PSA test: Promoting Stress and Anxiety?

by Steve Milloy
October 6, 1999,

I hate to admit it. But I’m at that age where prostate cancer enters the mind – especially since my father just completed a course of radiation treatment for his prostate cancer.

Prostate cancer is the most commonly diagnosed cancer among U.S. men. And at about 40,000 annual deaths, it is the second deadliest behind lung cancer. Prostate cancer is the male version of breast cancer. It’s not preventable and early detection is the key to survival. But – and it’s a big “but” – controversy has arisen over early detection.

The prostate is a chestnut-sized gland in the make pelvic area. It plays a role in generating seminal fluid that helps transport sperm. For unknown reasons, the gland can enlarge and cancer can develop. Some cancers are fatal. Some aren’t. While most prostate cancer occurs in older men, it can strike younger men as well. Half of prostate cancer deaths occur in men over the age of 75. Fewer than 5 percent of deaths occur in men who were under 60 at diagnosis.

Until about 10 years ago, prostate cancer was detected by a technique euphemistically named the “digital rectal exam.” But rectal exams often don’t catch cancers until after they have spread – at which point it may be too late to cure. Then came the PSA test, a blood test that measures the level of prostate specific antigen. PSA is usually elevated in men with prostate cancer, but can also be elevated, usually to a lesser degree, in men with benign prostate growth.

The PSA test did wonders for diagnosing prostate cancer. The number of men diagnosed with prostate cancer in 1985 was about 85,000. By 1996, the number diagnosed had jumped to almost 320,000. Sounds great right? It was early detection we needed and early detection we got. But maybe not.

Though more prostate cancer is being detected now than 10 years ago, it’s not that more men are getting prostate cancer. It’s just that more prostate cancer is being detected by the PSA test. Not all prostate cancer is fatal. In older men, prostate cancer can be slow-growing so that they will die with it, not of it.

An elevated PSA test does not automatically mean that cancer is present. Like the digital rectal exam, a PSA a test can erroneously indicate prostate cancer and erroneously fail to detect a prostate cancer. So while the screening may lead to life-extending diagnosis and treatment, it can also lead to treatment of cancers that don’t need to be treated – or even cancer that a man may choose not to treat. Treatment may cause urinary incontinence or impotence.

Several years ago, controversy arose over whether routine screening for prostate cancer.

The American College of Physicians says that routine prostate-cancer screening “is not for everyone” and that it is “a complex decision that patients should make after talking to their physician, understanding the risks and benefits, and coming to an informed, individualized decision. A urologist said in the British Medical Journal that [PSA testing] “merely Promotes Stress and Anxiety.”

But the American Urology Association and the American Cancer Society recommend that, annual PSA testing be done annually beginning at age 50, and earlier for men at high risk. The developer of the PSA test, Dr. William J. Catalona, professor and chief of urology and the Washington University School of Medicine says “PSA testing has exhibited all the features of an effective cancer-screening tool.” But note that he didn’t say it saves lives. Why? Because there’s no proof it has.

The National Cancer Institute criticized the American Cancer Society in 1992 for acting hastily in recommending routine screening without waiting for proof that mass screening reduces mortality. The ACS’ chief medial officer offered the weak defense that “Physicians and the public are demanding to be told what to do.”

Until recently, there have been no controlled studies on whether PSA testing reduces the prostate cancer death rate. The first clinical trial to examine the value of PSA screening, released in May 1998, reported that PSA screening led to a 69 percent reduction in prostate cancer death rates. While sounding impressive, researchers immediately raised questions about potential bias in the study data. Men who agreed to be screened may have been healther than those who did not agree.

Now, a new study in the Oct. 6 Journal of the National Cancer Institute reports that PSA levels may mean something entirely different than originally thought.

So what do you do? How do you choose between the American College of Physicians and the American Urological Association? Does it help to know that the ACP recommendation is “evidenced-based”? The ACP examined and reviewed more than 40 studies to determine the potential benefits of screening, the complication rate of treatment, and the balance of benefits harms and costs. In contrast, the AUA recommendation represents a consensus of expert opinion. Evidence vs. expert opinion? Wouldn’t you think expert opinion would be based on evidence? Confused? As my father-in-law, a prominent south Florida urologist said, “Urologists have the most experience, but they also have the most to gain from routine screening.”

What do urologists have to gain? You decide. PSA testing costs about $100. An elevated PSA could lead to more testing or a biopsy costing around $1,500. The prostate testing market is worth about $200 million to $300 million annually. Until recently, the developer of – and the leading cheerleader for – the PSA test, William Catalona, was receiving $1 million per year “to study the effectiveness of the PSA test,” largely from Hybritech, a pharmaceutical firm that manufactures the PSA test.

Recently, Catalona criticized the American College of Physicians for recommending against routine screening in favor of physicians and patients discussing the potential benefits and known harms of screening diagnosis and treatment and making individual decisions. Catalona wrote “This sounds reasonable but is impractical because busy doctors lack time for long discussions.”

Prostate cancer can be life-threatening. If your physician doesn’t have the time to discuss your options, get a new doctor. And whatever you do, don’t fall for the unproven and undeciphered PSA test.

Steve Milloy is the publisher of