Prostate

To PSA or Not to PSA: The Answer Is PSA Testing Plus…

New MRI Technology Is the Solution to the Vast Overtreatment of Prostate Cancer

When PSA testing was initiated in 1990, it reduced the death rate from prostate cancer 40%, from 50,000 to 30,000 deaths per year. Yet government agencies and medical associations are now telling us to discontinue this test, despite the fact we have nothing to replace it. How will these agencies rationalize the dramatic rise in prostate cancer deaths that will follow?
Yes, overtreatment of prostate cancer is rampant. Of the 50,000 prostatectomies done annually, 40,000 are unnecessary. The same with radiation therapy. This must be fixed, but the solution is not to retreat back to the 1980s, before PSA testing, when prostate cancer was typically discovered by digital rectal exam, too late for effective treatment.

PSA stands for “prostate specific antigen,” a small protein that normal prostate cells secrete into the bloodstream. A normal PSA blood level is 4 ng/ml or less. Prostate cancer cells, with their heightened metabolism, produce extra PSA. So when the PSA level rises above 4, it may indicate prostate cancer (or other prostate problems). Yet, despite the test’s usefulness, the new guidelines do not recommend PSA testing for any man. Not even for men at higher risk: African-Americans and men with blood relatives who’ve had prostate cancer. And if you are over 70, even if you are healthy and robust and expecting to live to 95, PSA testing is out.
This is ridiculous. The key to successfully treating prostate cancer is early diagnosis. PSA is our only reliable method. Men need to start testing at age 50. At-risk men, at 40. At 70, keep testing annually as long as you enjoy living.
The question really isn’t should we continue PSA testing. Of course we should. The question is how to prevent overdiagnosis and overtreatment. When approximately 80,000 men a year are receiving unneeded, aggressive treatment that often causes life-long impairment of sexual functioning and/or bladder control, overtreatment must be avoided.
But rather than retreating to the past, we must accelerate into the future and improve our diagnostic capabilities. In fact, we are already doing so. At major medical centers such as Sloan-Kettering in NYC, Massachusetts General, Mayo Clinic in Minnesota, MD Anderson in Dallas, and UCLA, they are using a new generation of MRI technology that can differentiate men who need aggressive treatment for prostate cancer vs. men who don’t.
Although MRIs have been used for almost three decades for every other part of the human body, previous MRIs could not differentiate normal prostate tissue from cancerous tissue. Now, with the advanced 3.0 Tesla MRI machines, we can. Known as the multiparametric MRI, this cutting-edge test is a game changer.
When I was diagnosed with prostate cancer in 2011, I spoke to four urologic surgeons, and each told me unequivocally I needed surgery. I believed them. They are good doctors. But I heard about the new MRI, obtained one, and it showed one localized tumor in a safe area of my prostate gland. I took myself off the surgery list.
The fact is, our current method of using PSA and prostate biopsy to determine who needs aggressive treatment is highly fallible. PSA and biopsy are simply not reliable enough to assure accurate diagnosis. The statistics of widespread overtreatment tell the story.
Retreating backwards to the 1980s and costing 25,000 additional prostate cancer deaths annually is not the answer. We need to move forward and widely implement the new MRI technology that can provide the accuracy men with prostate cancer need.

Jay S. Cohen M.D. is a prostate cancer survivor, faculty member at the University of California, San Diego, and author of Prostate Cancer Breakthroughs (2013). Contact: jacohen@ucsd.edu

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