Information for men who consider PSA testing

The PSA test is a blood test, which can help to identify prostate cancer at an early stage. Are you considering to have a PSA test done? In that case this information is meant to help you in taking that decision. You can also use this information in conversations with family, friends, or your doctor.

This information has been designed by The Dutch Cancer Society in co-operation with the departments of Public Health and Urology of Erasmus MC University Medical Center Rotterdam.

Who is a candidate for undergoing PSA testing?
Originally the PSA test was targeted for men with complaints which could point toward the presence of prostate cancer. Through the internet the PSA is now available for everybody. It is unknown at this time whether the PSA test is useful for men without specific complaints. The results of a large international study exploring the value of the PSA test are expected during the year of 2009 or soon thereafter.

If you are younger than 50 years of age and you do not have any complaints relating to the prostate then doctors in general advise against carrying out the PSA test. This is because prostate cancer is rare in men below the age of 50. Only if prostate cancer has been found in your family at a young age may a PSA test make sense.

As there is still no scientific proof of usefulness of the PSA test in men without complaints, the use of PSA testing is not (yet) generally recommended in The Netherlands and not by the Dutch Cancer Society. Despite the potential advantage of early detection of a cancer there are clear disadvantages in carrying out the PSA test. The well-known assumption “the earlier the better” is unfortunately not generally applicable to prostate cancer. This cancer often grows slowly without causing complaints and without being noticeable. Many men die of something else while, without their knowledge, prostate cancer is present. These men have been saved from going through annoying medical routines and from experiencing the possible complications of treatment. In addition to that, the PSA test is not accurate: in some cases prostate cancer is missed and in some instances men will undergo further medical studies for no good reason.

The PSA test measures the amount of prostate-specific antigen (PSA) in your blood. PSA (a protein the prostate makes) occurs also in small amounts in the blood of completely normal men.

Above the age of 50 however approximately 2 in 10 men (20%) have an elevated PSA value. The elevated value can point toward prostate cancer but may also be related to benign prostatic enlargement, a urinary tract infection or an infection of  the prostate. For this reason additional studies are always necessary if a PSA value is found to be elevated. However, the chance of having prostate cancer increases with higher PSA values.

80% of men above 50 have a normal (not elevated) PSA value. Still, men with a completely normal PSA test can have a (usually small) prostate cancer. This applies to at least 1 in 100 men (1%).

What kind of result can the PSA test produce?
Two results are possible:

The PSA test is normal (0-4)

• It is not likely that you have (an aggressive) prostate cancer at this time
• At this moment further action is not necessary. Depending on your age and the level of your PSA you can consider together with your doctor whether to repeat the test one or several years later.
  

The PSA test is elevated (higher than 4)

• Further medical study by a specialist is necessary to identify the cause of this abnormal elevation.

In considering further necessary studies, your doctor will consider your age, possible other disease which may negatively impact on your condition, and the elevated PSA value. It is therefore not only the PSA value, which determines if you are advised to undergo further medical studies.

Which other medical studies can follow?
If your PSA value is elevated a urologist has to figure out the reason. This specialist will palpate your prostate to identify abnormalities. Furthermore, he may take small amounts of prostatic tissue (biopsy) for microscopic examination. This will be done by means of a specific biopsy technique: the urologist will visualise your prostate through the anus or through the perineum by using ultrasound. This will allow him to see your prostate on a monitor. He will then use a hollow needle to take small amounts of tissue from different areas of the prostate.

Many men experience the biopsy of the prostate as unpleasant but acceptable. It is likely that after this examination your urine or sperm will stay bloody for some time and that you will experience some pain. Rarely an infection of the area of the biopsy accompanied by fever can result. To minimise the risk of this happening, short term antibiotic treatment will be prescribed.

The result of the microscopic examination of your biopsy will be known within one to two weeks. Eight of ten men on average can expect to have a normal result. However, a normal biopsy result may not conclusively exclude the presence of prostate cancer as the cancerous areas may not have been hit by the biopsy needle. In certain situations it may be necessary therefore to repeat the biopsy.

Though the PSA test may  raise suspicion about the presence of cancer  it does not give a diagnosis. In order to diagnose prostate cancer it is necessary to carry out a microscopic examination of tissue taken from the prostate. The following figure summarises the results, which may be expected in 100 men (age 50-70) who undergo PSA testing.

100 men age 50-70 without complaints undergo PSA testing
80 men have a normal PSA
In one of these prostate cancer is found at a later time
20 men have an elevated PSA leading to prostate biopsy.
Prostate biopsy: 16 men do not have prostate cancer, 4 men have prostate cancer

Should I decide for or against PSA testing?
The following section summarises the potential advantages and disadvantages. Put these in your own perspective, weight them against each other and apply them to your personal situation.

Arguments for testing

• If the result of the PSA test is favourable this will calm down my worries;
• The PSA test can help to find prostate cancer before it leads to complaints;
• If as a result of a positive PSA test I undergo successful treatment I may have a better chance of cure and may live longer;
• If the treatment is successful in an early stage I may not be confronted with the late symptoms of prostate cancer such as metastases.

 

Arguments against

• If my PSA value is elevated and further study does not show prostate cancer I will have undergone medical testing for nothing and this will have caused unnecessary anxiety;
• The PSA test can miss prostate cancer. After a normal result I may feel relieved for no good reason or may still remain worried;
• There is a risk of diagnosing through the PSA test a slow growing tumour which would otherwise never have given me any trouble;
• I may be confronted with the possible complications of the treatment of prostate cancer.

What is the prostate?
The prostate is a gland with a diameter of 2-3 cm. It produces prostatic fluid, which is mixed with sperm when I have an ejaculation. The prostate is located underneath the bladder around the urethra, the tube that runs from the bladder to the top of the penis. In most men beyond the age of 50 the prostate will grow. The enlarging prostate can partially compress the urethra leading to the old men’s micturition problems. These include frequency and difficulty in urinating. These complaints usually have nothing to do with prostate cancer.

What is prostate cancer?
Prostate cancer is the most frequent  cancer in men. Every year prostate cancer is diagnosed in almost 8,000 men in The Netherlands. Of these 2,000  will die of this disease.

Prostate cancer is rare in men below the age of 50 but the risk increases with age. Little is known about the causes of prostate cancer. In some families there is a genetic predisposition for prostate cancer. In this situation the disease is often diagnosed in men who are younger than 55 years. Also several direct family members may have the disease. Prostate cancer has nothing to do with sexual habits and it is not contagious.

Prostate cancer originates in cells of the glands of the prostate and grows usually rather slowly. Early on it is often difficult to state which one of the small tumours will become aggressive and which one will not. If a tumour becomes larger this can lead to problems with urination. A prostate cancer, which is no longer limited to the prostate and which has led to metastases may cause pain in other parts of the body. Although metatatic prostate cancer is incurable treatment is then still possible to decrease the suffering.

If I have prostate cancer what are the treatment options?
The most frequent forms of treatment for localized prostate cancer are:

• Surgery
• Radiotherapy
• Active surveillance

Surgery
During surgery for prostate cancer the whole prostate will be removed. To be eligible for surgery a man has to be in a good general condition. A large proportion of men will experience difficulty in obtaining an erection after having undergone surgery (impotence). In addition, some of the men will experience uncontrolled loss of urine (incontinence). Some of these men may have been troubled by impotence and incontinence even prior to the treatment.

Radiation therapy of the prostate
Radiotherapy aims at killing the cancer cells. Radiotherapy can be applied externally or inside the prostate.

External radiotherapy
In applying external radiotherapy (through the skin) parts of the bladder and of the rectum may also be irradiated. This may cause diarrhoea and/or loss of blood during and after the treatment. Patients may also feel tired during radiotherapy. After external radiotherapy about half of the men will experience permanent loss of erections (impotence). Damage to the rectum may also result. Some of these men may have been impotent or may have had problems with defecation prior to the treatment. Some men will experience incontinence. External radiotherapy is usually carried out in an outpatient setting: the treatment is applied on each working day for a period of 7 weeks.

Internal radiotherapy
Internal radiotherapy may result in less side effects but it cannot be carried out in all situations. Among others this depends on the size of the prostate, the PSA value, and the degree of aggressiveness of the tumour. To achieve internal radiotherapy it is necessary to implant radioactive seeds into the prostate. This often necessitates a hospital admission of 1-3 days. Also after internal radiotherapy some men will experience problems of impotence. The treatment can also result in difficulties with urinating and/or problems with the defecation.

Active observation
Active observation (active surveillance) can be advised if a small tumour is found which appears to be not very aggressive. Observation may also be indicated in men who have other serious disease. Active observation entails a regular control of the PSA value (for example every 3 – 6 months). If the PSA value remains identical or increases very slowly the advice will be to delay treatment further. Only if the PSA values rise or if other signs occur is surgery or radiotherapy  usually advised. The reason for active observation lies in the fact that prostate cancer does not always grow or lead to metastases or complaints.

Source:
http://www.kwfkankerbestrijding.nl/index.jsp?objectid=16113

Comments F.H. Schröder
This text has been made available on the website of the Dutch Cancer Society and is therefore public domain in The Netherlands. It is the result of cooperative work which means that we as medical advisors did not always get our say. The text has been modified after two rounds of testing with normal men “off the street”. The goal of the testing was understanding and in a more limited fashion also decision taking.

I see two major needs for change:

1. The cut-off value of 4 needs to be presented in a less absolute fashion.
2. In the diagram and text it should be indicated that instead of “1 in 100 cancers 3 in 100 cancers may be diagnosed at a later stage in spite of a normal PSA test”.

revision 3
September 2010