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Another View on PSA Testing

Kongo's picture
Posts: 1167
Joined: Mar 2010

Several recent threads have looked at PSA testing, what can cause it to rise, what does it mean, and so forth. Many of us were diagnosed with PCa after our PSA rose above a level our GP was comfortable with and we were referred to a urologist who did a biopsy and whoa --- Hello prostate cancer.

A recent Op-ed in the New York Times by Dr. Richard Albin, the man who discovered PSA in the form used to test today, presents an interesting perspective...and one that is probably contrary to most of the medical advice we get when we visit our medical teams.

Whether one agrees with Dr. Albin or not, one thing he mentions that I hadn't realized before: Over-the-counter drugs like ibuprophen can cause a PSA rise.

NY Times, March 9, 2010


EACH year some 30 million American men undergo testing for prostate-specific antigen, an enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the P.S.A. test is the most commonly used tool for detecting prostate cancer.

The test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970. As Congress searches for ways to cut costs in our health care system, a significant savings could come from changing the way the antigen is used to screen for prostate cancer.

Americans spend an enormous amount testing for prostate cancer. The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

Prostate cancer may get a lot of press, but consider the numbers: American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.

Even then, the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.

Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man’s P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy.

In approving the procedure, the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 percent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.

Still, 3.8 percent is a small number. Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments.

The medical community is slowly turning against P.S.A. screening. Last year, The New England Journal of Medicine published results from the two largest studies of the screening procedure, one in Europe and one in the United States. The results from the American study show that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over.

The European study showed a small decline in death rates, but also found that 48 men would need to be treated to save one life. That’s 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long.

Numerous early screening proponents, including Thomas Stamey, a well-known Stanford University urologist, have come out against routine testing; last month, the American Cancer Society urged more caution in using the test. The American College of Preventive Medicine also concluded that there was insufficient evidence to recommend routine screening.

So why is it still used? Because drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness” by encouraging men to get screened. Shamefully, the American Urological Association still recommends screening, while the National Cancer Institute is vague on the issue, stating that the evidence is unclear.

The federal panel empowered to evaluate cancer screening tests, the Preventive Services Task Force, recently recommended against P.S.A. screening for men aged 75 or older. But the group has still not made a recommendation either way for younger men.

Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer.

But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

Richard J. Ablin is a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research.

Posts: 18
Joined: Dec 2010

Interesting but from my perspective like most of the liberal trash that comes from the NY Times this follows.

Since I could not count the number of guys that I personally know whose live has been extended from the PSA test. What I see is a continued attack by a group of ego manic research doctors that are not getting the piece of the pie for developing the PSA test for prostate screening. The guy mentioned in your article is not the doctor or group that developed the PSA test specifically for PCa.

Anyway, food for thought but a waste of space even for the NY Times.

Posts: 11
Joined: Dec 2010

At 51 years old with rapidly rising PSA I was screened, biopsied and radiated. I found out later that I had a family history of the PC.

My wife is a nurse in the lab that tests me. She said the lab bills the insurance company $30 for PSA testing. That doesn't sound like anybody's making a whole lot of money out of screening.

I'll bet the authors of "Invasion of the Prostate Snatchers" are pulling in a bundle right now. Money is a huge motivator but the bottom line is that we all need to do our homework and research the best we can.

Posts: 18
Joined: Dec 2010

Yes for sure you have a good point here some of us forget that some people are pulling in a whole lot of money at the expense of guys like you and me. In the article above it states that over $3 billion is pulled in alone for PSA test a year.

Yes it is critical that we do our homework and research the best we can

VascodaGama's picture
Posts: 1887
Joined: Nov 2010

Hi Kongo
Interesting article. I have noticed along these years that the number of earlier PSA testing in USA has increased quicker than in Europe, detecting a bigger number now than one decade ago. In Europe the small decline in death rates it is thought to be due to the increased number of diagnosed patients, not (has I hopped) because of the number of saved lives from earlier treatments.
Somehow I agree with the whole article. I know that it is controversial to comment about it, but I have seen many guys over 55 that have not enjoyed the word “earlier”.
Since I was diagnosed in 2000 (50 years old), many of my friends followed my recommendation in having a PSA. Some of them rejected and some did it and were found to have PCa. Two of them joined me in my wagon. In these ten years, the ones that rejected are continuing a natural life with no worries or stresses from medical problems, in comparison with the ones that like me were positive for cancer.
Seeing my friends joining my wagon gives me a guilt feeling and that has caused me to stop recommending PSA testing to guys above 55 (just coincidence with the article). I do not want to see them in the “too late” group.
Nevertheless, I believe that earlier screening is good and it should be imposed in programs for the 40th.
Please, do not throw stones at me.

Kongo's picture
Posts: 1167
Joined: Mar 2010


I share much of your sentiments on this issue although I wouldn't go so far as to say I agreed with all of Dr. Albin's article. As my education about prostate cancer has matured in the last several months I've come to stronly suspect (as many prominent urologists now say) that many men with indolent forms of cancer are likely overtreated at enormous cost to the wealth of our population and the quality of life of the individuals involved. On the other hand, I would agree with others who have posted here that prostate screening has also saved thousands of lives and I believe few would argue that early detection of this disease is a key element in successfully treating it with a variety of effective treatment options available today.

My beef is not with the PSA test itself, but rather the screening process that has evolved since it's use became widespread. I think many men who otherwise have no physical symptoms and are found to have a single, "elevated" PSA result above a certain number are inexorably drawn into a process that frequently results in treatment whether they needed it or not. (To me, that was the gist of Dr. Albin's editorial) In my own case, a single elevated PSA led to a strong recommendation for a biopsy (another big money maker) which then resulted in a cancer diagnosis that was (as I know now) exceedingly low risk. (And, oh by the way, "just to be sure let's go ahead and do a bone scan and full blood workup.") Since about 25% of the men who have such biopsies will see a positive cancer diagnosis, this quickly adds up to thousands and thousands of men (and billions of potential dollars). Once that cancer diagnosis is made, and given our cultural fears of CANCER, many men are drawn into a sucking vortex of recommendations for treatment, pressure from family (who often don't know anything at all about PCa) to DO SOMETHING, and a very natural fear that failure to act will result in untimely death. While many doctors are making lots and lots of money on prostate cancer, I don't beleive they are acting on any diabolical motives to suck money from unknowledgeable men who fear cancer and think they need treatment when they don't. I belive physicians truly believe in their treatments and are acting out of an abundance of caution that is hard to argue with when you are the one with the cancer.

I now beleive that a single PSA reading less than 10 that leads to an immediate biopsy is unwarranted and I wish I knew then what I know now. If I could exercise the hindsight I now have, before agreeing to a biopsy I would have asked the doctors to calculate my PSA density from a history of PSA readings that went back more than 10 years. I would then have had them show me my PSA velocity and determine the PSA doubling time. If all of those indicators were well inside the "safe zone" (as mine were), I would have had them go to greater lengths to rule out BPH (my prostate was slightly enlarged), prostititus, or a potential uriniary infection. I wish my doctors had asked if I'd sex the evening before the blood draw or were taking any other medications that might affect a PSA reading. Then, I would have waited another three months and taken another PSA test. And perhaps even another test a month or so after that to determine if there really was an upward trend that needed attention or simply a spike that could have been caused by any number of non-cancer factors. That is the process I wish I'd had and if something like it was more common, I suspect we would treat far fewer patients without posing too great a risk.

Of course, hindsight is 20/20 and I'm now comfortable with the choices I made at the time based on what I knew and understood. Who knows whether the process I wish I had had would have found anything suspicious? As it was, they did find cancer and once that diagnosis is made, it's difficult to ignore. So it is what it is. Fortunately for me, I've experienced no side effects from my treatment and feel quite confident about my long term prognosis.

Since PSA cannot determine whether the cancer you have is indolent or aggressive we have to develop better tests and methodologies to sort it out. Until we do, I think we will still overtreat many men. Many lives will be saved but there will also be many men suffering from unnecessary side effects that could have been avoided with a better process or test. I hope they find one soon.

Posts: 694
Joined: Apr 2010

This is an important discussion with excellent information. IMHO, however, one critical detail was overlooked in terms of PCa screening--DRE (Digital Rectal Exam, or it’s euphemism: ‘the finger wave’). Whether PSA testing is determined to be a part of a man’s annual health exam or not (I believe it should be in most cases), the inclusion of a DRE as part of that yearly physical is not to be underestimated.

As Dr Albin critically points out in his article “Men with low (PSA) readings might still harbor dangerous cancers, while those with high readings might be completely healthy.” This was true for my husband. After 10 years of PSA readings never higher than 2.8, with no rapid doubling or rise, and negative DRE’s (no findings) by internists, GP’s and a few urologists, it wasn’t until earlier this year that my husbands stage T3 PCa was discovered, beginning with a DRE. Thus began “our” PCa journey when a palpable nodule was found on DRE by a skilled and experienced urologist (a different dr from the ones my husband had previously consulted). Perhaps the nodule was new and that is why it was discovered, or perhaps it was there all along and missed, we will never know. The good news (if you can call it that) is that the nodule discovery on DRE lead to a 12 core biopsy unfortunately indicating 9 cores positive, with many cores at 70-100% cancerous, PNI (PeriNeural Invasion) identified, and a revised 2nd opinion biopsy path report of a G 3+4=7. The other good news is that treatment decisions were made and started with an excellent chance of successful outcome.

My point here is that the debate about PSA testing/screenings leading to potentially unnecessary tx is one that must be mandatory reading for all men (and women interested their health). But that debate should not exclude the importance of an annual DRE, by a knowledgeable experienced urologist (not a GP or an internist), for men who might want to take a preventative & proactive approach when it comes to PCa screening.
mrs pjd

Posts: 6
Joined: Sep 2011

This is a wonderful site. I have had my PSA tested for probably the last 10 years. I am now 65. In 2008 my PSA finally rose above 4 and my primary doctor referred me to a urologist. After a brief exam and no other indications of Pca he told me I "needed" a biopsy. In fact he asked if I had taken any aspirin in last few days since he wanted to do a biopsy that day. I had "catastrophic" medical insurance at the time (I pay everything under $5,000) so I asked him how much a biopsy would cost and he said he had no idea!! I felt like I was on the lot of a used car dealer and he wanted to close the sale before I left the office. I walked out. I did a lot of research about Pca and decided on a watchful waiting approach. In July my PSA had risen to 7.5 and my free PSA was 8%. I realized that I needed to get a biopsy. The results were gleason 8, 6 of 8 cores positive. I am classified as a high risk and have started lupron and should start IMRT in a couple of weeks.

I think a lot of men are over treated. A PSA over 4, get a biopsy. If there is any cancer present they seek treatment. It is difficult to decipher the prognosis. In reviewing my condition over the last few years, 2 things raise a red flag. Percent free PSA (8%) and the annual incremental increase in PSA with the latest test (2.3). Both of these are indicative of a likely chemical recurrence after treatment and should be warning flags in addition to the absolute PSA test.

I haven't seen much diagnostic emphasis on free PSA (less than 15%) and annual increment (not doubling time)in PSA of more than 2. I think these are useful benchmarks in assessing the need for biopsy.

As many experts have said you can be over treated but you can't be over diagnosed

Posts: 259
Joined: Sep 2010

I've only known two guys who have died of PCa. Neither had gone through the PSA screening/Biopsy protocol untill sometime "after" their cancer had progressed out of the prostate. They were both in their 40's when diagnosed and both fought a long hard battle.

I wonder how many of the 30,000 men who will die of PCa in the USA this year were in the same boat, and could have benefited from earlier detection?

I don't think the answer to the high costs is less screening. As another poster has shown, screening does not cost that much. Maybe "better" sceening technology is on the horizon.

Maybe less treatment of lower grade PCa could lower costs. But I'd sure be hard pressed to draw the line between lower and higher grade based on current technology. Especially if the screening is limited to PSA and biopsy.

VascodaGama's picture
Posts: 1887
Joined: Nov 2010

Thanks kongo for the post.
Yes I am with you. I absolutely agree that early detection is the key element in the success of treating PCa. The term “earlier” however has not a conclusive identity of cure. It tends to have more a meaning like; “still within the limits” for the success of a certain treatment. There is no doubt that in a case like that, it could lead to save one life, if that particular individual dies with the cancer rather than from the cancer.
All denials or suspicious from poster in this thread are understandable. We become “hard to beat” wiser men from the many hours spent in researches, conferences, reading materials, year after year, and then experiencing treatment after treatment, tests and more test, etc. etc.
It becomes difficult to accept opinions from news men and from some GPs that in fact have no clue on the management of cancer.
I hope that the recent studies on the molecular environment, brings a new event for screening as earlier as at puberty age. Many works have been done to identify the genetic materials in indolent forms of cancer. If successful, all that PSA and doubling times and velocities and biopsies, etc. it would become absolute.
It seems that soon we will know the culprit of metastasis, which rests in cells proteins in the prostate stem cells. I can feel changes but don’t know if that is from what I read or from my new “mood” recently acquired from ADT.

Regards and a good Christmas to all.

Posts: 16
Joined: Feb 2010

Also had a General Practitioner who missed the nodal with a DRE. However my PSA was at 5.4 so he recommended a Urologist who found the Nodal with the DRE. Turned out to be 3+4 with 9 of 12 samples positive(sucessful-so far Robatics, etc.)-glad to have had the PSA test for sure!

CessnaFlyer's picture
Posts: 109
Joined: Aug 2009

As I mentioned in another post, I'm 69 years old with a history of colon cancer, and when I visited my family doctor this week for urinary problems he checked my last PSA test that was done in July, 2010 and casually told me the level had been 5.32 (which he didn’t tell me at the time) and decided to re-test it, and to also do a free-PSA test. The results came back yesterday and the PSA is 0.82 and my Free PSA is 28.8%. My doctor doesn't know why my PSA went to 5.32 last July, and is going to recheck it in 3-months. Still, I’m happy that I had this last PSA test, because it saved me from going through biopsies. I’m going to keep having this test on a regular basis, because the research I’ve done over the past few days has made me a believer that the reason nearly 100% of men survive colon cancer in the USA is because of early detection with tests such as PSA.

Posts: 36
Joined: Dec 2010

Kongo and friends,

Great information being shared! My PCP was concered that my PSA had jumped to 4.4 but what really concerned him was that the Free PSA was 3%. The lower the number he stated was concerning as it indicative of PC more so than the regular PSA higer reading. He too missed the nodules on my prostate, it was detected by my internest during a colonoscopy which resulted in my persuing the trail that I chose. I have never looked back after making my decision of treatment. Like all of you, my decision was based on reading, research and information available at the time. Wish all of you much success in your PC journey and want to thank you all for taking the time to post your experiences! Treatment completed and last PSA results are 0.6!


PawPaw J
Posts: 34
Joined: Jul 2011

Walter, The free psa was also the concern from my uro, not the psa itself. My psa was only 3.3 but free psa was 14%. Not sure why we hardly ever read or hear of the free psa as part of the diagnostic equation. It seems like this and velocity is more effective in diagnosis than psa. Go figure.


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