David Hall, MD

In a recent opinion piece published in the New York Times titled “The Great Prostate Mistake”, Richard J. Ablin, the man who discovered the Prostate Specific Antigen (PSA) that is now used in prostate testing, said, “The test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, PSA testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.”

In the article (www.nytimes.com/2010/03/10/opinion/10Ablin.html), Albin said use of the PSA test has led to “a hugely expensive public health disaster” costing $3 billion per year and leading to many unnecessary surgeries. He said while there is a place for PSA testing if someone has a family history of the disease or has had prostate cancer in the past, routine testing of men over 50 should not be pushed by those who stand to profit.
“The medical community must confront reality and stop the inappropriate use of PSA screening,” Albin said. “Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”

The American College of Preventive Medicine says there is insufficient evidence to recommend routine PSA screening, and the American Cancer Society has urged more caution in using the test. However, the American Urological Association (AUA) states that the PSA test should be offered to well-informed men aged 40 years or older who have a life expectancy of at least 10 years.

“The PSA test, as well as how it is used to guide patient care (e.g., at what age men should begin regular testing, intervals at which the test should be repeated, at what point a biopsy is necessary) is highly controversial,” the AUA said. “However, the AUA believes that, when offered and interpreted appropriately the PSA test may provide essential information for the diagnosis, pre-treatment staging or risk assessment and post-treatment monitoring of prostate cancer.”

Mohamed H. Kamel, MD, assistant professor of urology at the University of Arkansas for Medical Sciences in Little Rock, said PSA testing is still necessary. He recommends PSA testing annually starting at age 40 for patients who are African-American or have a family history of prostate cancer. For lower risk patients, he recommends PSA testing at 40, 45 and 50, followed by annual testing.

Kamel said urologists are correcting themselves, and no longer doing as much treatment for prostate cancer as in the past. 

“We don’t do unnecessary surgeries anymore,” Kamel said. “We are correcting the problem of PSA over-diagnosis of prostate cancer. Now when a biopsy shows a low risk, instead of surgery, we offer active surveillance. There is no need to do anything but monitor. If the biopsy shows they are intermediate or high risk, we offer the patient treatment whether surgery, radiation or cryosurgery. So, now patients are not over treated.”

David Hall, MD, staff urologist, Central Arkansas Veteran’s Healthcare System, said the literature supports PSA testing which allows prostate cancer to be diagnosed five to ten years sooner than without the test.

“Screening if you are in your 50s and 60s is not that controversial for urologists,” Hall said. “It is hard for me to imagine you can over diagnosis cancer in someone 50 to 60 who is going to live another 15 to 20 years. It will probably cause them problems at some point if they don’t receive treatment.”

Hall said urologists have to use a lot of clinical common sense to decide who needs a PSA and, if there is a high score, at what point you do a biopsy. There are a lot of other factors that go into the decision to do a biopsy including how fast the PSA is changing, family history, age of the patient, other illnesses, life expectancy, and ethnicity.

“You put all that together and make a decision whether to recommend biopsy,” Hall said. “Then you use all the information you have gathered along with the biopsy report to recommend treatment. In some cases, just watching the patient and not doing definitive treatment such as surgery or radiation is the appropriate decision.”

Hall said the important thing to remember is that when prostate cancer is found early, it is curable; once it has spread from the prostate, it is not curable. So the window to cure someone from prostate cancer is limited to early detection.

During the time Hall has been in active practice, he has seen it go from most prostate cancer being diagnosed after it has spread at least locally and isn’t curable to most being found before it has spread. The use of PSAs has allowed early detection.

“That tells you long term you will have a better survival rate by using the PSA testing,” he said. “There are good and bad kinds of prostate cancer, and we don’t have a good tool for identifying that before a biopsy. After a biopsy we have a good idea whether it is an aggressive or non-aggressive cancer, and that guides us in giving treatment recommendations.”

Hall said the controversy is a lot of elderly patients will die with prostate cancer and not of it. It is in this group of patients that over diagnosis and over treatment is a concern.

“Most people feel like if you are 75 and older, and your life expectancy is ten years or less, if your prostate gland feels normal and you have no symptoms, there is no reason to screen for it,” Hall said.

There has been some concern the recent controversy over the PSA test will mean many men might not seek testing when it is indicated. But Hall has some patients come in with elevated PSA levels who want something done even though it may not be a good idea.

“Patient responses are really all over the board,” Hall said. “Certainly not everyone with elevated PSA levels needs a biopsy and not everyone with a positive biopsy has to be treated. You have to look at the big picture.”

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