Paradox of the PSA Test: Is It the Start of a Slippery Slope?

It may be your first encounter with a prostate-specific antigen (PSA) test in a routine health check after turning 50. Or you wonder if you need to be tested since Warren Buffett said he caught prostate cancer early by using this particular test.

The PSA test is a blood test commonly used to screen for prostate cancer. The prostate gland produces PSA, a protein that helps liquefy semen, and small amounts of this protein naturally enter the bloodstream. High levels of PSA typically suggest a higher risk of prostate cancer.

However, the PSA test is known for its uncertainty. The simple blood test itself is minimally invasive, but it is notoriously rife with high rates of false-positive cases, leading to unnecessary invasive diagnostics for individuals who do not have prostate cancer. It can also be falsely negative (low values in the setting of important prostate cancer cases).

It is important to differentiate “screening” from work-up of patients who have symptoms (e.g. difficulty urinating). Screening by definition is done in patients who do not have symptoms, in an effort to diagnose asymptomatic cancers. Unfortunately, PSA-based screening has never been definitively shown to extend life, although there are many controversial caveats about trials of screening. PSA screening may be most valuable if applied to men in younger rather than older age groups and men with risk factors such as close family members with prostate cancer diagnoses, genetic predispositions to prostate cancer, and high-risk racial groups like Black men, although this too is controversial.

For men who know about the PSA test, many may fear taking the test, while some may have concerns or reservations about it. Ericka Johnson, a professor at Linköping University and author of ‘A Cultural Biography of the Prostate’, discusses several paradoxes associated with the PSA test, and how it can affect you and your relationships.

The PSA test generates a paradox where individuals hope that it will prove they are cancer free, but it also instills fear in them about the potential of having prostate cancer. This oscillation between hope and fear is a central paradox associated with the test.

The PSA test decision-making process requires rational, evidence-based considerations. At the same time, it is actually an emotional and fearful decision to make – the fear of cancer and mortality. Balancing these aspects can be challenging.

Public discussions on PSA screening are influenced by survival stories of young men who discovered their cancer early, and which they successfully treated. Like all other cancers, these stories emphasized the importance of early detection but there was little mention of the side effects of cancer treatment, or whether their cancer was sufficiently risky to necessitate treatment in the first place.

People want the PSA test to find cancer and potentially save lives, but it is also criticized for potentially identifying tumors that might not have affected one’s life, leading to overdiagnosis. Overdiagnosis can lead to the unnecessary treatment of tumors that might not have caused harm.

While early detection is promoted as a life-saving benefit of the PSA test, it can also lead to overtreatment, where individuals undergo unnecessary surgeries or treatments with potential side effects.

There are growing efforts to use MRI in order to triage which men with elevated PSAs even need to undergo a biopsy to establish a diagnosis. This may help cut down on the number of men needlessly diagnosed with prostate cancer that is unlikely to cause problems or require treatment. Moreover, active surveillance can be used for those men who are diagnosed with clinically insignificant prostate cancer to avoid overtreatment.

Healthcare communication often simplifies complex issues for clarity. However, a screening tool with high rates of false positives like the PSA test is inherently complex. In order to prevent one death, around 18 men need to be diagnosed (based on the European Randomised Study of Screening for Prostate Cancer, also known as ERSPC). According to results from the ERSPC and Goteborg prostate cancer screening trials, the American Urological Association now recommends regular PSA screening every 2 to 4 years for those between 50 to 69 years old, to limit the risk of advanced prostate cancer and reduce prostate cancer mortality rates.

While there may be risks of overdiagnosis, there should still be encouragement for screening for those at risk. A simplified health message for the PSA test undermines its potential consequences and emotional impact. Balancing complexity and clarity remains a paradox in the context of healthcare communication.

In considering whether to undergo a PSA test, you may need to look at your own emotions and preferences as well. Professor Johnson has provided insightful suggestions — "embrace all the feelings and other social considerations in our decision-making".

When talked about to men and from the perspective of their prostate health, she highlighted that the issue is “entangled” with their identities and their broader social environment. In turn, while the PSA test may be a personal medical choice, it can also be a social one, influenced by public messaging or fears of not meeting their loved ones’ expectations or needs.

If you are still wondering about whether you should take the PSA test, a discussion with your doctor may help clarify any fears or doubts you might have.

Find out more about Professor Johnson and her book via her article and talks.