In September 2004 Thomas Stamey, M.D., who helped pioneer the blood test for detecting prostate cancer, announced that he now believes the test should be largely abandoned because it detects too many harmless cancers. That call was quickly rejected by other experts, who claim the test, called the PSA (prostate-specific-antigen) test, is still the best way to save men from this potentially deadly disease.

There is heated controversy among researchers and frustrating uncertainty among men about nearly every aspect of prostate cancer, which kills more men who don’t smoke than any other cancer.

Here’s the heart of the problem: Most men eventually develop some cancerous cells in their prostate gland, but the cancer usually develops so slowly that they often die of something else. Many experts worry that the blood-screening test, which measures the telltale PSA protein, identifies too many of those very slow-growing cancers, leading to at least some needless treatments, which often leave men impotent, incontinent, or both. Moreover, the PSA test triggers numerous false alarms that require a costly, uncomfortable, and anxiety-producing biopsy. On the other hand, certain evidence suggests that early PSA testing may be saving some lives.

“The issues are controversial because there are still no definitive answers,” says Michael Barry, M.D., a researcher at Massachusetts General Hospital in Boston who has written extensively about prostate cancer. Clearer guidance won’t come for 5 to 10 years, when clinical trials comparing the death and complication rates in tested and untested men will be completed.

In the face of such uncertainty, leading public-health organizations—including the American Cancer Society and the U.S. Preventive Services Task Force, an influential government advisory panel—say that for now men should learn all they can about the pros and cons of the test and ensuing treatments. Using that information plus their own preferences and concerns, they should talk with their doctor and make their own decisions.

Unfortunately, that often doesn’t happen. For example, in a May 2003 survey by researchers at the University of Texas Medical School at Houston, 80 percent of respondents said they’d been tested for prostate cancer—but only about half of them said their doctor had discussed the test’s advantages and disadvantages beforehand.

In addition, men are not always fully informed about treatment options. Research suggests that the choice of surgery or radiation to treat the cancer depends mainly on whether the man consults a urologic surgeon or a radiation oncologist. When men are given a full, balanced picture of the issues, they often make decisions contrary to doctors’ typical recommendations.

For example, San Diego researchers found that 98 percent of men undergoing a standard checkup at a Kaiser Permanente health clinic ended up getting the PSA test, compared with only 50 percent of those who watched an educational video on the topic and then participated in a structured discussion.

This report will examine the controversies about prostate-cancer screening and treatment to help men make better-informed decisions.
Growing evidence suggests that testing for and treating prostate cancer may be saving lives. The number of men who die of the disease fell by 26 percent from 1991 (when the PSA test became widespread) to 2001 (the last year analyzed). Researchers at the National Cancer Institute concluded in a March 2003 analysis that the decline and similar trends in other countries probably reflected “a beneficial effect of PSA testing on prostate-cancer mortality.”

However, improved treatments probably account for some of that death-rate decline. So there’s still no proof that the benefits of the test outweigh its substantial risks: needless prostate-cancer treatment and, in turn, needless complications. That’s because the test and even a subsequent biopsy cannot reliably distinguish cancers that will probably kill from those that won’t.

How many men are being treated needlessly is hotly debated. While some experts estimate that up to 85 percent of cancers now diagnosed would never kill if left untreated, others dispute that figure. For example, a June 2004 analysis in the Archives of Internal Medicine concluded that some two-thirds of cancers found by the test pose at least a 50 percent chance of turning deadly.

Moreover, test supporters note that even nonfatal prostate cancer can cause much pain and disability. Several studies have found that most men who initially refuse treatment for PSA-detected cancer develop signs or symptoms so worrisome or severe that they opt for treatment within five years of diagnosis.

The bottom line: Prostate-cancer experts generally agree that men whose life expectancy is shorter than 10 years don’t need to be tested for the malignancy, since they’re very likely to die of something else first. Whether other men should be tested depends mainly on their personal preferences.

Those who are more concerned about the possibility of needless treatment and serious complications can reasonably skip the test. However, they should still consider periodic digital rectal exams, in which the doctor inserts a gloved finger into the rectum to feel for bumps on the gland; that can detect some cancers missed by the PSA test. While such cancers are more likely than PSA-detected cancers to have spread beyond the gland, there’s good evidence that treating manually spotted cancers can reduce discomfort and death from the disease.

Others will feel most comfortable learning whether they have cancer and getting it treated if they do. Many experts say those men should consider PSA and rectal testing every year or two, starting at about age 50 if they’re white, 45 if they’re black or have a family history of the disease, both of which raise the risk.

Identifying harmless cancers is not the test’s only shortcoming. It misses some cancers, so a low PSA doesn’t necessarily mean you’re cancer-free. And about three-fourths of PSA elevations—generally more than 4.0 nanograms per milliliter (ng/mL)—stem from noncancerous causes, notably a benignly enlarged gland or, less often, infection or inflammation.

Each of those false alarms necessitates a $500 to $800 biopsy to rule out cancer. To increase the PSA test’s accuracy, some doctors consider three elements: the man’s age, the individual parts of the total PSA score, and how quickly it rises. If you’re being tested, talk to your doctor about these possible refinements:

• Age-adjusted PSA. The chance that an elevated PSA level stems from benign enlargement, not cancer, rises with age. So some doctors recommend dropping the PSA threshold for biopsy from 4.0 ng/mL to 2.5 ng/mL in men under age 50 or so, and possibly raising it to 4.5 ng/mL in men over age 60. But the decision is complex, since those changes alter the odds of spotting cancer and of false alarms and needless treatment. So discuss the details with your doctor.

• PSA components. In the standard PSA test, physicians consider only the total amount of PSA circulating in the blood. But most of the PSA is bound to protein; the rest floats freely. Men with prostate cancer tend to have a particularly low percentage of unbound or free PSA.

When the total PSA is minimally elevated, some doctors recommend biopsy only when the bound, or “complex” PSA score is over 3.0 ng/mL or the ratio of free to total PSA is below 20 or 25 percent. Conversely, those unfavorable numbers may cause doctors to advise biopsy when the total PSA is slightly below the usual threshold of 4.0 ng/mL.

• PSA velocity. A rapidly rising PSA is a particularly strong indicator of a potentially aggressive tumor. Some doctors recommend biopsy whenever the PSA score rises 1.5 points or more during a two-year period (with no apparent cause, such as infection), regardless of the total score.

Certain other steps may also improve the accuracy of the PSA test and reduce unnecessary biopsies.

• Remind your doctor if you’re taking dutasteride (Avodart) or finasteride (Propecia, Proscar), which can lower the total PSA level (but not the free PSA).

• Try to be sure your doctor sends your blood samples to the same lab each time.

• To help prevent false elevations, don’t ejaculate for a day or two before the test.

• If the PSA reading is either slightly elevated or significantly increased since the previous reading, but still in the normal range, repeat the test in three or four months. If it’s clearly elevated, repeat the test immediately to confirm the finding. You may want to ask your doctor about taking an antibiotic before retesting to rule out infection.

When a biopsy confirms cancer, men must choose among several treatments that pose serious risks or simply do nothing unless symptoms develop, although that increases the chance that the cancer will spread and possibly kill.

The most common treatment—surgical removal of the prostate gland—causes permanent incontinence in roughly 15 percent of men and impotence in about 30 percent, even with ideal candidates and experienced surgeons who perform a now-standard technique designed to spare the nerves needed for erection. Moreover, some patients who choose nerve-sparing surgery wind up impotent because their surgeon discovers during surgery that the potency-preserving approach is not feasible. And any major surgery is traumatic and carries a slight risk of death.

The two main treatment alternatives—external-beam radiation or internal-seed radiation—are a bit less likely than surgery to cause lasting incontinence. But radiation therapies can also make men impotent at least as often as nerve-sparing surgery does; seed radiation may pose an even higher risk of impotence, possibly because the hollow needles used to insert the seeds may also damage the nerves. And both radiation treatments are more likely than surgery to cause bowel problems.

While the frequency and severity of all those risks are enough to make any man think twice about treatment, the prospect of leaving cancer untreated can be equally distressing.

Fortunately, a growing body of research that better documents the success and complication rates of the treatments can help patients choose the approach that’s right for them, based on the likely aggressiveness of their cancer, their concern about specific complications, and their age and overall health. For details, see “Treatment choices for early prostate cancer.”

• If your life expectancy is no more than 10 years, there’s little or no reason to take the PSA test, since you’re likely to die of something other than prostate cancer.

• If you have a longer life expectancy, weigh the test’s pros and cons—and whether you’re more concerned about cancer or possibly needless treatment and complications—with your doctor.

• If you opt for the test, you should generally have your PSA level measured every year or two, starting at age 50; high-risk individuals—blacks and those whose father or brother had the disease—could start at 45.

• To increase the test’s accuracy, talk with your doctor about factoring in your age, the components of the PSA score, and how quickly it rises.

• Whether or not you take the PSA test, all men should probably undergo periodic digital rectal exams.

• If a biopsy finds early prostate cancer, use the accompanying table to help you select the treatment that’s best for you.

If you suspect you have or are at risk for prostate cancer, make an appointment with your doctor soon. Prompt, proper treatment can help limit the spread of prostate cancer and restore your quality of life. With many surgical and therapeutic options available, having up-to-date, unbiased information is crucial.