Prostate Health Screening: Why the PSA Test Is Important

The United States Preventive Services Task Force got it wrong when they said that "healthy men should no longer receive a PSA blood test to screen for prostate cancer." The PSA test has many false positive results for cancer, but also detects benign prostate hyperplasia (BPH) and prostatitis (infection). If one of my patients has an elevated PSA, I treat them with antibiotics (after culture), which in many instances reduces the PSA to normal levels and avoids a biopsy. That treatment makes the diagnosis of prostatitis, and many of these patients urinate and feel better after the antibiotics.

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The United States Preventive Services Task Force got it wrong when they said that "healthy men should no longer receive a PSA blood test to screen for prostate cancer."
 
The PSA test has many false positive results for cancer, but also detects benign prostate hyperplasia (BPH) and prostatitis (infection). If one of my patients has an elevated PSA, I treat them with antibiotics (after culture), which in many instances reduces the PSA to normal levels and avoids a biopsy. That treatment makes the diagnosis of prostatitis, and many of these patients urinate and feel better after the antibiotics.

Sixty percent of prostatectomies (surgical removal of the prostate) for "cancer" are Gleason 6. These cancers are the ones that are perfect for nonsurgical treatment such as surveillance. In fact, the National Institutes of Health (NIH) is convening a consensus group in December regarding this issue. It is very likely that the NIH recommendations will be to not recommend surgery for Gleason 6 cancers and to strongly consider surveillance.

Now, it's important to remember that 20 years ago when I was a resident before PSA testing, we saw men dying of metastatic disease from late stage prostate cancer. These men had diffuse bone metastasis with severe pain. Today PSA testing has allowed us to diagnose "late" stage disease earlier. While the prostate cancer is already incurable, the treatments for late stage cancer has improved the lives of many of these men. No, we did not cure them, but earlier treatment of late stage disease may have prolonged their lives.
 
Lastly, PSA screening is worthwhile for men who have relatives that have died from prostate cancer, and those relatives that have prostate cancer (at least those with Gleason 7 and above), and African Americans (who have a higher chance of getting and dying of prostate cancer).

We need to understand the limitations of the PSA test for cancer and realize that it's a much better tool for diagnosing BPH and prostatitis. Both BPH and prostatitis affect many more men than prostate cancer. For those young men who have high grade cancer that are detected by PSA, and there are many of those, the PSA test is a lifesaver.

Lastly, the approach to carefully select men for prostate biopsy based on PSA levels is critical. Our approach is to avoid biopsy unless significant BPH and prostatitis has been ruled out. With this approach, the PSA test is perfect.

Blog written by Harry Fisch, MD
Dr. Fisch is the director of the Male Reproductive Center in New York City. He is a board-certified urologist and microsurgeon...