Should I get tested for prostate cancer?

The PSA test is actually used to detect the presence of the prostatic antigen in the blood. When its rate is high, this antigen shows that there is an issue with the prostate, but it does not necessarily mean prostate cancer. While this test is the best to screen for prostate cancer at the moment, it is not perfect. On its own, it does not show if it’s necessary to cure a patient nor how to do it.

Before deciding to have a PSA test, ask yourself these questions and discuss them with your doctor, your family, and your friends:

• What are my risks of prostate cancer?
• Would I be reassured if my PSA test results are normal?
• What will I do if my PSA level is high?
• If I am diagnosed with a slow-growing cancer that might not cause me any problems in my lifetime, would I want to undergo a treatment that could have side effects that impact my daily life?

Personal context

The PSA test is usually offered to any man over 50 years old and with a life expectancy of at least ten years. Moreover, a healthy man, who does not show any symptoms nor family background concerning prostate cancer, has very few reasons to worry and wanting to do a screening. On the contrary, a man at risk, meaning someone with a history of cancer or of African descent, would likely benefit from testing starting in his forties.

Based on the Canadian Urologist Association, screening should be discontinued in men at age 70 with no symptoms; however, for men 70 years of age and older, who are interested and in excellent health, screening may be considered in terms of their health, values, and preferences.

Despite all this, if cancer is detected, doctors may choose not to treat the patient because the disease is not advanced enough or is progressing too slowly, for example. In such cases, rigorous monitoring is now the norm.

Consequently, the PSA test can be a useful tool to screen prostate cancer quickly and to prescribe the appropriate treatment. However, it is not an absolute reference and men at risk are the ones who should take this test the most. In case of doubt, ask advice to your physician and discuss the advantages and disadvantages of being screened with a PSA test.

It is important to weigh the pros and cons of the PSA test. What might be an advantage for one man may not necessarily be the case for all men.

Avantages

• A PSA test can help detect prostate cancer before you show any symptoms.
• A PSA test can help detect an aggressive cancer at an early stage in its development and allows for treatment before the cancer spreads.
• A non-aggressive cancer may not need treatment. Regular check-ups and PSA tests can allow you to delay treatment and its associated side effects while keeping an eye on the cancer’s development.
• Regular PSA tests can be helpful for men at high risk of prostate cancer by allowing for the early detection of cancer.

Limitations

• • An elevated PSA level does not necessarily mean you have prostate cancer. Around 3/4 of men with a raised PSA level do not have prostate cancer (false‑positive result).
  • An elevated PSA may require you to undergo other tests that may pose certain risks. For example, a biopsy can cause pain, infection, and bleeding.
  • The PSA test can have a false-negative result. About 2% of men with aggressive prostate cancer have a normal PSA level.
  • A slow-growing cancer could have no impact on your life, but the fact that you know you have cancer can be worrisome and lead to unnecessary treatment.
  • Side effects of a treatment for prostate cancer can affect your daily life. These side effects can include urinary, bowel, and erectile problems.

Three doctors give their opinions

The PSA test is the best test currently available for detecting prostate cancer, but it is not perfect. This screening test allows us to detect prostate cancer at an early stage and potentially prevent deaths caused by this cancer, but it cannot be used alone to determine who to treat, when to treat, or how to treat patients with this disease.

The controversy surrounding this test does not come from the PSA test itself, but rather from how the results are used. Prostate cancer is very common but does not always require treatment in cases where the cancer is small and non-aggressive, or if the patient is not physically fit enough to undergo treatment.

Testing all men for prostate cancer regardless of their age or history is not recommended. This test has significant nuances in interpreting results and subsequent actions. Sometimes, a test is not necessary, for example in cases where it is impossible to treat an elderly individual with prostate cancer who also has other serious illnesses. In fact, conducting a PSA test in such a case would be futile.

At the time of the introduction of the PSA test in the late 1980s, researchers did not have the knowledge they now have regarding actions to take based on the results obtained. Nowadays, the test is used much more judiciously, making it much rarer for prostate cancer to be discovered at a critical stage. This in itself is a clear indication that the PSA test is being used appropriately. Although most prostate cancer patients undergo treatments in this regard, an increasing number of patients diagnosed with this cancer are being medically monitored without undergoing active medical treatment.

We recommend, at the very least, discussing with your doctor the relevance of taking a PSA test and a digital rectal exam if you are over 50 years old. It would also be advisable to consider taking these tests from the age of 45 if you have a family history of prostate cancer or if you are a black man.

Armen G. Aprikian M.D., FRCSC: Urological Surgeon at the McGill University Health Centre (MUHC).

Fred Saad M.D., FRCSC: Uro-oncologist and researcher at the Centre Hospitalier et Centre de Recherche de l’Université de Montréal (CHUM/CRCHUM).

Luc Valiquette M.D., FRCSC: Urological Surgeon at the Centre Hospitalier de l’Université de Montréal (CHUM).