PSA Testing: The Good, the Bad and the Ugly

A story about prostate cancer (PC) screening titled “The Great Prostate Mistake” which appeared in the New York Times last week, “went viral”.  Everybody’s talking about it.  (See http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?scp=1&sq=ablin&st=cse)   I refer to an opinion piece written by Dr. Richard Ablin, a researcher in immunobiology and pathology who invented the prostate-specific antigen (PSA) test in 1970, the most commonly used tool for detecting prostate cancer (PC) today .  The test measures the levels of  PSA, a protein secreted by cells in the prostate which leaks into the blood, excessively if there is prostate cancer.

Dr. Ablin is clearly unhappy that he released this particular genie from the bottle. He decries the widespread, indiscriminate use of  the PSA test, by which he means the practice of testing all men over a certain age regardless of risk.   (The recommended age used to be 50, but it  was recently lowered  to 40 by the American Urological Association).    Dr. Ablin believes mass PSA testing has become a “costly, profit-driven public health disaster”, spurred by greedy drug companies who “peddle” the test and overzealous patient-advocates who sponsor screening events as part of “prostate cancer awareness”.

Dr. Ablin claims the PSA test is hardly better at detecting PC than a coin toss.   The test generates a lot of false positives because many common factors other than cancer can cause PSA levels to be elevated.  And the PSA test misses 30% of cancers.  But by far the biggest problem with the PSA test is that it can’t distinguish between the majority of  PCs which are slow-growing and harmless and may not need treatment, and the fast-growing PCs, which require aggressive treatment.

In spite of these limitations, moans Dr. Ablin, doctors have widely embraced the PSA test and used it as a rationale for performing a whole lot of painful biopsies and invasive treatments, most commonly surgery to remove the prostate, radiotherapy and androgen deprivation therapy. These interventions have left hundreds of thousands of men with profound, quality-of-life-diminishing side effects such as impotence and incontinence, for questionable benefit.

Dr. Ablin argues that widespread, routine PSA testing is not worthwhile because PC claims so few lives anyway – only 3% of men who get the disease actually die of it. And any benefit derived from the PSA test is far outweighed by the harm it causes.  Dr. Ablin cites a European study which found that to prevent one man from dying of PC,  47 others would have to be treated  (surgery is the most popular choice).  Somebody likened this to a lottery. One person wins big, very big ,but the other 47 are losers.

I think Dr. Ablin overstates his case.  The PSA test is not quite as useless as he makes it out to be.  Dr. Ablin acknowledges as much at the conclusion of his article when he urges that men with a family history of PC continue to be tested.  But I do agree with the spirit of Dr. Ablin’s argument, that although PSA testing has benefited a lucky few (probably including my own husband), it has been a source of great anguish for many others .

So is it time to dump the PSA test?  Not so fast.

To be continued.

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About Leah

Some introductions: First is yours postess with the mostest, yours truly. My name is Leah, but I sometimes I use the nickname "callalily," after my favorite flower. Next is dear husband Ted, who is the Prostate Cancer patient and the inspiration for everything. I consider everyone in the PC community to be family. So what I would like to do with this blog is to advocate for the humane and compassionate treatment of people with prostate cancer and their loved ones, and to try to do it by example. One area that could use a lot of improvement, in my opinion, is doctor-patient relations. I hope to write passionately and compassionately, and especially with a liberal sprinkling of *humor,* because I believe in its exceptional power to heal. I have also learned a lot of factual information about prostate cancer in the past year, from patients and from doing research, especially in the area of erectile dysfunction. So there will be a lot of substantive stuff as well. About me: late 40s, proudly born in Brooklyn, lived there for the first half of my life, then crossed over the bridge to Manhattan, where I've spent the second half. Have a B.A. in history and a law degree. Also worked in corporate communications, doing writing and editing. I love old movies, poetry and watching forensic shows on TV. My favorite topic is murder and mayhem. If I had my life to live over I think I would be a medical examiner, arson investigator or homicide detective. About Ted: He is 55, born in St. Louis, good-looking, fit, has an M.S. in Computer Science but has begun a new career as a writer for a medical ad agency. Ted was diagnosed with PC in August '05, had robotic prostatectomy on 10/15/05. The surgery failed. Ted had a positive PSA test last January, and underwent salvage radiation therapy at Memorial Sloan Kettering. Ted is the intellectual type, reads a lot, but he is also into working out and praying. Anything else, you want to know, you can email me privately @ lfcjjk@aol.com.

6 thoughts on “PSA Testing: The Good, the Bad and the Ugly

  1. Rachel Pappas

    I’d like to ask folks who come here if they’d take a minute to look at my site, including the prostate cancer tab. Lots of other resources. I myself am a breast cancer survivor and daughter of a brave man fighting late stage prostate cancer, though on a good note he as lived with it for 13 years now.

    Best in health

    Rachel

  2. Rachel Pappas

    My father’s PSA was being continually monitored after he underwent radical surgery for prostate cancer. But though it was rising, the docs didnt’ bother to scan him – claimed it was rising slowly and no reason for concern. He ended up in the ER for a totally unrelated problem and at that time learned his prostate cancer had spread to both his lungs. His oncologist estimates it was in his lungs for about 6 years. I hate to be the bearer of bad news, especially since we survivors have to keep on and stay as positive as we can. But just want to join the rest of you offering some education. PSA test is only so dependable.

  3. Pingback: Four popular prostate cancer myths — busted. Guest post by Bernice Spradlin « Men and Health: It’s a guy thing

  4. mike ferguson

    I am definitely 1 of the lucky few. My PSA level was drawn at age 50., initially it was 3 and then a month and a half later went to 4. I was negative on the exam and negative on ultrasound. I had multiple cancers on the biopsy,and stage 4 on the pathology that weren’t found on biopsy.that cancer would have spread as i had positive apical margins.at age 50 its a different game.i love PSA.it saved my life

  5. John Watts

    Any discussions on differential PSA and on pca3?
    Supposedly these tests provide a more reliable picture. Any thoughts.

  6. Guest

    Since the article in the NY TImes was published, there have been a number of review articles in the medical literature evaluating the value of widespread PSA screening. Without exception, and I repeat, without exception, the conclusion that has been reached is that the use of PSA as a screening test for prostate cancer is not supported by available evidence.

    The widespread use of the PSA test has result in tens of thousands of prostatectomies being carried out. with a very large proportion of them rendered impotent to various degrees and a somewhat smaller but still very large number of men rendered incontinent to various degrees. Almost all of these men had they not had the PSA test would have gone to their graves with an indolent malignancy in their prostate not having cause them any problems. Yes, a small – a very small number and percentage – perhaps 1-2% – would have gone on to develop metastatic prostate cancer and died an unpleasant and painful death. But the number would have been very small in contrast to the huge number of men who for all intents and purposes were castrated by their prostate surgery and consigned to a lifetime of adult diapers and incontinent pads, with only memories of anything remotely resembling a normal sex life.

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