For some cancers, the guidelines for screening are fairly cut-and-dried: If you are 50–75, you should get routinely screened for colorectal cancer. If you are 40–74 and female, you should be routinely screened for breast cancer. If you are 55–74 and are a heavy smoker, you should get routinely tested for lung cancer.
But for prostate cancer, there is a tug of war on opinions, especially with regard to the prostate-specific antigen (PSA) test, one of the two primary methods used in routine, asymptomatic screening for prostate cancer.
For instance, while the Mayo Clinic recommends PSA testing for men aged 50–70 years old with life expectancies greater than 10 years, the US Preventive Services Task Force recommends no PSA screening at all, regardless of age, saying that the possible harm of such test outweighs its benefits.
Taking the middle ground is the American Cancer Society, which makes no recommendations for or against PSA testing at all, but advises men aged 50 and above to individually explore the pros and cons of the test before making their own informed decision, with guidance from their doctors.
The Prostate Specific Antigen Test
If you have never had a PSA test, you might now be imagining that it is perhaps an unusually invasive or painful procedure, to cause such a divide among experts in the medical community.
You may be surprised to learn that it is, as far as the patient is concerned, a mere blood test, requiring a quick blood extraction procedure, like what you get for a complete blood count (CBC).
So what’s the big issue? How could a tiny blood test cause anyone any harm? The tiny blood test does not cause harm; the danger is in what happens afterwards.
Although the PSA test is currently the conventional option for screening prostate cancer (along with the digital rectal exam), it is still far from ideal in terms of sensitivity and specificity. According to the US Preventive Services Task Force, 10%–12% of all men who get screened for prostate cancer via PSA testing receive a false-positive result.
That means the test results show elevated PSA, which suggests cancer, but in fact, there is really no cancer. Instead, it may just be a prostate inflammation or a non-cancer prostate enlargement.
However, the PSA test will not tell you, “It might not be cancer.” The only test that can tell if something is a cancer or not is a biopsy. So if person receives a false-positive PSA test result, he is likely to undergo biopsy. This is where the harm begins.
The Cons of Testing
In a way, the PSA test for men is similar to the mammogram that women undergo for routine breast cancer screening. Both the mammogram and the PSA test will not tell you conclusively that you have cancer, but they will signal that there might be cancer, so you can get a biopsy for confirmation.
The thing is, it is one thing to get a biopsy from a breast mass. It is an entirely different thing to get a biopsy from the prostate. The procedure, as you can imagine, is quite different: One inserts a needle directly into the breast mass. The other inserts a needle through the rectum, urethra (where your urine comes out), or perineum (the tender area between your scrotum and your anus).
The risk of infection is different: After a breast biopsy, your doctor may or may not prescribe prophylactic antibiotics. After a prostate biopsy, you will definitely need to take antibiotics, because the number of infections after a prostate biopsy is rising.
The benefits are different as well. While there is clear evidence that early detection of breast cancer actually saves lives, we cannot say the same for prostate cancer.
Studies show that, without PSA screening, 5 out of every 1,000 men will die from prostate cancer 10 years after the cancer develops. On the other hand, with PSA screening, 4–5 out of every 1,000 men will die from prostate cancer 10 years after the cancer develops.
There are cancers where the benefits of routine screening and biopsy outweigh the risks because the cancer spreads quickly and kills quickly.In many cases, prostate cancer does not spread. While a lot of men die with prostate cancer, few men die because of it.
Some studies have even shown that men who know they have prostate cancer have a higher risk of dying in the first year after diagnosis, not from cancer but from suicide or cardiovascular disease.
The Pros of Testing
There are still times when the individual may benefit from testing. One instance is when a person who is worried about cancer feels much more comfortable knowing than not knowing.
If the quality of your life is significantly and adversely affected by the mere thought of “What if I have prostate cancer?” then it may give you peace of mind to be tested and find out there is nothing after all, or to find out there is indeed something and be able to do something about it.
If you choose to get tested and the doctors find out that you do have prostate cancer and it is the aggressive type, then you have a somewhat better chance of getting it treated if it is detected in its early stages.
Although prostate cancer is uncommon in young males, it is precisely this age group that will benefit the most from detecting prostate cancer, because the disease usually develops so slowly, if it appears late in life, its victim is more likely to succumb to heart disease before he succumbs to prostate cancer. But if the cancer appears in a young man, then it poses a true risk of reducing the young man’s life expectancy.
If you belong to a high-risk group – specifically, if you have one or more first-degree relatives who had been diagnosed with prostate cancer before 65 years old or who died of prostate cancer before 75 years old – you are also one of those who are more likely to benefit from routine prostate cancer screening.