diagnosis of prostate cancer is made. Prostate cancer is a silent disease. Without PSA screening, there is no way to find the majority of organ-confined, early-stage, curable prostate cancers. We are still searching for a better test, but at this time none exists.
Another argument against PSA testing is that many (if not most) prostate cancers discovered are typically so slow growing that they will have no impact whatsoever on a man’s life. The reasoning is that everyone dies of something, so it is better to die with prostate cancer than of prostate cancer. It is true that, given the relatively large number of men that are screened for prostate cancer, relatively few will die of this disease. But what about aggressive or multifocal cancers of the prostate that are diagnosed at an early (curable), organ-confined stage and that are amenable to safe and effective treatment? Remember, prior to the PSA era, more than 42,000 men died in the United States of this disease each year. Since the advent of the PSA screening test and its wide implementation, the number has dropped by more than 44 percent.
For men over 75 years of age, many groups recommend no PSA testing, assuming that the patient’s actuarial life expectancy is less than ten years. However, there is no doubt in my mind that today’s 75 is the 65 of the 1990s. When I started in practice, it was rare to see a functional 100-year-old man in my office. In 2011, I see three or four each month, some surprisingly fit and active.
The takeaway message regarding PSA testing for prostate cancer screening is this: It is an individual decision between the patient and his doctors and should be one of many factors mixed into a formula that dictates treatment or no treatment. This is not a decision that should be made by a government task force based on cost cutting and potentially biased analysis.
Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).
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