The PSA Controversy

Winter 2000 CSANews Issue 37  |  Posted date : Mar 07, 2007.Back to list

In Canada, using the PSA test as a screening tool is surrounded by controversy. Of our 10 provinces, only Manitoba and Nova Scotia absorb the cost of testing to facilitate early detection. Why, then, if prostate cancer is the third most common cause of death from cancer in men of all ages, is PSA not used as a screening tool?

When asked why testing such as mammograms receive provincial coverage and PSA does not, a spokesperson for the Ontario Ministry of Health replied, "Mammograms for women over 50 have been proven to be of value for early detection of breast cancers. A PSA test is not the best screening technique for detecting cancer in men. The test is inaccurate roughly 10 per cent of the time." He later went on to say, "(the) PSA test is a valuable tool for doctors when they believe that a patient has problems with their prostate. It is not the best tool for mass screening...the American Cancer Society, which once advocated PSA testing for all men over 50, has now backed off that recommendation."

Dr. Richard Sorace, a leading prostate cancer specialist in Florida, has his own views as to why PSA testing isn't covered ­ and his opinion matches that of men across Canada. "Paying for everyone in the country to have a PSA test adds up to a lot of money, and that's the controversy. But, certainly, every male over age 50 should have an annual physical examination that includes a PSA measurement and a digital rectal examination. If you have a family history of prostate cancer, then you probably should start having PSAs done at age 40."

Currently, out of 100 men over the age of 50 having a PSA test performed, 10 will have a higher-than-normal PSA level. Of these 10, three will be found to have prostate cancer after the first biopsy, and seven will be found not to have prostate cancer at that time ­ a false positive result. Over the next few years, two of these seven will develop prostate cancer. Therefore, five of the original 10 will be found not to have prostate cancer. Of the 90 who "passed," two will actually have prostate cancer ­ a false negative result.

Jack Parry is adamant that having the PSA test probably saved his life. "I feel good. The insidious thing about prostate cancer (is that) unless you get the PSA blood test, you have no idea you've got it. There's no pain, there's nothing." "Mine's a perfect case...here I am, 70 years old. At 69, I was okay, at 70, I've got it and no indication whatsoever. If I hadn't been taking the PSA tests, who knows? Maybe in another six months to a year, the cancer would have spread beyond the prostate gland and into the bone or some darn thing and then, three or four years downstream, I'd be dying of bone cancer."

PSA levels rise gradually as a normal part of aging, and there are a number of reasons for this ­ cancer being just one factor. The most common prostate problem is called benign prostatic hyperplasia (BPH) ­ an enlargement of the prostate, and its symptoms mirror those of prostate cancer. According to the Canadian Cancer Society, more than half of men over age 50 have BPH ­ which is not related to cancer at all. Other causes for having a high PSA count may include a prostate infection, strenuous exercise, biopsy or operation on the prostate.

Dr. Sorace is a firm advocate of PSA testing, "...that's probably the single most important test that you could have. Next, would be a digital rectal examination... however, you can have an abnormal PSA and still have a normal digital rectal exam." "If the PSA is abnormal, and the digital rectal is abnormal...you're going to have a biopsy. If the PSA is abnormal, and the digital rectal exam is normal, you may, depending upon the magnitude of the PSA, watch it and see if it's going up, do a more extensive PSA test and see if they're in a higher risk, or we may just go ahead and biopsy."

Quality of life is at the focus of the debate surrounding PSA as a mass screening tool. Donna Czukar, Ontario Director for Cancer Information Services, stated that, "it's (PSA) not shown to necessarily be effective as a screening tool. The effectiveness is still being studied." Unlike breast cancer, where it was proven years ago that early detection by self-examination and mammograms increases chances of survival, there is yet to be definitive proof that PSA testing will make a difference in patient longevity, once the disease has been discovered.

For some, prostate cancer may be very slow-growing, and may not cause any complications during their lifetime, therefore not requiring any treatment. Others are diagnosed too late to cure. Whether or not prostate cancer is diagnosed early, the majority of men who have the disease will not experience significant symptoms and will, in fact, die from another cause. Autopsy studies have shown that by the age of 90, most men have latent or microscopic prostate cancer, which has not been the cause of death.1 But what of those who do require treatment? How many deaths, either directly or indirectly from prostate cancer, are too many? Those with the illness say, 'one.'

Once a diagnosis of cancer has been made, a method of treatment has to be discussed. There are three methods of traditionally accepted treatments: watchful waiting (patient is treated only if disease progresses), prostate surgery and radiation therapy. "Urologists like to do a prostatectomy if they feel the disease is confined to the prostate and has not spread," says Dr. Sorace. "They usually will recommend it if you're younger, i.e. less than 70 years of age, or if you're a good surgical risk."

Pic: Jack Parry's battle for Government-paid PSA testing became personal with his diagnosis of prostate cancer.

Some feel that if a patient is in good health with a long life expectancy, the probable side effects of a prostatectomy - incontinence and impotence - may be worth it. If a patient has other serious medical conditions that would most likely be the cause of death, before cancer, then the side-effects may simply not be worth risking. It's a difficult decision.

Dr. Sorace and his partner, Dr. Dattoli, have built their practice around Brachytherapy ­ the placement of radioactive pellets in a tumour for the purpose of generating a dose of radiation around the cancer, to kill it. This type of therapy can be used on any kind of tumour, provided the pellets can be physically placed in the space. Side-effects are minimal and patients are up and around the next day. "Any patient that has a high chance of disease outside of the prostate, we would recommend the combined therapy using the beam (external radiation) and seed approach, so that we cover not only the inside, but the outside," says Dr. Sorace.

The side-effects of Brachytherapy are relatively insignificant, in comparison with other treatments. Short term, there are anesthetic risks, although even patients with cardiovascular conditions can tolerate spinal anesthesia. Bleeding complications are almost zero, because there's no cutting or stitching and infection complications are also quite small. "Once the seeds are in place, as they're depositing the radiation into the tissue, they will cause some irritation to the bowel and urinary apparatus, so you'll get some urinary frequency and some gripiness and conflicts of that nature...you might get burning urination...that's a direct result of the radiation being delivered to the prostate from the seeds."

"If you're 70 and above, they don't want to operate," continued Mr. Parry. "My Gleason scale (a measure of how 'angry' the tumour is under the microscope) is high enough that during the operation there might be a migration of cancer cells, and that's why they don't want to take the chance ­ they want to keep it encapsulated so it doesn't go to the bone." " Radiation in my case is more likely to be seven weeks, five days a week
(thirty-five doses).

"Three out of every 10 men diagnosed with prostate cancer will die from this disease. This behooves the point of how much of that 30 per cent never had a PSA, or had a PSA when it was too late...maybe there was no need for them to die of prostate cancer if they were properly screened. An older man living on old age pension is unlikely to pay the 20-25 dollars for this test...especially in the absence of any symptoms."

The PSA test is a blood test ... as simple as that. Should the provincial governments cover the cost? Is having a PSA test worth the risk of a false positive or false negative? Jack Parry thinks so. Doctors at one of the States' leading prostate cancer centers also believe so. Radical treatments aren't the only solution. Quality of life can very often be maintained, depending on the treatment type. Drs. Sorace and Dattoli have treated thousands of men with great success and are building a state-of-the-art treatment and education centre in Sarasota, Florida to continue their work.

Jack Parry's looking on the bright side these days. For the first time in 18 years, his whole family will be home in Canada for Christmas, and he's doing his best not to dwell on his diagnosis. He does have some advice to all men ­ "Get a PSA test, period, and if you have siblings or sons, then they should be tested as well. Get a PSA test done a minimum of once a year...this was the only marker in my whole episode."

Good luck, Jack ­ you're a fighter and we know you're going to win.

These symptoms hold true for a number of prostate problems. If you're experiencing these symptoms, visit your doctor.
  • Frequent, painful or difficult urination - especially at night
  • Having difficulty starting the stream
  • Having a weak or interrupted stream
  • Urine leakage
  • Blood or pus in urine
  • Pain in the lower back, pelvic area or upper thighs
  • Painful ejaculation
Research has shown that some cancers can be prevented. The Canadian Cancer Society recommends these seven steps to reducing your risk:
  • Be a non-smoker and avoid second-hand smoke.
  • Eat five to 10 servings of fruit and vegetables each day. Choose fibre and lower-fat foods. If you drink, limit your alcohol consumption to one or two drinks daily.
  • Be physically active on a regular basis ­ this helps to maintain a healthy body weight.
  • Protect yourself from the sun. Check your skin regularly and report any changes to your doctor.
  • Follow cancer-screening guidelines. For women, discuss mammograms, Pap tests and breast exams with a health professional. For men, discuss testicular exams and prostate screening with a health professional. Both men and women should also discuss screening for colon and rectal cancers.
  • Visit your doctor or dentist if you notice a change in your normal state of health.
  • Follow health and safety instructions, both at home and at work, when using, storing and disposing of hazardous materials.
For more information on how to reduce your risk of cancer, contact your local unit of the Canadian Cancer Society or call the Canadian Cancer Society's Cancer Information Service at 1-888-939-3333.

To reach Drs. Sorace or Dattoli, contact The Dattoli Cancer Center and Brachytherapy Research Institute, 2803 Fruitville Road, Sarasota, Florida, 34237. Call toll-free (877) DATTOLI. or www.dattoli.com

1 Ontario Ministry of Health and Long-Term Care ­ Ontario Prostate Antigen (PSA) Testing


Response:
Jack Parry's battle for Government-paid PSA testing became personal with his diagnosis of prostate cancer.