VOL UME 17 • N UMBER 3
INSIDE
Should you skip your PSA test?
The science is uncertain for now, so arm yourself with deep knowledge of the
pros and cons of prostate cancer screening.
Photo: Thinkstock
I
n May 2012, the United States Preventive
Services Task Force (USPSTF) issued its
final report concerning screening for prostate cancer using the prostate-specific antigen (PSA) test. After weighing the evidence,
the expert panel concluded
that PSA screening for prostate
cancer should not be offered
routinely to men—typically
as part of a regular physical
exam. Screening means testing
a seemingly healthy person for
signs of a hidden disease, like
prostate cancer.
This voluntary recommendation, aimed at physicians,
triggered numerous media reports that presented men with
conflicting expert opinions
and raised serious questions without offering clear answers. Should you get a PSA test?
If so, when and how often? If you follow the
USPSTF advice and decline PSA testing, do
you risk being diagnosed someday with advanced disease that might have been treated
earlier and, possibly, cured?
Right now, experts do not all agree on the
answers to these questions. Amidst the uncertainty, the best strategy is deeply informed
decision making.
“Before making any final choice about PSA
tests, men first need to understand what is
involved before and after they receive the results—whether it’s good news or bad,” says Dr.
Marc Garnick, an expert on prostate cancer
and a clinical professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical
Center. “Only then can they have a thorough
discussion with their doctors to determine
whether or not a test is in their best interests.”
OCTOBER 2012
What is a PSA test?
The PSA test measures the level of prostatespecific antigen protein in your blood. The test
was introduced in the 1980s to monitor the recurrence or progression of prostate cancer. At
that time, prostate cancer was
often diagnosed at an advanced
stage, when the cancer already
caused symptoms of pelvic pain
or discomfort, difficulty urinating, or blood in the urine. So
doctors started using PSA testing to check for hidden prostate
cancer. This offered the hope of
detecting prostate cancer at an
earlier stage, when it is hypothetically more treatable.
But PSA has some limitations. For one thing, it is not
really that specific to cancer. An elevated
PSA may indicate prostate cancer, but it may
also indicate a noncancerous cause, like an
enlarged prostate or a prostate infection. As
a result, PSA alone cannot tell you whether
you have cancer; nor can it assure you that
you are cancer-free. Only a biopsy can definitely diagnose prostate cancer.
The PSA dilemma
Cancers detected as the result of PSA
screening and biopsy include both fastgrowing “aggressive” tumors that kill and
slow-growing “indolent” tumors that never
cause symptoms or shorten a man’s lifespan.
Lacking a reliable way to identify the truly
dangerous cancers, men have usually opted
for prompt treatment.
Fast forward to 2012, when the USPSTF
officially recommended that men and their
continued on p. 7 ▶▶
On Call: Your questions
answered . . . . . . . . . . . . . . 2
� Should I take calcium
supplements for bone strength?
� What is the best treatment for
dry, itchy skin?
Is low-dose aspirin safe
for you? . . . . . . . . . . . . . . . 3
If you take daily aspirin, make sure
you understand the small but real
risk of bleeding.
Testing testosterone . . . . . 4
Diagnosing and confirming low
testosterone requires thorough lab
testing and careful interpretation of
the results.
Stomach-soothing steps
for heartburn . . . . . . . . . . . . 6
First, change the behaviors that
contribute to heartburn. If the pain
persists, switch to medication.
In the journals . . . . . . . . . . 8
� Large waistline linked to urinary
and erectile difficulties.
� “Keyhole” vein harvesting for
coronary bypass is safe.
� Popular cardiac drug may prevent
pneumonia.
WHAT’S NEW
Not requiring a co-pay boosts
colorectal screening
Eliminating co-pays may convince
more people to seek colorectal
cancer screening. Under the
Affordable Care Act (ACA) insurers
can’t always charge co-pays for
certain preventive procedures. In a
study in Clinical Gastroenterology
and Hepatology, researchers
looked at the effect of co-pays on
colonoscopy rates among nearly
60,000 adults in one health plan.
continued on p. 8 ▶▶
PSA screening … from page 1
What should you ask your doctor about PSA?
doctors rethink PSA testing. After reviewing the best research data available,
the panel concluded that PSA screening
only slightly reduces the number of men
who die from prostate cancer.
1
How does PSA harm?
2
To fully understand the pros and cons of
PSA screening, you have to think beyond
the test itself. The PSA test is just the first
step in a process to screen for, diagnose,
and treat prostate cancer. There can be
many potential problems along the way.
If your PSA level is high, your doctor
may recommend a biopsy. In roughly
one-third of men, biopsy causes bleeding, urinary obstruction, or infection, and
one out of 100 men are hospitalized. Postbiopsy, the next step could be treatment.
The risks of treatment include impotence
and urinary incontinence (in 20% to 30%
of men) and bowel problems.
Because PSA screening so often leads
to biopsy and treatment—and their associated risks—it is not “just a test.” It
is a gateway to unpredictable outcomes,
so stepping through it is a serious decision. “It’s not that we are ‘overtesting,’
Dr. Garnick says. “We are opening a
door to a possible long, expensive, and
potentially painful path with no viable
long-term benefit or outcome, from a
statistical perspective.”
Who can benefit from testing?
This does not mean you should never
consider having a PSA test. It still provides valuable information that can
help you make sound medical deci-
Here are five questions to ask your physician about a PSA test:
Do I really need this? A doctor may suggest a PSA test if he or she considers you at
high risk. But some may recommend it routinely to protect themselves from potential
lawsuits from men who are not tested, but are later diagnosed with prostate cancer. Make
sure you know whether and why you are being tested.
Can I choose the test even if I am not at high-risk? You may want the test for peace
of mind despite the fact you are considered a low risk, and a doctor will not deny you
the test. But if your PSA test indicates possible cancer, and if it turns out to be a false
alarm upon further testing, your peace of mind will be disrupted for no reason.
3
4
How is the test conducted? A PSA test is simple and inexpensive. Blood is drawn for
analysis. The cost is approximately $60 to $80.
What will the test show? The test measures the amount of PSA protein in your blood.
A reading of 4.0 to 10 nanograms per milliliter (ng/ml) is often considered a worrisome number, and anything above 10 is even more of a concern. Keep in mind a low
number does not indicate you are cancer-free, nor does a higher number guarantee you
have cancer. The test indicates your probability of having prostate cancer—nothing more.
5
Can the test be “wrong?” Yes. Elevated PSA levels can occur for reasons other
than cancer, such as non-cancerous enlargement of the prostate gland, infection, or
recent sexual activity. Numbers in the so-called gray area of 4.0 to 10 ng/ml should be
rechecked and confirmed before deciding whether to follow up with a biopsy.
sions. A PSA test is a data point, but
not a decision point.
Also, the USPSTF recommendation
is just that—a recommendation. The final decision is up to you and your doctor.
PSA screening offers the most potential
benefit to men at high risk. Here are the
key risk factors:
� Age: The risk of prostate cancer rises
with age. Most men with prostate cancer are diagnosed in their 70s.
� Family history: You are at higher risk
if your father, brother, uncle, and/or
grandfather died of prostate cancer
younger than 70. You are at average
risk if they didn’t.
Screening & diagnosis (over 10 years)
96
60
Number of men diagnosed
Number of men diagnosed
with prostate cancer out of
with prostate cancer out of
1,000 screened.
1,000 not screened.
RESULT
36 additional cancers diagnosed for every 1,000 men
screened with the PSA test.
Race: African American men are at
higher risk than Caucasians.
The USPSTF recommends that healthy
men should not undergo PSA testing as
part of a medical checkup. But no doctor will prevent you from having the test
if you so choose, although some may decide to stop suggesting it to their patients.
All men need to grasp the potential
costs that may follow a PSA test and not
treat it like just another blood test you get
at every physical. Armed with this knowledge, you can then have an informed
conversation with your doctor and make
a decision that best meets your health status and concerns.
�
Lives saved (over 10 years)
4 in 1,000
5 in 1,000
Number of men who die of prostate Number of men who die of prostate
cancer after being screened.
cancer without being screened.
RESULT
Screening 1,000 men prevents 1 cancer death, but results in 36 additional
cancers being diagnosed (and potential side effects of treatment).
SOURCES: US Preventive Services Task Force; European Randomized Study of Screening for Prostate Cancer
www.health.harvard.edu
October 2012
| Harvard Men’s Health Watch | 7
Your PSA test result: What’s next?
If the test result hints at cancer, your doctor will need to rule out
noncancerous causes and may perform additional tests.
hen you take a test for
a serious medical condition, most of all you want
certainty: Do you have the
disease, or do you not? But
the only thing that you can
rely on about PSA testing for
prostate cancer is that the results will be uncertain.
“The problem is that PSA
is a nonspecific measurement,” says Dr.
Marc B. Garnick, a prostate cancer specialist at Harvard Medical School and
Beth Israel Deaconess Medical Center. “It can mean you may have cancer,
nothing more.”
Screening means testing a seemingly healthy person for signs of a hid-
den disease. When used as
a screening tool, the PSA
test aims to uncover prostate cancer at an early stage,
when (hypothetically) it
may be more curable. But
only one of the two largest and best clinical trials has shown that routine
PSA screening decreases a
man’s risk of dying of prostate cancer,
and then only slightly. Also, screening
comes with a risk of a man being diagnosed with and treated for a tumor
that might never have become a threat
to his health or longevity. (See Harvard
Men’s Health Watch, October 2012).
Despite the uncertainties, millions of
Photo: Thinkstock
W
Additional prostate cancer risk tests
�
Free PSA level: PSA circulates in the blood in two forms: bound to other proteins or
unbound (free). Some studies suggest that the lower the ratio of free to total PSA,
the greater the risk of cancer. The free PSA level may be useful in deciding whether
a biopsy is the appropriate next step. But even if the free PSA is favorable, the risk
of underlying cancer remains around 8%.
�
PSA density: This number is calculated by dividing the PSA level by the size of the
prostate in grams, as measured by ultrasound. The higher the PSA density, the
greater the likelihood of cancer. As with free PSA, a PSA density can look normal
but you may still have cancer.
�
PSA velocity: Doctors have tried to assess cancer risk based on how rapidly PSA
rises over a series of several annual PSA tests, a quantity called PSA velocity. But
once again, this strategy has proved unreliable. PSA scores may rise more rapidly
in men with cancer—or they may not. “PSA velocity adds very little to the actual
PSA value in helping diagnose prostate cancer,” Dr. Garnick says. Still, PSA velocity
is something that your doctor may want to know.
�
Prostate health index (PHI): The PHI combines measurements of three forms of
PSA that circulate in the blood, including free PSA and a subcategory of free PSA
called proPSA (or p2PSA). The PHI is intended to help doctors determine if a biopsy is warranted.
�
PCA3 score: In cancerous prostate cells, the PCA3 gene is highly active. If a doctor
massages a cancerous prostate gland, a protein made by the PCA3 gene “leaks”
into the urine, where it can be detected with a test. The PCA3 protein level doesn’t
rise if a man has a noncancerous prostate condition, so this measurement more
closely correlates with cancer than PSA level does. The FDA has not approved
PCA3 for routine prostate cancer screening, but some laboratories may offer it.
4 | Harvard Men’s Health Watch | December 2012
American men still choose to undergo
PSA screening. If you get tested, what
can the results tell you? What additional tests and procedures might follow?
And what risks do you face? It turns out
that, like everything about PSA testing,
interpreting the test result is anything
but simple. Here is what to expect.
The test result
Prostate-specific antigen (PSA) is a
protein made in the prostate gland.
PSA testing measures the total amount
of PSA in your blood in nanograms per
milliliter (ng/ml). Doctors use the test
to screen for prostate cancer because
the level of PSA in your blood may rise
if you develop a prostate tumor.
Unfortunately, there is no absolute
PSA level that always means you have
cancer—or that rules out the possibility of cancer. In the past, many doctors have considered a PSA level below
4.0 ng/ml as in the normal range, and
a PSA above 4.0 ng/ml as a potential
concern. But this rule of thumb is unreliable. In an often-cited study, 17% of
men with a PSA of 1.1 to 2.0 had prostate cancer, and 24% with readings of
2.1 to 3.0 had the disease.
To determine if your PSA result
requires follow-up, your doctor will
take into account a number of factors,
including age, race, family history of
cancer, the likelihood of other noncancerous medical conditions that affect
the prostate gland, and the results of
any previous PSA tests.
For example, a man’s average PSA
level tends to rise with age, often because his prostate gland grows larger
and therefore produces more PSA
overall. This means that for a 70-yearold man, a PSA of 5.0 would not necessarily be abnormally high. But a
reading of 3.0 in a 50-year-old man
could be considered high enough to
be a concern.
Deciding to have a biopsy
If your doctor is worried about your
PSA result, a next step could be simply
www.health.harvard.edu
the gland. A pathologist examines the
samples for cancer.
Biopsy comes with the risk of pain
and discomfort as well as infection.
So your doctor may first want to perform additional tests to get a better
sense if biopsy is warranted. None of
the tests available can confirm the presence of cancer; only a positive biopsy
result can do that. But you want to make
sure the biopsy is really necessary
before you go ahead with it. There
are additional measurements that
your doctor may consider to assess
your risk of cancer (see “Additional
When it’s okay to delay hernia surgery
Unless a hernia is causing you distress or limiting your activities, you
can safely delay repair.
A
dull ache and a lump in the groin or
scrotum—these are the typical signs
of an inguinal (groin) hernia. According
to an August 2012 report by the Agency
for Healthcare Research and Quality,
about 40% of men will develop an inguinal hernia at some point in their lives.
The fix for your father’s hernia was
usually immediate surgery, but today you
have another option: coexist with the hernia and seek surgery when the condition
becomes painful or limits your activities.
This approach is often called watchful
waiting. “There are a lot of people who
had hernias for a long period of time, and
it didn’t interfere with their life,” says Dr.
David Brooks, an associate professor of
surgery at Harvard-affiliated Brigham
and Women’s Hospital.
Fear of strangulation
An inguinal hernia occurs when a portion of the intestine or the fatty tissue
surrounding it bulges through a defect
or weak spot in the abdominal wall and
into the groin or scrotum. An estimated
600,000 or more hernia repairs are performed every year in the United States.
It was once common to repair a hernia
upon diagnosis, because of the worry that
www.health.harvard.edu
the hernia could pinch a portion of intestine or other tissue and cut off its blood
supply. Such a “strangulated” hernia can
be life-threatening.
An important study published in 2006
helped to reduce fear of this outcome.
Only about three out of 1,000 men in
the study developed a strangulated hernia. And the rate of complications after
hernia repair was the same in men who
initially chose watchful waiting as those
who chose immediate repair.
prostate cancer risk tests” on page 4).
Uncertain outcome
It’s important to keep in mind that
having a PSA test that leads to biopsy, a diagnosis of cancer, and prompt
treatment does not guarantee a good
outcome. Go into the PSA process
with your eyes open and no expectation of easy decisions or simple answers. Do it if your “need to know”
whether you have cancer and the
possible chance to benefit from early
treatment outweigh your concerns
about the risks of testing.
Surgery pros and cons
Surgery does not come risk-free. “If complications were rare, it would make sense
to fix everyone’s hernia, but indeed there
is a relatively serious problem that can occur relatively often,” Dr. Brooks says.
Dr. Brooks estimates that up to 10%
of people who have hernia repair end up
with persistent pain and discomfort in
the groin. The complication rates vary according to the type of surgery performed.
Should you ever consider surgery,
discuss the repair options and risks with
your surgeon. But for now, if you have a
hernia and it is not getting in your way,
there is no strong evidence that you will
be better off rushing into surgery.
If it ain’t broke…
Today, most surgeons recommend hernia
repair when the hernia causes enough
pain, discomfort, or concern that a man
wants to have it fixed. “The pain may not
be intense, but it’s bad enough that they
want it taken care of,” Dr. Brooks says.
Men who do a lot of traveling sometimes ask about surgery because they are
concerned that the condition could take
a turn for the worse while they’re away
from their usual health care.
Some men ask for repair out of concern the hernia has grown unsightly, although it’s also true that many hernias
are so small that even a doctor would not
notice unless he or she felt for it carefully.
Inguinal (groin) hernia
Intestines
Hernia
Illustration by Harriet Greenfield, © 2010
to retest. That could help to rule out
known reasons for short-term spikes in
PSA. Besides prostate enlargement, an
infection of the prostate (prostatitis),
having ejaculated in the previous 24
hours, or even a long bicycle ride could
all cause a temporary blip in PSA.
If you get retested and the result still concerns your doctor, you
may be on your way toward being offered a biopsy. In a prostate biopsy, a
device is inserted into the rectum that
shoots a needle through the rectal wall
into the prostate to remove samples,
or “cores,” from multiple locations in
Pubic bone
Scrotum
An inguinal hernia occurs when a portion of
the intestine or the fatty tissue surrounding
it bulges through a defect in the abdominal
wall and into the groin or scrotum.
December 2012
| Harvard Men’s Health Watch | 5