Why No PSA? Why No Digital Rectal Exam?

 Source: USPSTF, https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1

Source: USPSTF, https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1

Many of our male patients are accustomed to getting the annual Prostate Specific Antigen (PSA) blood test and the digital rectal exam, to screen for prostate cancer. However we at Progressive Health have been phasing this out for some years now.

Why?

Because the science says that both tests are a failure at reliably saving lives from prostate cancer.

The US Preventive Services Task Force (USPSTF) has looked thoroughly at all the data published on PSA testing, and they have concluded that for men over 70, PSA testing is not recommended because it generally does more harm than good.

Why would that be? As we get older, the risks of PSA testing increase while the benefits decrease. We have fewer years left to live and prostate cancer typically takes 5 or more years to kill.

I get the question all the time, what is the risk of getting a simple blood test?

The blood test itself does not cause harm. It is what that blood test compels us to then do that poses risk. A very large percentage of men over 70 will have an elevated or rising PSA. So if I test your PSA and it too is elevated or rising, what will you want to do? Most men want to move to the next stage, which is imaging or prostate biopsy. And more often than not, this leads to more problems than it solves.

The researcher who invented the PSA test agrees.

Richard J. Ablin is the man who invented the PSA test, and he calls it “A Profit-Driven Public Health Disaster”.

In his book Overdiagnosed, Gilbert Welch, MD reviews the extensive science that PSA screening is far more likely to yield a false positive than a true positive. Much of the evidence suggests prostate cancer screening fails to save deaths from prostate cancer, and there is essentially no evidence that PSA screening saves lives overall.

They say a man’s chance of having prostate cancer roughly equals his age. If that is true, a 75 year old man has a 75% chance of having some cancer in his prostate. But the majority of those cancers are slow growing. But alas, we cannot accurately detect which are slow growing and which will kill.

So a PSA test is far more likely to overdiagnose you with prostate cancer than it is to save your life. And once overdiagnosed, you suffer the consequences of worry, depression, painful procedures, and often impotence and incontinence.

What about men under 70? The evidence that PSA might be of benefit is not much better for men of any age actually. Hence the USPSTF suggests there is insufficient evidence to support doing PSA in anyone. They acknowledge that many men simply want to get the test, and so they suggest that men can decide to get the test if they want. That is pretty much the approach we follow at PHOD.

What about digital rectal exams (DRE, aka “finger up the butt”)? The most recent review of the topic examined all studies on the topic and found that the DRE is 51% sensitive and 58% specific. That means its accuracy is barely better than a coin toss. The authors recommend against doing DRE for prostate cancer screening.

PHODDavid Donohue