Value of PSA Prostate Screening Debate

With its timely discovery of aggressive cancers, the objective of PSA screening is to reduce the risk of cancer-related death, surely making it an unequivocally important weapon in our fight against cancer; some have now started to question the value of PSA screening and this has stirred a debate amongst both healthcare professionals and prostate cancer patients alike, so just how has this basic blood test come to cause such a commotion?

Since its 1994 introduction and approval for use within the US, cancer-related death rate statistics reflect a 50% decrease amongst prostate cancer patients; this is hugely significant considering the fact that annual prostate cancer deaths are only exceeded by those of lung cancer. ¹In the UK, prostate cancer is the most common diagnosis given to 1 in 8 (47,500 per year) cancer patients, with 1 dying every 45 minutes (11,500 per year).

¹ Prostate Cancer UK, Facts and figures, July 2019

PSA screening test
Credit: Getty Images Ltd.

Despite the life-saving potential that PSA screening presents, it’s also true to say that all patients diagnosed with prostate cancer typically live with their cancer for another five years minimum; this is especially true in non-aggressive or non-fatal cases of cancer. When a sudden spike in PSA screening inevitably lead to a spike in prostate cancer diagnoses, both our personal and collective fears undoubtedly increased, along with the search for answers.

It’s obvious that prostate cancer diagnoses and their associated treatments can cause stress and anxiety, so it’s important not to overlook the impact of these side-effects; patients commonly endure symptoms such as incontinence and/or impotence. Upon receiving their diagnosis, many patients understandably agreed to any treatment deemed necessary, so numerous prostate biopsies and other surgical procedures were perhaps performed unnecessarily.

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With the over-diagnosis of prostate cancer came over-treatment and many patients failed to realise that surgery could be avoided and deemed unnecessary or inviable; one in three men aged seventy or older are found (during autopsy) to have previously undiagnosed prostate cancer at their time of passing. So perhaps it’s the not so much the PSA screening itself that’s proving contentious, but more the current guidelines that dictate suitability.

An article featured in the The Urology Times by Dr. Henry Rosevear (private urologist and PSA screening advocate); his words and frustration (at least where test suitability is concerned) perhaps highlight a need for greater consideration… or common sense:

“Not everyone needs to be screened, not everyone found to have an elevated PSA needs to be biopsied, and Lord knows that not everyone with prostate cancer needs aggressive treatment.” ²

² Dr. Henry Rosevear, The Urology Times, May 5, 2014

If and how often a patient should be PSA tested, test-result interpretation and the authorisation of further testing and/or bio are all aspects of a prostate cancer treatment that’s under scrutiny. Research shows that following biopsies inspired by unexpectedly significant increases in a patient’s PSA score, 4 out of 5 cancers found were unlikely to threaten a patient’s life; this effectively justifies just a small percentage of the surgery performed.

This statistic serves as an important reminder that high PSA scores can also be caused by specific conditions or incurred following certain activities; these can include BPE, cycling, physical exertion (including recent sexual activity) and prostate inflammation. To account for factors such as these, tests are repeated and treatment is delayed for weeks; in rarer cases, patients have proven to be cancer-free, whilst maintaining a sudden and unusually high PSA score.

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The benefits of PSA testing are in no way invalidated by these factors however. Including African-Americans, who are prone to more aggressive prostate cancer, PSA screening could prove beneficial for most patients in their early forties; those who have had cancer-related illnesses within their family and/or carriers of either the BRCA1 or BRCA2 mutation are proven benefactors of PSA testing and its timely detection of their cancer.
The suitability of PSA screening is increasingly assessed with the involvement of both expert healthcare professionals and their patients, with individual preferences and personal beliefs being considered alongside more medical factors such as risk. Some suggest that the option of PSA screening should be withheld from those with a disinclination towards further cancer treatment, as well as those with numerous health problems or low life expectancy.

While it’s true that for some patients in their seventies, the advantages of PSA screening, diagnosis and treatment could be outweighed by their potentially harmful effects, meaning regular screening is best avoided; conversely, those with a prognosis of good health or with at least 10 years left to live are excellent candidates for PSA testing. Ongoing research and development also continues to streamline the testing process.
As with most studies, false-positive results were recorded during the trials undertaken to assess the effectiveness of PSA testing; a sixth of all subjects were falsely diagnosed with possible prostate cancer, with just a third of first round PSA screening proving accurate. This has led to the recent introduction of tests such as the 4K score test and the PHI (Prostate Health Index) which, as well as accuracy, have greater scope and cancer detection capabilities.

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By combining sometimes inconclusive data sourced from biopsies, DREs and PSA testing, the diagnosis accuracy can be improved and the best course of prostate cancer treatment dictated. Advanced MRI scanners are also being studied; it’s hoped that they can detect potentially lethal, high-risk cancer whilst low-risk cancer goes undetected. Along with active monitoring, this will reduce false-positive results and help eliminate needless surgical procedures.

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