PSA Testsing-WWYDD or What Would Your Doctor Do?

There is probably nothing that has become more controversial than the PSA screening for prostate cancer in men.  There is one group that suggests annual screening for all men after age 50 and sooner after age 40 for African-American men and men with a relative, i.e., a father, a brother or an uncle with prostate cancer.  Then another group that recommends no PSA testing be done as the testing does not significantly reduce death from prostate cancer and screening tends to over-diagnose prostate cancer and with over-diagnosis more men receive treatment including radiation and surgery that results in complications such as erectile dysfunction and urinary incontinence.  So what is a man to do?  For this article I will not definitively answer the question but will shed light on the issue and then let you decide what you should do or what advice you should give the important men in your family.

What are the facts?  Approximately 35,000 men die each year from prostate cancer, which is the second most common cause of cancer death in men.  There are 250,000 newly diagnosed cases of prostate cancer diagnosed each year.  The PSA test is the screening method of choice for dearly detection of prostate cancer.  The determination of PSA values, when followed annually is the single most convenient, cost-effective and workable way of selecting men who need close monitoring, close follow up, or need to consider further treatment with radiation, surgery or hormone therapy.

What is PSA?  PSA is a blood test that measures a protein manufactured in the prostate gland, which is secreted into the blood stream.  We do know that PSA is age-dependent or increases naturally as men get older.  In normal men less than 50 years of age the value should be less than 2.5ng\ml and in men over age 70 a normal PSA values is less than 6.5ng\ml.

The real value of the PSA test in early detection is based on establishing a baseline PSA value and performing the test once a year in order to observe changes from the baseline value.  Increases of PSA of .75ng\ml in a year should be investigated.  The take home message is that a trend is more important than a single measurement.  An elevation of the PSA may not automatically represent prostate cancer.  Elevated levels occur with advancing years, large prostates, prostate infections, a digital rectal prostate exam, and even sexual intimacy with ejaculatin 24-48 hours before the blood test.

For those who have an elevated PSA test, there is a more refined test called the free\total ration of PSA.  The ratio of free\total PSA is less than 25% in men with prostate cancer and if the free\total is greater than 25% is much less likely to have prostate cancer and probably doesn’t need a further workup such as a prostate biopsy.

So what to do?  If you are at risk for prostate cancer with a relative who has prostate cancer or an African American man, I suggest a PSA and a digital rectal exam beginning at age 40.  All others should consider a PSA test once a year.  If the PSA increases more than 0.75ng\ml\year, then you should consider an evaluation by a urologist and a prostate biopsy if you have more than ten years of life expectancy and would be a candidate for treatment.

Bottom Line:  So what would Dr Baum do?  He gets a PSA every year and the last time it was 0.7ng\ml!

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