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Why most men don't need a PSA test for prostate cancer

Much of what you’ve heard about how to prevent, detect, and treat this common cancer is wrong

Published: February 13, 2015 04:00 PM

If you’re a man older than 50, or just know one, there is good reason to be concerned about prostate cancer: Roughly 27,500 men will die of the disease this year, making it the second deadliest cancer among American men, after lung cancer. To make matters even worse, much of the information about how to best prevent, detect, and treat the disease is downright confusing.

Consider: Many experts say the prostate specific antigen (PSA) blood test, meant to detect the disease early, poses more risks than benefits. What’s more, the best therapies may not be the high-tech robotic surgeries or computer-­guided radiation treatments pitched in ads but careful monitoring of the disease. And research now suggests that certain supplements once thought to help prevent the disease increase your risk.

Detection: Don’t rush to get the PSA test

Once a man reaches 50, he’s likely to be told to get his PSA measured. Voices urging the test include not only many primary care doctors but also sports stars and other celebrities in public service announcements.

But notable exceptions to that chorus include the U.S. Preventive Services Task Force, an independent group of experts that provides evidence-based guidelines on health care. In 2012, the task force recommended that doctors stop PSA screening of all men because many more men “will experience the harms of screening and treatment of screen-­detected disease than will experience the benefit.”

Efforts to promote prostate cancer screening rarely discuss the downsides of the test.

Even the American Cancer Society is lukewarm on the PSA test. The group warns of the potential harms associated with the test and recommends that men “make an informed decision with their health care provider about whether to be screened for prostate cancer.”

Read about cancer test you need and those you don'tp. And use our hospital Ratings to compare hospitals in your area. 

What harms? For one, in most men a high PSA score (historically, anything more than 4.0 nano­grams of PSA per milliliter of blood) stems from something other than cancer, such as an enlarged or infected prostate, recent sexual activity, or even a long bike ride. But men with high PSAs often undergo a prostate biopsy, a potentially painful procedure that can lead to infections. Most of those biopsies come back negative for cancer.

The test has another downside. About a third of men older than 50 have some cancer cells in their pros­tate, and by age 85, as many as three-quarters do. Though most cancers never spread quickly outside the gland, it’s difficult to dis­tinguish between those tumors and more aggressive ones. Faced with that uncertainty, almost 90 per­cent opt for treatment.

But that treatment is more likely to harm than help: Research suggests that for every 1,000 men ages 55 to 69 who undergo screening every one to four years, up to one life will be saved; treatment will lead to a serious complication such as a heart attack, blood clot, or death in three; and 40 will be left impotent or incontinent.

Our take: Men ages 50 to 74 should carefully weigh the small chance that screening will save their life against the high incidence of the harms of prostate-­cancer testing and treatment. Men older than 75, or those whose life expectancy is less than 10 years, should avoid screening because prostate cancer usually progresses so slowly that those men are more likely to die with the cancer than from it.

Treatment: Robots aren’t better

Many hospitals advertise high-tech prostate cancer treatments.

Most men who receive a cancer diag­nosis understandably want to do something about it, fast. And that inclination is often fueled by the heavy promotion by hospitals and clinics of new high-tech surgical and radiation procedures.

Many ads, with pitches such as “the future of prostate surgery is here,” tout robotic-assisted surgery. The ads seem to work: Eight out of 10 surgeries to remove all or part of the gland are now performed that way.

But there’s little evidence that robotic-­assisted surgery is safer than the tradition­- al approach. One 2014 study comparing the two suggested that they have the same risk of complications, hospital readmissions, and need for additional cancer therapies. Other research traced the rise in robotic surgery to hospitals that invested in the machines, which cost up to $2.5 million each.

Another heavily pitched treatment is stereotactic body radiation therapy, better known as CyberKnife. One ad for the therapy says it’s “the ultimate cancer-­fighting weapon.” But it fails to mention a 2014 study that linked more urinary com­plications among men who underwent CyberKnife treatment, compared with those who had a more standard external beam radiation, known as intensity modulated radiation therapy.

Older prostate-cancer surgeries aren’t all that great, either: At least 20 percent of men who have their prostate gland removed will experience urinary incontinence, erectile dysfunction, or both, according to the task force.

That’s why many experts say a good option for many men is active surveillance, or carefully monitoring the cancer with regular PSAs and other tests and treating it—with hormones, surgery, radiation, or a combination—only if there are signs or symptoms that the disease is progressing.

Our take: Deciding how to treat prostate cancer is a difficult decision. A man must balance his concerns and anxiety of living with an untreated cancer with the significant risks of treatment. For a comparison of the success and complication rates of prostate-cancer treatments, see the chart, below.

Prostate cancer treatment options

 

Treatment

12-year survival rates*

Long-term adverse effects**

Treatment description

Good candidates

Observation (active surveillance)

About 97% for low-risk tumors; about 91% for intermediate-risk tumors; about 85% for high-risk tumors.

 

Anxiety about cancer progression.

 

Regular PSAs and other tests, sometimes including biopsies

 

Men with low-risk tumors who highly value freedom from treatment side effects. Men with life expectancy of 10 to 20 years or less.

Surgical removal (prostatectomy)

About 97% for low-risk tumors; about 95% for intermediate-risk tumors; about 92% for high-risk tumors.

 

Reduced sexual function: 47%

• Urinary leakage or dripping: 13%

• Frequent, urgent or painful bowel movements: 4%

 

Requires 1 to 3 days in a hospital and a week or two with a urinary catheter.

Otherwise healthy men who have the longest life expectancy and the least surgical risk.

 

External-beam radiation

 

Rates likely between observation and surgery.

 

• Reduced sexual function: 40%

• Urinary leakage or dripping: 3%

• Frequent, urgent or painful bowel movements: 6%

 

• Requires 7 to 8 weeks of daily treatments.

• Sexual problems tend to worsen over time.

 

Men who want to avoid major surgery or whose poor health or advanced age makes

surgery too risky.

 

Internal-seed radiation

(brachytherapy)

Rates likely between observation and surgery.

 

Rates likely similar to external-beam radiation.

• Requires one outpatient operation in which doctors implant radioactive seeds

in prostate using hollow needles.

• Sexual problems tend to worsen over time.

 

Same as external radiation but more practical for those who can’t easily make daily trips to the hospital.

 

* Survival rates are based on a randomized trial examining radical prostatectomy surgery versus observation for localized prostate cancer, published July 19, 2012 in the New England Journal of Medicine.

** Adverse effect rates are five years after completion of treatment, as reported in a January 31, 2013 study published in the New England Journal of Medicine in which researchers surveyed 1,655 men about quality of life after prostatectomy and external-beam radiation.

Prevention: Beware of supplements

Not so long ago, vitamin E and the mineral selenium were held out as a great hope against prostate cancer because research suggested that men who consumed diets rich in the nutrients were less likely to develop the disease. But last year the authors of a randomized clinical trial funded by the Na­tional Cancer Institute that looked at 5,000 men and lasted about 10 years concluded that “men should avoid selenium or vitamin E supplementation at doses that exceed recommended die­tary intakes.”

Why? Their research found that the supplements offered no protection whatsoever and that, in fact, men taking vitamin E had a 17 percent increased prostate-cancer risk. The benefits once linked to the nutrients may have stemmed from other food components in their diets or healthy lifestyle habits. Research has also failed to confirm the benefits of other supplements touted for prostate health, such as saw palmetto, lycopene, and green tea extract.

Our take: Skip the supplements, including multivitamins. When it comes to preventing prostate cancer, the best advice is the same as for staying healthy in general: Maintain a healthy weight, eat a diet rich in produce, and exercise regularly.

Editor's Note:

This article also appeared in the April 2015 issue of Consumer Reports on Health.



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