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Should You Have a PSA Screening Test? Johns Hopkins Responds to Recent USPSTF Recommendations

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By now, you’ve probably heard that prostate-specific antigen (PSA) screening is no longer recommended for healthy men under age 75. This controversial draft recommendation was issued by the United States Preventive Services Task Force (USPSTF). Given previous recommendations from the medical community encouraging PSA screening, many men are confused. Following are answers to some questions you may have about this recommendation -- and our advice on whether you should follow it. 

What is the USPSTF? The USPSTF is an independent group of 16 medical experts whose recommendations serve as guidelines for doctors throughout the country. In addition, the group’s recommendations ultimately impact what tests Medicare and private insurers will pay for. 

Why did they make this recommendation? According to the USPSTF, the potential harms caused by prostate-specific antigen (PSA) screening of healthy men as a means of identifying prostate cancer far outweigh its potential to save lives. The group discourages the use of any screening test for which the benefits do not outweigh the harms to the target population. 

What are the potential harms of PSA screening? An elevated PSA reading can lead to an unnecessaryprostate biopsy. Although biopsies often reveal signs of cancer, depending on a man’s age, 30 to 50 percent will not be harmful -- even if left untreated.  

After a positive biopsy comes the decision about what to do. Most men choose radical prostatectomy, external-beam radiation therapy or brachytherapy. But each of these treatments has the potential to cause serious problems like erectile dysfunction, urinary incontinence or bowel damage. And men who choose active surveillance must live with the uncertainty of knowing that they have an untreated cancer that could start to progress at any time. 

Why does the Task Force believe PSA screening does not save lives?  The USPSTF evaluated data from five large randomized clinical trials of PSA testing, including the Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Trial, which reported no mortality benefit among 77,000 men who underwent PSA testing and were followed for t10 years. 

Do these recommendations apply to all men? These recommendations apply to all men regardless of age, race or family history as long as they do not have symptoms of prostate cancer. 

Our advice. Many leading cancer and patient groups and doctors agree that there is harm with PSA screening and the treatment that follows diagnosis. But a more targeted screening approach focusing on those at greatest risk of developing prostate cancer, and active surveillance for those who don’t need immediate treatment, could shift the balance of benefit and harm toward benefit.

PSA screening is the best test available for the detection of cancer cells in the prostate. Rather than discontinuing use of the only test available to detect the disease early and treat it successfully, efforts should focus on reducing harm. 

Therefore, every man should discuss the benefits and risks of PSA screening with his physician. If you choose to be screened and the result is positive, you and your doctor should discuss whether any further intervention is appropriate or necessary. 

Posted in Prostate Disorders on November 1, 2011

Medical Disclaimer: This information is not intended to substitute for the advice of a physician. Click here for additional information: Health After 50 Disclaimer

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im 61 with a psa of 6.9 (gradually creeping up over the last 5 years) im in perfect health 5'10" 175 lbs work out 6-7 times/week great diet and don't drink or smoke. I absolutely have no symptoms of prostate cancer. Im nervious about the biopsy and am haveing second thoughts about it. I live near Harrisburg PA which is not a big city and the doctor I saw recommended a biopsy asap. I am thinking about going to Johns Hopkins in Baltimore or one of the cancer centers in Philadelphia to seek second opinions on getting a biopsy done. any thoughts out there

Posted by: patrick_cassidy | November 13, 2011 9:56 PM

i am 82 5ft6and half 151 lbs stripped i too have a creeping psa latest beng 5.1 pevious 7.1 /// 5.4 4.5. first line of alert says screening is no longer recomended for healthy men under age 75 . QUESTION WHAT ABOUT MEN OVER/ 75/ DO WE GET BIOPSIES OR WAIT AND WATCH MY FIRST VSIT IN 10 YRS WITH UROLGIST HE RECOM BIOPSY AND FLOMAX 2 MONTHS NOW STILL DCEIDING NEXT MOVE PLEASE ADVISE

Posted by: holiday21 | November 15, 2011 5:20 PM

I decided to seek other opinions as far as my options in dealing with an increasing psa; going to John Hopkins, Phila Cancer Center and Fox Chase; will let you know what the opinions are.

Posted by: | November 28, 2011 2:54 PM

As you have noticed, getting a biopsy (even getting a PSA test done) is increasingly controversial. I'm 52, normal DRE, very healthy, watch diet, exercise and run regularly, and yet as a result of a my fluctuating PSA between 4-10, I have had 3 biopsies over the last 2.5 years, the last one a saturation biopsy. I continue to be the "poster child" for the PSA controversy, and my case confounds the Urology community. Fortunately for me, all 3 biopsies were all negative. I have also had 2 PCA3 tests, and they were also both very negative. Not all Urologists will offer a PCA3 test, and many discount its effectiveness. That may be true at certain PCA3 "cut-off" levels, however my values were so low (i.e. negative), that they were proven quite accurate by the biopsies, or should I say they accurately predicated that the biopsies would be negative. All I have is a very high (and fluctuating) PSA.

Unfortunately, PSA (and PCA3) and DREs can do only one thing. They can yield enough concern by your Urologist, that he/she is largely forced to recommend that you "rule out" cancer by getting a standard 12-core biopsy. Problem is, biopsy is only ~80% accurate, and if your PSA continues to be "abnormal", they will likely suggest you have a second, and as in my case, a third biopsy to increase the pathological accuracy and further "rule out". The math is simple, the odds of 3 false negative biopsies is increasing small (1st biopsy 20%, 2nd biopsy 4%, 3rd biopsy <1%).

Is PSA a good marker? Answer: No, because statistically 1 out of 4 men that have high Total PSA and low Free PSA have positive biopsies and the vast majority of those are not life threatening even though they end up getting treated largely for the fear of the diagnosis. To JH credit, the "Watchful Waiting" programs led by Ballentine H. Carter, M.D and others are becoming more prevalent.

Have I suffered considerable anxiety, discomfort, and financial pain as a result of PSA testing that I would not have otherwise suffered? Answer: Yes

Would I suggest you seek out second opinion World leading Centers/Doctors such at the Brady Center at JH? Answer: Yes

Bottom Line: All I can do is tell you my story. It largely confirms the fact that PSA is not enough and has done as much harm as it has done good (in my humble and very well read opinion and experience). I simply followed my Urologists advice and got the biopsies done. I have peace of mind now, but I went through hell to get it.

Posted by: mcoplon | December 3, 2011 11:50 AM

My initial reaction to the USPSTF finding that the potential harms of PSA screening for healthy men under age 75 far outweighs the potential to save lives, and the corresponding recommendation that this test not be routinely performed, was that both the finding and the recommendation missed the point. The problem is not with the PSA test itself, but with the prostate treatment industry it has spawned, and its aggressive and profitable promotion of harmful and unnecessary prostate cancer treatment. The sad truth is that once an abnormal (whatever that is) PSA is diagnosed, all of the emotional, legal and financial forces align to dictate treatment regardless of whether this is the appropriate medical approach.

My own experience illustrates this clearly.

I developed a relationship of trust with a urologist affiliated with a large Chicago teaching hospital in the course of my treatment for kidney stones. I believed he understood and respected my strong desire to avoid treatment unless absolutely necessary. In the course of my treatment, he also monitored my PSA. After a couple of years of fluctuating but gradually rising PSA levels, my PSA was 4.3 with free PSA of 11.7% in January, 2010, and the doctor strongly recommended a biopsy. I reluctantly underwent a biopsy in January, 2010 at the age of 58.

The biopsy found prostate cancer in 5% of one core, primarily Gleason 3, but with a small amount of Gleason 4, yielding a Gleason score of 7. My delight in this seemingly insignificant finding turned to dismay when the doctor advised me that immediate treatment was necessary and a radical prostatectomy or external beam radiation therapy were my only recommended options. Following a discussion that lasted about an hour and a half, much of which was with a nurse, the doctor persuaded me to undergo a robotic radical prostatectomy. In the course of the discussion, he assured me that the surgery had been greatly improved and that recovery of continence and sexual functioning should be expected.

After doing some research, I became uncomfortable with the robotic procedure and consulted with another doctor in the same practice who used the open surgical approach and who had performed in excess of 5,000 of this procedure. This physician also said that recovery of continence and sexual function should be expected. In response to a specific question, he said that orgasm could be expected to be normal even in the absence of erections, and that something almost always could be done to restore erectile function. Based on these assurances and those of the first doctor, I underwent an open radical prostatectomy in March, 2010.

The pathology report disclosed cancer in two lobes, Gleason 3 and Gleason 4, affecting about 10% of the prostate, with final staging of T2c.

Nothing prepared me for the hell that followed this surgery. I found orgasm difficult to achieve and of extremely poor quality, even with injection induced erections. My sexual functioning was essentially non-existent. In response to my concerns expressed beginning about four weeks post-op, the doctors told me to be patient. My frustration caused my blood pressure to rise to the point that it required medication. I became depressed, and was put on medication and began psychotherapy when I became suicidal. As I approach two years following surgery, I have not experienced a satisfactory orgasm, I have not experienced a spontaneous erection, I leak urine unpredictably during sexual activity (although my continence is otherwise good), and I have experienced significant penile shrinkage. Nothing in my discussions with the doctors prepared me for this. I will regret having this surgery until the day I die, and, frankly, I wish that I never agreed to undergo a PSA test.

Posted by: wolfdog | February 28, 2012 9:00 PM

great new info looking forward to update especially HIFU INFO I AM 83yr old male no biopsys yet last psa 6.1after dropping from 6.7 will do watchful waiting 5ft 7 160 lbs no prescriptions thank you long island ny

Posted by: holiday21 | May 30, 2012 1:32 PM

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