The PSA experts’ kerfuffle! Is there an evidence-based algorithm?

Recently I was listening to a health call-in show on public radio during which a urologist gave advice on the diagnosis protocol for prostate cancer seemingly different and more aggressive from the one used by my urologist.
I remember when the “gold standard” for PSA prostate screening was a score of 4 or below. Then lost favor and PSA trajectory became the new GS, more specifically and increasing PSA score over time was cause for alarm. It seems that expert advice changes every few years resulting in less guidance on what to do rather than more evidenced-based recommendations.

So I started Googling:
“It can be hard for physicians to follow current thinking of experts on medical care. It must be exponentially harder for the public to make sense of it. Recently, the United States Preventive Services Task Force changed its recommendation on prostate cancer screening from a D (that is, don’t do it) to a C (discuss it with your doctor).”
“Five years ago, the task force gave prostate cancer screening a D recommendation because there are real harms from over-diagnosis of the disease. Over-diagnosis leads to unnecessary treatments, and a newly discovered cancer could lead to no symptoms or harm over the patient’s lifetime. The treatments for prostate cancer, including radiation and prostatectomy, have high levels of adverse events. About 75 percent of all the men treated will have impotence, incontinence or both.”
Further, at the time of the 2012 statement, there appeared to be little evidence that screening with a prostate-specific antigen blood test (PSA) reduced prostate cancer mortality. With no clear benefit, and significant harms, a D recommendation seemed appropriate.
…..I’m sure the nuances of A, B, C and D recommendations can be confusing to the public. They can also make it seem as if experts are constantly changing their minds. But this is how we want our experts to react: When new evidence is found, it should be added to older evidence to change our thinking when appropriate. (A)

CHOOSING WISELY
“For years, doctors have used a PSA blood test to screen men for prostate cancer. The test measures a protein made by the prostate gland, called a prostate-specific antigen (PSA).
But the PSA test can do more harm than good. Here’s why: The test is often not needed.
Most men with high PSAs don’t have prostate cancer. Their high PSAs might be due to: An enlarged prostate gland; A prostate infection; Recent sexual activity; A recent, long bike ride.
Up to 25% of men with high PSAs may have prostate cancer, depending on age and PSA level. But most of these cancers do not cause problems. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. They are not likely to spread beyond the prostate. They usually don’t cause symptoms, or death.
Studies show that routine PSA tests of 1,000 men ages 55 to 69 prevent one prostate cancer death. But the PSA also has risks.
There are risks to getting prostate cancer tests and treatments…” (B)

When is a PSA test needed?
If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits.
Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.
You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.(C)

Talk to your urologist about Watchful Waiting and Active Surveillance
“Active surveillance is often used to mean monitoring the cancer closely. Usually this approach includes a doctor visit with a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) about every 6 months. Prostate biopsies may be done every year as well. If your test results change, your doctor would then talk to you about treatment options.
Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.”
“One of these approaches might be recommended if your cancer: Isn’t causing any symptoms; Is expected to grow slowly (based on Gleason score); Is small; Is just in the prostate…
Watchful waiting and active surveillance are reasonable options for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments to try to remove or destroy the cancer.” (D)

I f you wind up having a biopsy, consider getting a second opinion before starting one of the various therapies available.
Options include: Surgery. Radiation therapy. Cryotherapy (cryosurgery). Hormone therapy; chemotherapy; Vaccine treatment; Bone-directed treatment (E)

And always keep your primary care physician involved, the doctor who knows you best.

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) The ABCs and Ds of Whether to Get Prostate Cancer Screening, by Aaron E. Carroll, https://www.nytimes.com/2017/06/26/upshot/the-abcs-and-ds-of-whether-to-get-prostate-cancer-screening.html
(B) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(C) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(D) Watchful Waiting or Active Surveillance for Prostate Cancer, https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html
(E) Treating Prostate Cancer https://www.cancer.org/cancer/prostate-cancer/treating.html

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