Health Library Should I Have a Prostate-Specific Antigen (PSA) Test to Screen for Prostate Cancer?From Healthwise

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

The prostate-specific antigen (PSA) test is a blood test that is used to screen for prostate cancer. Many men who are older than 50 have this test, along with a digital rectal exam, as part of their regular checkups. But experts disagree on whether PSA testing should be recommended for all men.

If you are thinking about having a PSA test, consider the following risks and benefits of screening.

• There are other causes of a high PSA level besides prostate cancer. After receiving a high PSA result, it is common to have more testing and then find that cancer is not the cause.
• Prostate cancers that are found early tend to be curable.
• Prostate cancer usually grows slowly. In some cases, it never affects a man's health.
• Sometimes prostate cancer grows or spreads quickly. Unless it is treated, it leads to death.
• Treatment for prostate cancer can cause serious side effects, including loss of bladder control and not being able to have an erection. (In many cases these problems improve within a year.¹)
• After an abnormal PSA test, your next choice is to have a biopsy to look for signs of prostate cancer. If you learn that you have cancer, you then make choices about treatment.
• If you have a family history of prostate cancer, your risk of getting it is higher than average.

What is prostate cancer?

Prostate cancer is the abnormal growth of cells in the tissues of the prostate gland. It is the most common cancer in men. Most men who get it are older than 65.

Unlike many other cancers, it is usually slow-growing. Most men will die with prostate cancer but not of prostate cancer.² This does not mean that you will get it. Each person is different, and tests cannot show who will get prostate cancer and who won't.

Early prostate cancer usually does not cause symptoms. When prostate cancer is diagnosed early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate. As prostate cancer grows or spreads, symptoms may develop, including urinary problems (such as blood in the urine) and bone pain.

If your father, brother, or son has had prostate cancer, you have a higher-than-average chance of getting the disease.³ Men whose families carry the gene changes that cause breast cancer, BRCA1 or BRCA2, are thought to be at increased risk for prostate cancer.⁴ African-American men have higher rates of prostate cancer and are more than twice as likely to die from it as men in other racial and ethnic groups in the United States.⁴

While PSA testing can find cancers earlier, and research studies show that men who have cancer now live longer, these extra years may just be from finding the cancer earlier. And there may be a decrease in the quality of life after cancer treatment, from the side effects of treatment.

What is the prostate-specific antigen test?

The prostate-specific antigen (PSA) test is a blood test. PSA is released into a man's blood by the cells that make up the prostate gland. Low amounts of PSA may be found in the blood of healthy men. The amount of PSA in the blood normally increases as a man's prostate enlarges with age. It also increases after ejaculation and after trauma to the prostate caused by such things as a long bike ride. It is also increased by inflammation of the prostate gland (prostatitis) and by prostate cancer.

The PSA test is usually done along with a digital rectal exam. Together they can help identify men who may have prostate cancer and should consider further tests.

How does age affect the decision to have a PSA test?

Your chance of getting prostate cancer increases as you age. Men who are younger than 50 and men who are between ages 50 and 70 who do not have serious health problems may gain the most from early detection and treatment.

After reviewing research on routine screening for prostate cancer using the PSA test, the U.S. Preventive Services Task Force (USPSTF) recommends the following:⁵

• Men age 75 and older should not be screened for prostate cancer.
• Men younger than 75 should talk with a doctor about the pros and cons of PSA testing before being tested. Men younger than 75 with long-term medical problems or who are expected to live less than 10 years are unlikely to benefit from screening.

Your chance of getting prostate cancer increases as you age. Men who are younger than 75 and who do not have serious health problems may gain the most from early detection and treatment.

What kind of results can a PSA test show?

A high PSA result can be the first warning sign of prostate cancer. A high PSA can signal a higher risk of getting prostate cancer in the future.⁶ But a high PSA can also be linked to other causes that are not cancer.

The amount of PSA in the blood normally increases as a man's prostate enlarges with age. But the PSA level increases more over time in men who have prostate cancer than in men who do not.

• A PSA level below 1.0 ng/mL means a very low risk for prostate cancer. In one large study, no men with this low of a PSA developed prostate cancer in the next 3 years. So, retesting 3 years later is likely to be a safe choice.⁶
• A PSA of 1.5 ng/mL is low, but a small number of men at 1.5 get prostate cancer within the next few years. Experts say it is best to retest your PSA every year if it is over 1.5 ng/mL.
• Your doctor will tell you if you need more tests based on your age and how your PSA has changed over time. More testing can tell you if the high PSA is caused by cancer or by something else, like an enlarged prostate or a prostate infection.

The PSA test and digital rectal exam can suggest a problem when there is not one (false-positive result). Only about 20% to 30% of men who have a PSA test result greater than 4.0 ng/mL actually have prostate cancer. These tests may also fail to detect a problem when there is one ( false-negative result). One study found that 15% of men who have a PSA level of 4.0 or less developed prostate cancer.⁷

What the PSA test does not tell you

The prostate naturally enlarges as a man gets older. More than half of all men who are older than 50 have an enlarged prostate. Prostate enlargement affects the PSA level, making it less accurate as a cancer screening.

Because several other things can make a PSA level go up—for example, ejaculation or an infection in the prostate—your doctor may recommend that you have another PSA test later before you make any further decisions.

If your PSA test suggests that you may have prostate cancer, your doctor may recommend a biopsy, which is the only way to confirm the presence of prostate cancer. If the biopsy confirms cancer, you must decide how or whether to treat it.

A few prostate cancers grow rapidly. Men who have fast-growing cancers are more likely to die from prostate cancer than men who have slower-growing cancers. A PSA test cannot accurately predict which type of prostate cancer a man has. But in men who have not been diagnosed with prostate cancer, a PSA velocity test can measure how rapidly PSA levels increase over time. The PSA velocity test checks the rate of change in PSA levels over a 2- to 3-year period. PSA levels increase more rapidly in men with prostate cancer and more slowly in men with prostate enlargement.

What do the experts recommend?

Medical experts disagree on whether men age 50 or older should routinely have PSA tests to screen for prostate cancer. They do agree that men should be given the pros and cons of PSA testing so that they can make their own decisions.

Some experts worry that PSA testing for prostate cancer begins a process that can force a man to make difficult decisions and can lead to other health problems that are caused by the treatment for prostate cancer. Studies continue to evaluate the effectiveness of PSA tests.

• The American Cancer Society recommends that if you are in good health and have a life expectancy of at least 10 years, you should be offered annual screening tests beginning at age 50.
• The American Cancer Society and the American Urologic Association recommend screening if you are an African-American man who is older than 45.
• The American Cancer Society recommends screening even earlier—starting at 40—if you have several close relatives who developed prostate cancer before age 65.
• Some medical groups are more cautious. They recommend that doctors discuss the pros and cons of PSA tests with men who are considering screening and then make decisions based on the man’s needs.
• The U.S. Preventive Services Task Force (USPSTF) recommends that men age 75 and older should not be screened for prostate cancer and that younger men should discuss the pros and cons of PSA testing before being tested. The USPSTF also states that men younger than 75 with long-term medical problems or who expect to live less than 10 years are unlikely to benefit from screening.
• Some medical groups such as the American Academy of Family Physicians, the U.S. National Cancer Institute, the U.S. Centers for Disease Control and Prevention, and others do not recommend routine testing for prostate cancer.

For more information, see the topic Prostate Cancer.

Your choices are:

• Have a PSA test to screen for prostate cancer.
• Do not have a PSA test to screen for prostate cancer.

The decision about whether to have a PSA test takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having a PSA test. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have a PSA test.

Check the box below that represents your overall impression about your decision.

Return to the topic:

• Prostate Cancer
• Prostate-Specific Antigen (PSA)

Citations

1. Eastham JA, Scardino PT (2002). Radical prostatectomy. In PC Walsh et al., eds., Campbell's Urology, 8th ed., vol. 4, pp. 3080–3106. Philadelphia: W.B. Saunders.

2. Frankel S, et al. (2003). Screening for prostate cancer. Lancet, 361(9363): 1122–1128.

3. American Cancer Society (2006). Cancer Facts and Figures 2006, pp. 1–56. Atlanta: American Cancer Society. Available online: http://www.cancer.org/docroot/STT/stt_0.asp.

4. National Institutes of Health (2007). Prostate cancer genetics: Fact sheet. Available online: http://www.nih.gov/about/researchresultsforthepublic.

5. Lin K, et al. (2008). Benefits and harms of prostate-specific antigen screening for prostate cancer: An evidence update for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 149(3): 192-199.

6. Aus G, et al. (2005). Individualized screening interval for prostate cancer based on prostate-specific antigen level. Archives of Internal Medicine, 165(16): 1857–1861.

7. Thompson IM, et al. (2004). Prevalence of prostate cancer among men with a prostate-specific antigen level less than or equal to 4.0 ng per milliliter. New England Journal of Medicine, 350(22): 2239–2246.

Author:	Bets Davis, MFA	Last Updated: June 27, 2008
Medical Review:	E. Gregory Thompson, MD - Internal Medicine Christopher G. Wood, MD, FACS - Urology/Oncology
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