Prostate cancer screening is a hot-button issue for men, with a lot of press over the years. Even celebrities like Ben Stiller have weighed in on the question of whether or not to get a PSA test and/or a digital rectal exam (in which a doctor or nurse practitioner directly examines your prostate with their finger placed inside your rectum). You may also be familiar with the public awareness campaign known as Movember, in which men would attempt to grow a prominent mustache in support of prostate cancer screening.
Many men, and sometimes their wives, request a prostate-cancer screening at our office, and usually they are asking for a blood test called a PSA, or prostate-specific antigen, test. They have heard that after the age of 50, men should probably get this blood test to make sure they do not have prostate cancer.
Unfortunately, it’s not that simple.
First of all, you should know that prostate cancer, even though fairly common among cancers in older men, does not usually make an impact on most men’s lives. Does that sound strange? Well, it turns out that most men with prostate cancer have a mild version that they will die with, rather than die of.
Is it possible that prostate cancer can kill you? Absolutely. Occasionally, prostate cancer presents as an extremely aggressive and sometimes quickly fatal cancer. But that is not the norm. We cannot ignore all the prostate cancers out there that would not hurt you, and would be discovered only if you ordered a PSA test.
If you had a cancer that was not going to hurt you or kill you, would you still want to know about it? I’m going to explain why, in this case, that’s not an easy question to answer.
In reality, if the PSA test is abnormal—and usually that means a number on the lab test of above 4 or 5—other tests are needed to figure out whether the prostate cancer is one of the more aggressive ones or one of the more mild ones. The next test (other than a couple of add-on tests to the original PSA) is usually a biopsy of the prostate. This biopsy has to be ordered by a urologist – the type of surgeon that deals with prostate cancer – and takes place at the hospital with a transrectal ultrasound probe (and yes, that does mean an ultrasound probe placed into your rectum) which takes 12 or so small samples of the prostate with little biopsy needles.
This test is, of course, no walk in the park: causing pain, bleeding, and rarely infection. But unfortunately, even though it sounds like that would be pretty accurate at figuring out what is going on, a high proportion of the biopsies will come back with results that are still disappointingly inconclusive as to whether you are in the clear, or actually need to worry about your prostate cancer being aggressive or dangerous.
So here is the really tough part: imagine this surgeon then gives you the option to keep an eye on the PSA over the next few months and years, but tells you that the only way to be sure to be rid of the prostate cancer is to operate on it and remove it.
Nowadays, if one is trying to cure prostate cancer, one does a radical prostatectomy which removes not just the prostate but also a whole host of other lymph nodes. This can be done quite safely now, even though it is quite a complicated surgery deep in the pelvis. Still, it carries significant risks, in the range of 10% to 30%, of permanent erectile dysfunction (meaning you would not be able to get an erection ever again if it was quite severe) and/or urinary incontinence (which at its worst would mean permanent leaking from the bladder). Probably an even higher likelihood than either of these is the chance of a major depression.
In fact, starting down a path that leads to major depression, permanent erectile dysfunction, and permanent urinary incontinence is over 100 times more likely than the PSA test detecting a dangerous prostate cancer and saving your life.
This is why I usually counsel patients about all of this before even agreeing to order a PSA test, as it is important to know the pros and cons of any test you are going to undertake.
For some context, this conversation is similar to one that I have with women about breast cancer screening, as that is another screening test that is known to cause much harm when women are told they might have an aggressive breast cancer and it turns out to be a whole lot of worry for nothing. But, keep in mind that breast cancer screening is a lot more effective than prostate cancer screening. The number of women hurt by breast cancer screening in proportion to how many have their life saved is much smaller than the number of men potentially harmed by PSA testing.
I should come back quickly to the digital rectal exam, in which the doctor or nurse practitioner examines your prostate by feeling it directly with their finger through your rectum. That test is always on offer for men over the age of 50, if they want us to try to make sure that their prostate does not feel concerning for cancer. However, there is not a lot of evidence to suggest that this is an effective way to find a prostate cancer, especially since we can only feel about one-third of your prostate, and it’s the other two-thirds of your prostate that usually develops cancer if you do get it. But the real danger to doing this rectal exam when you feel fine is if the prostate actually does feel abnormal and we end up ordering a PSA test, and of course I’ve already spoken at length today about how that could potentially hurt you.
So, let’s call this a rabbit hole that you may want to avoid, and be aware that the ways to fall into that rabbit hole are most commonly doing a PSA test or having a doctor or nurse practitioner perform a prostate exam.
Of course, it’s natural to wonder what the experts say about all this.
There will be another video that I will record about “authority in medicine”, or how to tackle the challenge of what to do when different doctors do not agree. But, here, let me give you an approximate rundown.
Specialists in a certain area, in this case urologists and oncologists, tend to have the most experience with severe disease, and look more aggressively for that disease in the hopes of helping people avoid some of the bad outcomes that they have seen. This is called bias, and all doctors have it, myself included.
Meanwhile, urological associations in Canada and in the United States recommend offering PSA tests to screen for prostate cancer to every man over the age of 50. Some of these associations even recommend offering it earlier.
At the other end of the spectrum are “high level” governmental bodies like the Canadian task force for preventative health, which has, to my knowledge, never recommended that men over any age who feel fine get a PSA test to look for prostate cancer. Their argument would definitely be that more men are hurt by this test because of the problems I’ve already mentioned, compared to the number of men who might potentially have their life saved by getting the test.
In fact, you may already be aware that while in Ontario the government pays for the majority of Canadians’ healthcare costs, the PSA test is a blood test for which you must pay out of pocket.
Family doctor guidelines in Canada have moved towards recommending that men get a PSA test if they have significant risk factors for prostate cancer, like a family history of someone dying of an aggressive prostate cancer at a younger age, or perhaps screening only men who are extremely worried about prostate cancer and whose anxiety about having prostate cancer might be helped by getting the PSA test.
If you were grappling with whether or not to get the PSA test, these are some of the things you should be thinking about. It probably would be helpful, if you are not sure what to do, to continue this conversation with my healthcare team and me. We can help talk through whether or not this test makes sense for you.
In summary, I do not routinely recommend either the PSA test or a rectal exam to examine a prostate, for most men, regardless of their age. If men are old enough, that is, they are over 50, I do think it is worth a conversation about whether or not you should get a PSA test or rectal exam. But I will want to make sure you know about that rabbit hole I just talked about.
Keep in mind that after the age of 70, your risk of having prostate cancer of some sort is so high that I cannot think of any organizations out there that suggest that a man over the age of 70 should get a PSA test, or have his prostate examined, if he feels fine. This is because of the much higher risk of finding a prostate cancer that was probably never going to hurt him.
This is a tough topic and I thank you for watching this video. I do want to remind you that we are always happy to continue this conversation in the office.
