Should we do PSA Screening?

This is a frequently asked question and the answer will vary on who you ask.
PSA screening is recommended by the American Urologic Association . An excellent review of the original guidelines can be found at the American Family Physician website.
I came across a post on medlogs.com from a blog (retired doc\’s thoughts) by Dr. Gaulte. He summarizes that studies in the literature not only do not answer this question, but also are contradictory.


My views as a urologist are obviously slanted towards finding prostate cancer as early as possible.
The reasons why include the following:
1) Historically, a high percentage of men die from prostate cancer (about 3%).
2) Prior to screening for PSA many man (about 1/3) presented with cancer that was not contained to the prostate.
3) My feeling is if I find the cancer early enough, most men that would have died of cancer can be cured.
The argument against my reasoning, which I explain to patients as well:
1) Most men are diagnosed with cancer currently a long time before they would have any symptoms.
In treating them near the time of diagnosis, we are causing significant side effects and potentially diminishing their quality of life.
Some patients with very favorable characteristics may choose watchful waiting with curative intent, but this has its own risks and sometimes has a psychological burden on the patient.
2) Some men will be treated that may never had a problem from their cancer.
3) Some patients are diagnosed properly with screening, but still are not cured.
Fortunately with robotic surgery and newer radiation methods that may target tissue more precisely the morbidity of treating prostate cancer is becoming less. One day I think there will be a vaccine or gene therapy that will localize the prostate and treat the cancer without any significant side effects. Until that day I recommend screening with PSAs for any man who is at least 40-50 (depending on other risk factors) and has a 10 year life expectancy. Also men who have urinary symptoms or an irregular prostate exam get a PSA test as well.
As the retired doc put it in his blog “I am not sure if it is or not but I am sure that another case control study purporting to show either positive or negative results is not going to convince many physicians to change their minds.”
I will be convinced in my thinking and another study wont change my mind because:
1) Prostate cancer probably develops at an earlier age than people realize.
2) Prostate cancer often grows very slowly, and I counsel patients that they may have 15 years or more before the cancer effects them.
3) The only study that would convince me is to follow all patients from age 40 – 50, depending when you would normally screen them, and screen half (rectal exams and PSA blood tests) and don’t screen half (rectal exam only).
Then these patients would be followed for as long as they live. Following them until they were diagnosed with cancer or treated, even surgically, would not be enough. Many patients that have cancer recurrences after surgery will still die from other conditions.
This would allow us to see the lead time that cancers are diagnosed and the effects of treatment. It would also allow us to see how many people would suffer the consequences of untreated prostate cancer (blockage of bladder, kidneys, bone pain, etc). And most importantly it would tell us how many people less people die from prostate cancer with screening.
To be fair, there are some organizations including the American College of Preventive Medicine that counsel against the routine use of PSA for screening, but do suggest that a patient should be counselled about the pluses and minuses of screening.