Prostate cancer: PSA test in the crossfire of criticism

"The PSA test is useless and sometimes even dangerous." This statement is being mistakenly conveyed more and more often by the media. Recent broadcasts include the RBB political magazine Contrasts "Early detection of prostate cancer: the business with anxiety". The German Society of Urology (DGU), the Professional Association of German Urologists (BDU) and the Federal Association of Prostate Cancer Self-Help (BDU) criticise the one-sided reporting, which leads to a deep insecurity of men.

Criticism of the PSA test is triggered by a European study1 that is currently being carried out on 1,800,000 men for the benefit of PSA-assisted prostate cancer screening. Preliminary interim results show that by using the PSA test in healthy men aged 65 to 69 years, the probability of dying from prostate cancer can be reduced by 20 percent. Conversely, this also means that statistically speaking, a total of 48 men must be treated in order to prevent prostate cancer deaths. Since prostate cancer often occurs at an advanced age and usually grows slowly and therefore may never cause symptoms, there is sometimes the risk of "over-therapy". It is therefore particularly controversial whether the early diagnosis by means of PSA test would not unnecessarily treat too many patients.

PSA values are often misinterpreted

It's not the PSA test that's dangerous, but how to deal with the results,"says Dr. Stephan Neubauer, urologist at the West German Prostate Center in Cologne. Although the interdisciplinary guideline on the early detection, diagnosis and therapy of prostate cancer gives clear recommendations as to when and under what circumstances the test should be used, it still happens that PSA values are incorrectly interpreted and acted on prematurely, criticises the Cologne urologist. For example, a biopsy is often initiated due to briefly increased PSA values, instead of first observing the course of the values. 

Dr. Neubauer also calls for a different approach to the treatment of tumours discovered by the PSA test:"It is not acceptable for a patient with an elevated PSA level to automatically land on the operating table and return home with side effects such as incontinence and impotence," said the prostate specialist. Radical prostate surgery, which is still the most common treatment in Germany, is often accompanied by a high incontinence and impotence rate. According to the recommendation of the guidelines, it can often be sufficient for men with a low risk prostate carcinoma to closely monitor the tumor (Active Surveillance). If treatment should become necessary, however, it is important to focus more strongly on achieving optimal healing rates with minimal side effects,"emphasizes Dr. Neubauer.

Focus on therapies with few side effects

Modern radiation therapy methods such as brachytherapy are particularly suitable for this purpose. In contrast to radical removal of the prostate, the prostate gland remains intact. The ultrasound-guided introduction of radioactive radiation sources directly into the prostate gland destroys the tumour and at the same time protects the surrounding tissue. The advantage of "internal irradiation" is that patients have to accept significantly lower side effects for the treatment without fearing any loss of healing. For advanced stages, the procedures are also demonstrably superior in terms of the effect of the operation, so that significantly better healing rates are achieved with fewer side effects.

In the controversial debate, we must not forget that prostate carcinoma, with more than 60,000 new cases per year, continues to be the most frequently diagnosed cancer in men and, according to the Robert Koch Institute, still ranks third, especially in terms of mortality with more than 12,000 deaths per year. And the PSA test is still the most important instrument for the early detection of prostate cancer,"summarizes Dr. Neubauer. Otherwise, men with an aggressively growing tumor that would lead to death without adequate therapy would fall through the precautionary grid, according to the Cologne urologist. A recent analysis of data from the largest cancer registry in the USA published in the renowned journal "Cancer" showed that thanks to improved early detection using the PSA test, only 8,000 men today reach a late stage of cancer in the USA instead of 25,000.2 This means that without the PSA test, three times as many men would not notice their cancer until the tumor has already metastasized.

Literature:

  1. Schröder FH et al.: Screening and prostate-cancer mortality in a randomized Euro-pean study. N Engl J Med. 2009 Mar 26;360 (13): 1320-8 Epub 2009 Mar 18.
  2. Scosyrev E, Wu G, Mohile S, brass EM.: Prostate

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