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When should you check your PSA for prostate cancer?

Ben Stiller encourages early screening as he reveals he had “aggressive prostate cancer”.

By Daliah Wachs, MD, FAAFP

Physicians, such as myself, took a lot of heat over the last decade when we would offer middle-aged men a PSA, prostate specific antigen test, to screen for prostate cancer. We were accused of ordering “unnecessary tests” and urged to not to offer the test as “prostate cancer grows too slowly anyhow.”  This was frustrating to say the least and we turned to the US Preventative Services Task Force for clarification.

After extensive review, in 2012 the USPSTF recommended AGAINST screening for prostate cancer. Their assessment was as follows:

USPSTF Assessment
Although the precise, long-term effect of PSA screening on prostate cancer–specific mortality remains uncertain, existing studies adequately demonstrate that the reduction in prostate cancer mortality after 10 to 14 years is, at most, very small, even for men in what seems to be the optimal age range of 55 to 69 years. There is no apparent reduction in all-cause mortality. In contrast, the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death. Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit. The inevitability of overdiagnosis and overtreatment of prostate cancer as a result of screening means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives. Assessing the balance of benefits and harms requires weighing a moderate to high probability of early and persistent harm from treatment against the very low probability of preventing a death from prostate cancer in the long term.
The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.

Many medical providers did agree that false positives and some types of prostate cancer treatment could inflict risks that outweighed the benefits of universal screening, but finding and treating the early aggressive prostate cancer cases was a goal that could not be ignored.  But the USPSTF guidelines were generally accepted.  Subsequently, insurance companies and employer-subsidized physicals stopped paying for the screening PSA and many men stopped requesting the test.

Fortunately, one 46 year old man DID REQUEST the PSA test, and his physician found it necessary to repeat the tests later in the year to see if it continued to rise. When the levels rose, his physician recommended a prostate biopsy.  To the actor’s shock, he was diagnosed with prostate cancer.  Ben Stiller reported he had his prostate removed a few months later by robotic assisted laparoscopic radical prostatectomy, and is now cancer free.

He states, regarding his physician,

“If he had waited, as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated,” 
“If he had followed the US Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.”

Now the American Cancer Society does recommend prostate cancer screening, but does so with these recommendations:

  • Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
  • Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).
  • Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).

After this discussion, men who want to be screened should be tested with the prostate-specific antigen (PSA) blood test. The digital rectal exam (DRE) may also be done as a part of screening.

If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the man’s general health preferences and values.

If no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test:

  • Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years.
  • Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.

So a case such as Ben Stiller’s could have been missed without his and his physician’s persistence.

So when should one follow the “guidelines” and when should one follow his instinct?  Here’s how I break it down…..

Firstly, the USPSTF and American Cancer Society’s guidelines, are just that…guidelines. These are recommendations based on multiple studies and years of data and although are accepted by the medical community, are not meant to be the “law”.   Even though the guidelines deter insurance companies from covering and many medical providers from ordering the test, patients can still ask their physician to order a PSA and make a case to their insurance company if needed.

Secondly, every one is an individual.  We all may not follow the norm.  Depending on our age (over age 50), ethnicity (higher risk for African Americans), geography, family history and gene mutations (such as BRAC1 and 2) we may individually be at a higher risk for cancer.  Moreover studies are investigating if our diet, tobacco use, chemical exposures (such as Agent Orange), employment (such as firefighters), or surgical procedures (such as vasectomies) could put us at increased risk as well.  These all need to be taken into account and discussed with our medical providers.

Thirdly, if an insurance company does not cover a test, this does not imply the exam is not necessary.  Although most insurance companies will cover a basic physical, we as consumers may have to come out of pocket if we want additional tests.  The insurance company does not dictate what a human body needs.  Its job is to provide coverage, so one must not assume “if an insurance company doesn’t pay for it, its not necessary”.

Fourthly, tests come with risks.  False positives can start an expensive cascade of testing and at times painful procedures.  Treatments for cancer are not easy and without risks either, and we must use caution with many tests that “screen for cancer” and understand that screening and treatment are not “risk free”.

Finally, a single blood test should not diagnose cancer. A baseline PSA is just that, a baseline.  Even though a normal PSA can run from 0 -4.0 (nanograms per milliliter),   a subsequent PSA demonstrating a rise of 0.5 per year could be concerning.  So if a patient has a level of  1.4 ng/ml one year and the next year 3.2 ng/ml, that would be a little more concerning than one who is 3.4 ng/ml one year and 3.4 ng/ml the next.

 

What happened to Ben Stiller was a rare case, being that he was in his 40’s and diagnosed with an aggressive prostate cancer. This however was not a “fluke”.  Men in their 40’s, can face a very small risk of prostate cancer.  This case should not cause anyone to panic and storm their doctor’s clinic to get screened but instead should serve as a reminder that cancer may have a mind of its own and not want to follow the “guidelines”.   So we strategize…..

Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network and Board Certified Family Physician

 

 

 

 

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Author:

Nationally Syndicated Radio Host, Board Certified Family Medicine Physician, Assistant Professor Touro University Nevada

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