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Deciding If You Should Be Screened for Prostate Cancer Using the PSA Blood Test

On October 11, 2011, the U.S. Preventive Services Task Force released its recommendation that healthy men of any age no longer be routinely screened for prostate cancer using the prostate-specific antigen (PSA) blood test. After a review of the clinical research, the panel concluded that the PSA test does not save lives but rather results in unneeded biopsies and treatments that can cause serious complications, including incontinence and impotence.

In 2008, the same panel advised against PSA screening for men age 75 and older and noted that the evidence was not sufficient to establish a benefit for PSA screening of men under age 75. The change in the newest statement is the recommendation against routine PSA screening of the general population, regardless of age. With the new recommendation, more than 44 million men over the age of 50 will now need to decide in consultation with their physicians whether the test has value for them individually.

Below are answers to some of the questions men may have about PSA screening and the new recommendation, offered by a panel of leading prostate cancer physicians at Fox Chase Cancer Center. Their names are provided at the bottom of this page.

Q: What is PSA and what is the PSA test?

A: Prostate specific antigen (PSA) is a protein secreted by prostate cells, both benign and malignant. The PSA test is a simple test that measures the amount of PSA in a person's blood. Currently, the PSA test, along with a digital rectal exam (DRE), is approved by the U.S. Food and Drug Administration (FDA) to help detect prostate cancer in men age 50 and older. The more elevated a PSA level is, the more likely that a man might have prostate cancer. However, an elevated PSA test by itself does not mean a man has prostate cancer.

Q: What can cause an elevated PSA?

A: Factors that can cause an elevated PSA include cancer, infection, inflammation, BPH (benign prostatic hyperplasia or enlargement), and age.

Q: What should you do if your PSA test is elevated?

A: There are several things that can be done if your PSA test is considered elevated above normal. Many times, your doctor will simply recheck the PSA after some time has passed. An examination of the prostate by your physician (a digital rectal examination, or DRE) can be performed, if it has not already been done, to determine if an abnormality can be felt. Your doctor may treat an infection, if symptoms are present. A biopsy of the prostate may be recommended if the PSA remains elevated.

Q: What are the risk factors for developing prostate cancer?

A: Known risk factors include age (older men are at an increased risk), race (African American men are at an increased risk compared to Caucasian men) and a family history of prostate cancer: Having a father or brother with prostate cancer puts you at an increased risk of developing prostate cancer. It should be noted though that the majority of men who develop prostate cancer do not have any of these risk factors.

Q: Besides these new recommendations from the U.S. Preventive Services Task Force, what are the current recommendations from other national groups?

A: Currently, the American Urological Association (AUA) recommends that men with life expectancy over 10 years should have a baseline PSA at age 40. The American Cancer Society (ACS) recommends that men have a discussion with a health provider regarding the risks and benefits of prostate cancer screening. That discussion is recommended to occur at age 50 or at age 45 if you are African American or have a father or brother with prostate cancer, particularly if that cancer occurred at a young age (less than 65 years). The National Comprehensive Cancer Network (NCCN) recommends that a discussion of the risks and benefits of prostate cancer screening occur at age 40 for men to make an individual and informed decision regarding screening.

Q: Is there any other current research to validate if PSA can be used to screen for prostate cancer?

A: The National Cancer Institute (NCI) is conducting the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, or PLCO Trial, to determine if screening for these cancers can reduce cancer deaths. The first reported results for the prostate cancer portion of this trial suggested that PSA screening did not reduce cancer deaths. However, an updated report from the PLCO in 2010 reported a reduction in death from prostate cancer by PSA screening after 10 years of follow-up among men in otherwise good health. The European Randomized Study of screening for Prostate Cancer (ERSPC) found a 20 percent reduction in cancer deaths associated with PSA testing every 4 years. A study from Sweden reported a reduction in death from prostate cancer by PSA-based screening after 14 years of follow-up. Further updates from these studies as well as other ongoing studies will be important to clarify the use and interpretation of PSA for screening.

Q: If I am an otherwise healthy man, should I be screened for prostate cancer using the PSA test? If so, at what age and how often should I be screened?

A: It is recommended that men discuss the risks and benefits of screening for prostate cancer with their doctors. Several factors can influence screening decisions, such as family history of prostate or other cancers, symptoms, etc. You may not be aware of such factors until a detailed discussion takes place with a health care provider. Based on thorough risk assessment, you can make a personal decision regarding prostate cancer screening.

Q: What are the risks, if any, associated with having the PSA test performed? How can those risks best be managed?

A: PSA levels can be abnormally high when prostate cancer is not present due to other causes that are benign. For this reason, prostate biopsies are usually recommended. Although generally safe, there is a small risk of infection or significant pain associated with prostate biopsy. The PSA test can detect prostate cancer at an earlier stage, when curative treatment is possible, but not all prostate cancers that are detected by the PSA test will be life threatening or cause symptoms. This means that many men will undergo treatments that cause significant side effects, including incontinence or impotence, without a clear benefit. In addition, the PSA test may not be abnormally high when a prostate cancer is present, so that a normal PSA is not a guarantee that a man is free of prostate cancer.

Q: If, in consultation with my physician, I choose to have a PSA test done, will I still be able to get it? Will my insurance pay for it?

A: Currently, Medicare provides coverage for an annual PSA test for all men 50 years and older.

Q: What is the bottom line regarding these new recommendations?

A: The 2011 U.S. Preventive Services Task Force recommendations are similar to those previously made by the American College of Physicians and American Cancer Society. These groups recommend that men should discuss with their physician the potential benefits and risks of having a PSA test. The U.S. Preventive Services Task Force recommends that physicians understand the evidence "but individualize decision making to the specific patient or situation."

Prostate cancer is the second-leading cause of cancer related deaths in US men. The challenge is identifying which men will die from prostate cancer and screen accordingly to prevent death from prostate cancer in these men. Research is ongoing to refine screening to be more personalized and informative. In the interim, all men, and particularly men at high risk (family history positive, African American men, history of early onset prostate cancer in a family), should have individual discussions with their physicians about the risks and benefits of screening.

Contact Us

We encourage you to call the Prostate Cancer Risk Assessment Service at Fox Chase Cancer Center with questions or to schedule an appointment to address your prostate cancer screening concerns and receive appropriate recommendations. The number is 1-877-627-9684.

The Fox Chase physicians who contributed to preparing these questions and answers are:

Veda N. Giri, MD, Assistant Professor, Clinical Genetics; Director, Prostate Cancer Risk Assessment
Richard E. Greenberg, MD, FACS, Chief, Urologic Oncology
Eric M. Horwitz, MD, Chair of Radiation Oncology; Gerald E. Hanks Chair in Radiation Oncology
Gary R. Hudes, MD, Professor, Medical Oncology; Director, Genitourinary Malignancies
Robert G. Uzzo, MD, FACS, Chair of Surgical Oncology ; G. Willing "Wing"Pepper Chair in Cancer Research