The man who discovered PSA — prostate-specific antigen — says most men who get tested for it are thinking about it the wrong way.
"It cannot do what it's been purported to do. It can't detect prostate cancer," says Dr. Richard Ablin of the University of Arizona. "And it's resulted in a public-health disaster."
Can't detect cancer? That's the very reason millions of men and their doctors pay close attention to their PSA number.
It's why a PSA that creeps up from, say, 3.8 to 4.2 causes men sleepless nights — and sends them to the urologist, who will often respond to an "elevated" PSA by sticking a needle into their prostate gland to retrieve tissue samples, looking for cancer cells.
High PSA Not Always A Problem
But wait, Ablin says. Many conditions can cause PSA to go up — prostate infection, the benign enlargement that occurs in most men of a certain age, even sex within 48 hours of a PSA test.
And when PSA leads to biopsy and biopsy turns up cancer, many if not most of those men will soon find themselves undergoing surgery to remove the prostate, or radiation to kill the cancer.
Most of the time, that's totally unnecessary, Ablin says, because many prostate cancers found this way are so slow-growing they would never have caused a problem.
Think of the prostate gland as an open box, Ablin says. Most prostate cancers are like a turtle that slowly crawls around that box but never gets out.
"We can think of an aggressive cancer as a rabbit that jumps out of the box and spreads," Ablin says. "But we don't know which cancers are turtles and which are rabbits."
Treatment Can Cause Impotence And Incontinence
Many men who get treated for "turtle" cancers end up with lifelong impotence and urinary or fecal incontinence. That's the "disaster" part.
A large European study published a year ago found that for every man whose life is saved by PSA monitoring and early treatment, "there are 48 others who may not have died but had the treatment," says Dr. Craig Redfern of Portland, Ore. "A number of those are impotent, and some of them are incontinent."
Redfern knows one such patient. "He was about 66, had a 1- to 2-millimeter area of cancer on his pathology. I think he had one core biopsy, which was positive," Redfern said. The pathologist assessed his cancer's aggressiveness as borderline.
"He probably did not need the surgery," he continues. "He's suffering quite a bit from urinary incontinence. He needs to wear a pad. So he's one who has done poorly."
If Redfern had been the man's doctor at the start, he would have counseled him to hold off doing surgery and monitor the situation closely — an approach that some call "active surveillance."
The American Urological Association is pushing "active surveillance" rather than immediately treating every prostate cancer that is found.
But Dr. Michael Phillips, a Washington, D.C., urologist, says it's the unusual man who's comfortable with watching and waiting.
"Even if a man says, 'Well, if I have this low-grade cancer, it might not cause any problems during my natural lifetime, maybe I'll forego surgery,' " Phillips says. "It's hard to lie in bed at night and look at the ceiling and think, 'I have this cancer inside of me.' "
Phillips disagrees with Ablin that PSA blood testing is a disaster. But he says there is a rethinking going on about how to use PSA in a way that does men more good than harm.
More Men Die With Prostate Cancer Than From It
He agrees with Ablin on one big thing: "We're 'curing' a lot of men with prostate cancer who don't need to be cured," Phillips says. "There are probably way too many PSAs being done. And in some areas, there are probably way too many biopsies being done. I've been around long enough to know that you can get burned either way by the PSA — by picking it up too quickly or by missing it altogether and finding cancer too late."
In fact, Craig Redfern, the Portland doctor who is a PSA skeptic, cites one case that proves the value of the test — if it's interpreted the right way.
That patient is Brad Baugher, a 55-year-old teacher. Baugher and Redfern met in high school and have been best friends ever since.
Baugher got his first PSA test at age 44, before he was Redfern's patient. When he turned 50, he asked his friend to do a PSA test, just to see if there was any change. The results showed nothing to worry about.
But a few years later, Baugher began having the urinary problems that plague many men beginning in middle age. "I had a few symptoms at night, getting up to go to the bathroom," he says. "My wife was bugging me about going to the doctor, getting my PSA measured, getting checked out. So I did."
PSA Test Can Help Save Some Men's Lives
This time Baugher's PSA was 5.5 — above the 4.0 cutoff that has traditionally been considered a potential marker for cancer but not necessarily a worry.
Still, Redfern says, "since he was my friend and I didn't want any potential conflict of interest over decision-making, I suggested he just see the urologist and decide whether to proceed with the biopsy."
The urologist suggested a course of antibiotics in case Baugher's PSA reflected a minor prostate infection, followed by a repeat PSA. Two months later, that PSA test showed Baugher's level had gone up to 7.2. That triggered a biopsy, which found cancer in four out of five tissue samples.
A pathologist assessed Baugher's cancer as potentially aggressive, which convinced him to have a radical prostatectomy — surgical removal of the entire prostate gland. Fortunately, that surgery, done in October 2008, has not caused the side effects that men and their doctors dread.
So Baugher is happy he watched his PSA. "I think maybe the test did save my life," he says.
Redfern agrees: "In a couple of years, [the cancer] would have come to light in other ways and probably wouldn't have been curable."
Ablin agrees that Baugher represents the right way to use and interpret PSA — get a baseline test in middle age, check it periodically, don't rush to biopsy or treatment when the PSA level goes up.
But still, the 69-year-old Ablin has never asked his doctor to do a PSA test to screen him for cancer. And neither has Redfern.
"I think the decision in my mind is really whether it's worth it to screen or not," the Portland doctor says. "And my assessment is the burden of harm outweighs the potential benefits, and I don't want to step onto that slippery slope. Every man has to make his own decision."