In case you haven’t heard, the U.S. Preventive Services Task Force (USPSTF) is getting ready to update their recommendation on prostate cancer screening. And surprise! It turns out that their previous advice to ditch the PSA test was ill-advised.
Not that this is the first time something like this has happened. (Which is exactly why I ignored their guidelines in the first place.) It never ceases amaze me how the baby gets thrown out with the bath water when it comes to one-size-fits-all medical guidelines. Especially because, once again, the broad-brushing has backfired.
You may recall the study that triggered the USPSTF to turn on the PSA test several years ago. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial appeared in the New England Journal of Medicine back in 2009. And its results showed no difference in mortality rates between men who received PSA screening and those who didn’t.1
These results were a real lynchpin for the USPSTF, for obvious reasons. Trouble is, we’re now finding out that they were just plain wrong.
A major oversight with deadly consequences
Researchers have since reanalyzed the data from this landmark study. And further scrutiny has revealed that the control group in this trial included men who had already received PSA testing. In fact, the rate of PSA screening turned out to be even higher in the “unscreened” group, than in the screened group.2
In other words, this “control group” wasn’t really controlled at all. Which means that any results regarding the benefits of PSA testing are essentially meaningless. And worse, that the USPTF drew its conclusions without even studying the data.
Now what does that tell you?
It tells you that there was indeed a serious problem with prostate cancer screening. But instead of addressing the real issue—doctors over-treating and mutilating millions of men based on uncertain PSA results—the government just decided to stop screening for the disease altogether.
This misguided recommendation against routine PSA testing was just another example of the government butting its head into things it shouldn’t—and absolving today’s physicians of the responsibility to think critically and treat accordingly.
As a result of the USPSTF recommendation, PSA screening has plummeted nationwide. Fewer prostate cancers are being diagnosed. And more and more doctors are starting to believe that screening for the disease just isn’t a big deal. All this, despite the fact that the science clearly demonstrates that routine PSA screening saves men’s lives.
Case in point: The results from the European Randomized Study of Screening for Prostate Cancer (ERSPC) came out back in 2014. This was the largest trial of its kind in the world. And it showed that PSA testing cuts prostate cancer deaths in half.3
I think it’s pretty clear which of the two studies in question is more credible. Yet for some reason, it’s the first, flawed study that has largely dictated your access to the PSA test for the better part of the last five years.
PSA is just one piece of the prostate cancer puzzle
As I’ve explained here at great length before, the PSA test isn’t dangerous. (Quite the opposite, in fact—it’s about as non-invasive as screenings can get.) So instead of ditching it, how about we finally shift our focus to stopping overzealous treatment decisions based on misinterpretation of PSA results?
Here’s the bottom line: You absolutely should get screened for prostate cancer—and that absolutely should include routine PSA testing.
Published research shows that PSA testing does in fact reduce prostate cancer deaths. So while it may not be appropriate for everyone, guys who are at high risk should definitely be getting screened more often. And even otherwise healthy men should have at least a baseline PSA test at some point by the time they’re in their 50s.
Whether or not you should undergo the barbaric treatments that are currently recommended for prostate cancer is another story altogether. One that I covered in detail back in the September 2014 issue—if you missed it, I definitely encourage you to visit the archives and read it.
For now, suffice it to say that most men with prostate cancer don’t need these extreme interventions to survive. But the PSA test is—and always has been—one potentially life-saving piece of the puzzle when it comes to figuring out where you happen to stand.
And that’s more true now than ever, thanks to the introduction of a number of more advanced tests that help to put PSA results into a clearer, more meaningful context.
Three technologies that offer a bigger picture of your prostate
Prostate Cancer Antigen 3 (PCA3) test: Like the PSA, this is a simple urine test. But unlike the PSA, it’s specific to prostate cancer. (As you may recall, a number of other factors can affect PSA levels, including infection, inflammation, or even recent ejaculation.)
The PCA3 looks for a genetic marker produced only by prostate cancer cells. So whatever your PSA results may be, a high score means that cancer is likely present, while a low score means it’s less likely.
The limitation with this test, however, is that it can’t tell you how aggressive the disease is, or what stage it’s in. And as I’ve explained at great length before, these are both crucial pieces of information to have before you make any big treatment decisions.
Biopsy remains the best way to get that information. But it’s an invasive procedure, and can cause pain and complications, so you don’t want to agree to one without a good reason to do so. This test can help you to make that decision.
You can learn more about the PCA3 test by visiting www.PCA3.org.
The 4Kscore test: This new blood test looks at four different prostate-specific biomarkers: total PSA, free PSA, intact PSA, and a protein called Human Kallikrein 2 (hK2). The results are put into an algorithm along with personalized clinical data—including patient age, digital rectal exam results, and previous biopsy results—to come up with an individual score.
The personalized results of this combination test have a pretty clear advantage over PSA testing alone—and even over the PCA3. Namely, that it can tell you how likely it is that a biopsy will uncover a high-grade (that is, aggressive and lethal) cancer upon biopsy, with results ranging from less than 1% risk to greater than 95% risk.
Knowing this percentage risk can help you to avoid unnecessary or excessive biopsies. But it can also offer valuable information after a negative biopsy—which, based on the hit-or-miss nature of this procedure, is pretty important.
In other words, if 4Kscore results are also low risk, you can rest easier knowing that those negative biopsy results are likely accurate. If, however, they suggest the presence of aggressive disease despite a negative biopsy, then it’s worth considering a repeat biopsy.
What’s more, 4Kscore results also predict the likelihood that your cancer will spread through your body over the next 20 years. Again—a crucial piece of the puzzle when making life-altering treatment decisions.
To find a lab that offers the 4Kscore test, visit www.4kscore.com.
MRI/ultrasound fusion biopsies: In case you haven’t noticed, most of these more refined tests are focused on avoiding unnecessary or excessive prostate biopsies. And there are a few reasons for that.
First, biopsies are invasive. Having a needle inserted into your prostate is not most men’s idea of a good time. Not to mention the fact that they come with risks—including ED, pain, and bleeding.
All this would be easier to tolerate if reliable results were guaranteed. But unfortunately, they’re not. That’s because most doctors perform “blind” biopsies where they take as many as two dozen random samples (or “cores”) for analysis. This procedure is guided by ultrasound imaging—so it’s not entirely random. But the fact is, ultrasound doesn’t clearly distinguish between cancerous and non-cancerous prostate tissue.
As you can imagine, that’s a whole lot of room for error. With this kind of standard biopsy, your doctor could miss the cancer altogether, leaving you with negative results despite the presence of disease. Or it could expose a cancer that would be better left alone, resulting in a cascade of overtreatment.
Obviously, the more tools you and your doctor have to eliminate second guesses on the path to biopsy and diagnosis, the better. And while the two tests I just mentioned will give you a clearer idea as to whether a biopsy is even warranted, this next bit of new technology is helping to make that biopsy as efficient and accurate as possible.
It’s called a “fusion” biopsy. As the name suggests, it combines two types of imaging—MRI and ultrasound.
With fusion biopsy, you get the crystal clear detail of an MRI fused with the ease and maneuverability of an ultrasound—ensuring more precision and less error when removing tissue samples. In other words, it offers doctors a roadmap to cancerous lesions.
Needless to say, this is the kind of biopsy you want, if you can get it. And unfortunately, that’s still a big “if.” It’s fairly new (and thus, expensive) technology. So for now, you’re more likely to see fusion biopsies in regular use at academic hospitals than in smaller clinics.
That said, I hope that it’s only a matter of time before this approach becomes the new standard. Because if the PSA debacle over the last several years has taught us anything at all, it’s that urologists need to get a whole lot smarter if they’re serious about saving lives.
- Andriole GL, et al. N Engl J Med. 2009 Mar 26;360(13):1310-9.
- Shoag JE, et al. N Engl J Med. 2016 May 5;374(18):1795-6.
- “Prostate Cancer Screening: Highlights From the 29th European Association of Urology Congress Stockholm, Sweden, April 11–15, 2014,” Rev Urol. 2014; 16(2): 90–91