Prostate cancer is the third common type of cancer in men. About 27,000 men in the United States die from prostate cancer yearly. The Prostate Specific Antigen (PSA) test was developed in order to reduce the number of deaths from prostate cancer.
It was later discovered soon after, that the PSA could also be used as a marker for patients with early disease and was used to diagnose prostate cancer earlier. Studies found that the PSA tended to rise about 5-10 years before men developed cancer. Men with early-stage prostate cancer do well while those with metastatic disease do poorly — with a life expectancy of approximately five years or 30% — and therefore using the PSA test for early detection has made it an important goal.
After PSA screening was widely adopted, not only did prostate cancer diagnoses increase, but more importantly, the number of men dying from prostate cancer decreased.
Many organizations have developed guidelines for evaluating and treating prostate cancer. The American Urologic Association recommends that for average-risk men between 55 and 69 years of age, the decision regarding the PSA test should be individualized and discussed in a shared decision-making model. They did not find any evidence to support a digital rectal examination. Screening could be every year or every two years, based on PSA levels.
The American Cancer Society also suggests shared decision-making, with screening of average-risk men beginning at age 50 and continuing until men reach 10 years from their life expectancy. Screening can be with or without the digital rectal exam. PSA screening should be annual or every two years for men with lower PSAs.
The United States Preventative Task Force does not recommend prostate cancer screening, as it believes the benefits of screening do not outweigh the harms. They suggest that men who request screening be informed of the pros and cons of the decision.
I have had patients ask me many times if they can skip the physical prostate exam and do the PSA blood test and I tell them yes. Studies have shown that a physical prostate exam may elevate the PSA, but only by 0.4. This is a statistically significant, but not clinically significant, increase. Meaning that a small PSA increase of only 0.4 in my patients would NOT make a difference in how I choose to manage their care. As a provider, I have done both the physical exam and the blood test and personally prefer the blood test because sometimes with prostate nodules, it may be harder to feel them, depending on their location. However, I have also done physical exams in my office, which were found to be abnormal and I ordered both PSA level and digital rectal examination for confirmation of my physical findings.
Keisha Ellis is a certified family nurse practitioner for Eastern New Mexico Medical Group’s Quick Care. The advice offered in this column is that of the author.