Prostate specific antigen (PSA) is a protein measured in the blood that is produced by the prostate gland. It is used as a marker for the early detection of prostate cancer. Currently, the American Cancer Society recommends all men begin screening their PSA at age 50, with annual tests thereafter. Since the implementation of this screening protocol, the number of men who unnecessarily undergo invasive diagnostic and treatment procedures, including radical prostatectomy (complete removal of the prostate), has increased dramatically.
To understand why this test causes more harm than good, when used alone as a general screening guideline, we must first establish that there are aggressive and non-aggressive forms of prostate cancer. Aggressive prostate cancer was responsible for approximately 32,000 deaths in the United States in 2010, making it the second most common cause of cancer related deaths in U.S. men, second only to lung cancer. Localized prostate cancer (also known as benign or slow growing cancer) is far more common. Research has shown localized prostate cancer is present in approximately eight percent of men in their twenties and 83 percent of men in their seventies.
The PSA test does not differentiate between these two types of cancer. Neither does it differentiate from other very common prostate conditions like Prostatitis or Benign Prostatic Hyperplasia (BPH), which is found in 50 percent of men over age 50 and 80 percent of men over age 80. It is very common for a man with normal enlargement of his prostate to have an elevated PSA that warrants further investigation like an invasive biopsy.
One study published in the New England Journal of Medicine in 2010 demonstrated that for every one case of diagnosed aggressive prostate cancer, 1,410 men will undergo prostatic biopsy and 48 will have additional invasive treatments (radiation, chemotherapy, or prostatectomy). Side effects associated with these invasive procedures include up to 50 percent of patients experiencing include urinary incontinence, erectile dysfunction, and bowel problems. Clearly this is a case where the risks far exceed the benefits.
A series of large clinical trials in 2003 came to the conclusion that “serum PSA between 2.5 and 10 ng/ml is unrelated to prostate cancer and is most surely caused by benign prostatic hyperplasia.” Despite these conclusions, the current screening guidelines and many urologists will still recommend prostate biopsy with a PSA greater than four ng/ml.
There is no single alternative for the screening PSA test. Each man must work with his physician to decide what is appropriate, given his risk factors. As a minimum, I recommend that my patients have annual digital rectal exams (DRE) starting at age 50, preferably following up with the same doctor every year thereafter so that doctor can recognize changes. If they have a family history of aggressive prostate cancer, I would start screening at age 45.
A transrectal ultrasound can reliably determine the volume of the prostate and help the clinician make a more informed decision about whether a biopsy is necessary. A larger prostate as demonstrated by ultrasound could be expected to correlate with a higher PSA, whereas a smaller prostate should expect to have a lower PSA. A smaller prostate correlating with a higher PSA value is a good candidate for biopsy, whereas a larger prostate with the same PSA value may not be.
Other analytical tools that have shown some promising initial results are a free to total PSA ratio, PSA velocity, and a urine PCA-3 test. The urinary PCA-3 test has a much higher specificity for prostate cancer than do the related PSA tests. It is not affected by BPH or prostatitis, so a higher result can help the patient determine their need for biopsy much more confidently than with PSA alone.
For my patients with prostate issues, I will generally recommend dietary modifications along with a healthy exercise regimen and stress reduction. I also utilize a variety of herbs and nutritional supplements aimed at supporting the immune system to target potential cancer cells and decrease the growth rate of the prostate.
While PSA may be prostate specific, it is not disease specific. Most elevated PSA does not result in aggressive prostate cancer. As with all important medical decisions, a clinician should take into account the individual patient’s history, risk factors, and their overall health status. No single lab value should determine the course of care recommended by the physician. This ideal is especially true when considering a screening PSA. FBN
Dr. Ryan Sweeney is a Naturopathic Physician at Root Natural Health in Flagstaff, Arizona. His approach to medicine is to treat the cause of disease, not just address symptoms. In addition to being a primary care physician, his clinical focus is in Men’s Health, Autism, ADHD, and Gastrointestinal Disorders.
Root Natural Health is Flagstaff’s newest integrative medical clinic offering Holistic Primary Care, Preventive Medicine, Nutritional Medicine, IV Nutrient Therapy, Herbal Medicine, Women’s Health, Endocrine and Hormone Balancing. For more information on Dr. Sweeney and Root Natural Health, visit www.rootnaturalhealth.com or call 928-637-6795.