Might a PSA test at age 60 simplify decision-making about screening?

Marc B. Garnick, M.D.

Editor in Chief, HarvardProstateKnowledge.org

By Marc B. Garnick, M.D., Editor in Chief, Annual Report on Prostate Diseases

Almost daily, a man asks me, “Should I have a PSA test or not?” But this seemingly straightforward question doesn’t have an easy answer.

Since its introduction in the late 1980s, the prostate-specific antigen (PSA) test has been a routine part of the average man’s medical checkup. The test measures levels of a protein produced by the prostate and can predict whether a man has cancer. In fact, it has enabled doctors to diagnose more than 80% of prostate cancers before they spread, when they are at their most curable stage. If you’re over 50, you’d think that having the test regularly would be a no-brainer.

Unfortunately, the test has significant shortcomings. For one thing, PSA isn’t specific for cancer. Although the likelihood of cancer increases as PSA rises, levels considered abnormal—in the range of 4 to 10 ng/ml—occur in men who don’t have cancer. Adding to the confusion, 15% of men with a PSA below 4 ng/ml who have a biopsy actually do have cancer. That’s right: men with a “normal” PSA test result may have cancer, and most with an “abnormal” result don’t.

Furthermore, the test can’t distinguish potentially deadly tumors from insignificant ones. Some tumors grow and spread rapidly, but many grow so slowly that they may never cause problems during a man’s lifetime. In such cases, the cancer doesn’t need to be treated.

But when a man learns that he has cancer, he often can’t just live with it. He wants the cancer out, and he agrees to aggressive treatment, usually surgery or radiation therapy. The complications of treatment that often follow—namely impotence and incontinence—may cause more trouble than the disease ever would have. And two large studies have shown that PSA screening saves few lives. That’s why both physicians and patients struggle to decide whether screening makes sense.

A new report in the British medical journal BMJ might help simplify decision-making. It suggests that a single PSA measurement at age 60 can predict the likelihood that a man will die of prostate cancer by age 85, and that at least half of men no longer need to be screened after age 60.

Researchers from Memorial Sloan-Kettering Cancer Center in New York and Lund University in Malmo, Sweden, assessed PSA levels in 1,167 Swedish men at age 60 and then followed them until they died or reached their 85th birthday. In total, 126 men developed prostate cancer, and 35 died of the disease. They found that men with PSA levels of 2 ng/ml or higher at age 60 were 26 times more likely to die from prostate cancer over the next 25 years than men with scores below 1 ng/ml.

These findings suggest that screening efforts could be targeted at men with a PSA above 1 ng/ml at age 60, shifting the risk-benefit ratio, the researchers write. They also say, “Our findings suggest that 60-year-old men with low [PSA] concentrations can be reassured that even if they do harbor cancer, it is unlikely to become apparent during their lifetime and even less likely to become life-threatening.”

Yet, they continue, “A raised prostate-specific antigen is far from being an inevitable harbinger of advanced prostate cancer.” Their findings show that a 60-year-old man with a PSA just over 2 ng/ml has only about a 6% chance of dying of prostate cancer over the next 25 years.

However, the study has some significant limitations that need consideration. For starters, the number of participants (and thus the number of men who developed prostate cancer) was small. In addition, the participants all hailed from Sweden, known for its homogenous population. We have no idea whether the study findings would apply to a larger, more diverse group of men—or to specific racial and ethnic groups, such as African Americans, who have the highest risk of developing and dying from prostate cancer. I’m skeptical.

But I’m also curious to know what you think. If you don’t have your PSA checked, do these findings reassure you that you’ve made the right choice? If you have opted for PSA screening in the past, does this study make you think you can stop?

Posted Oct. 8, 2010

Comments:

  1. 62 psa today 5.6 quit saw palmetto 2 weeks prior to test, no sex 3 days prior. Many things will affect results. 2 years ago I pulled a 9.0 on test but had sex an hour before. Rectal exam and Tesla MRI scanned fine. This is not positive science and may never be. Nobody is going to shoot holes in my prostate. At least not until I see an alarming psa rise. Never smoked, normal weight, balanced diet. Plenty sex. Hope to live long.

  2. Dale Nenjaminson

    Thomas
    My PSA levels double in 4 years. Had a biopsy done last week 14 samples taken all cam back benign 😀. Didn’t hurt a little uncomfortable but the piece of mind is well worth it.

  3. Thomas

    I’m a 61 year old white male. I’ve always had a 2.0 ps
    My last 2PSA test or a 4.8 and my doctor wants me to have a biopsy. Is it safe to have a biopsy and should I agree?

  4. John Walton

    A British study involving 400,000 men and published in the Journal of the American Medical Association March 2018 concludes that screening for prostate cancer using the PSA test does not save lives and may do more harm than good.

    These results have been covered in the British press whose treatment is analyzed by the National Health Service’s ‘Behind the Headlines’ team:-
    https://www.nhs.uk/news/cancer/routine-blood-test-prostate-cancer-doesnt-save-lives/

    Isn’t socialized medicine wonderful?

  5. Dr. Robert T. Morrison

    I find the PSA measurements experiences of other men very interesting that demonstrates the great variation between individuals.Activity levels, emmotional state and current well being do effect PSA levels.
    I am a 68 year old very active sportsman with an enlarged prostate, have to urinate once during the night and more frequently if I get cold and have had my PSA levels monitored during the past 2 years after my Doctor suggested it might be a good idea. For my part, I was intersted to record a pattern for my future reference and in particular, a “baseline” reference point. My understandings are that if PSA levels dramatically and suddenly increase more investigations should follow. During the past 2 years the results of my 6 monthly tests fall within the band of 4.0 – 5.7 with my most recent being 4.7 after recording the highest prior to this of 5.7.
    I have a very high metalbolic rate, very slow heart rate, am 5 feet 10 inches tall and weigh 9 stone 9 pounds. My weight remains constant and therefore do not concern myself with what I eat my way of cakes etc.
    I shall carry on with the monitoring program but do not trouble myself with ill health imaginings.

  6. Ganesh Ram

    Recently I had checked my serum psa by Elisa test. The result is 5.32 NG/ML. I have been taking Flokind F regularly since March 16. Albumin trace,sugar nil,deposit 3-5 pus cells,2-4 EPI cells seen. What is the level of psa for men of 63 age. Expecting reply .r

  7. Richard D

    Dear Steve. Don’t be nieve. On Oct 4 I had a prostate biopsy because my PSA 3.51 at age 66. I have been a smoker for 50 years, and smoking can significantly increase your risk of cancer, in this case, the kidney, bladder and prostate since they all are directly connected and involved in the excretion of urine. You will be under general anesthesia (out of it)for about an hour. It’s an outpatient procedure you normally can walk away from but you must have someone accompany you when you are discharged because of the residual affects of the anesthesia. You will leave with a long catheter in your uretha inside your penis extending up through your bladder. Of course you will also
    be wearing a bag on the outside to catch your urine.
    In short, the procedure is relatively simple. You will likely have very painful urgent feelings to urinate with feeling of wanting to strain or force yourself to urinate when the catheter is removed after 4-5 days. You will also be passing blood in your urine for several weeks (4-6) after the procedure. I am 3 weeks post op and still experiencing painful urination with some blood discharge.
    Getting better though. I hope this helps you.

  8. peter

    no the biopsy doesn’t hurt .
    it like the flick of an elastic band
    .
    however , if you imagine a removing 6 match sticks from the centre of a walnut . that is effectively what you do to your prostate

    just saying

  9. Steve Klarfeld

    I’m i’m 60 years old and my PSA came back at 6.2 were 6.0 from a 4.8. I’m sorry a 5.8 they went down to in the fours. Read several articles and I don’t know who to believe in what to do about my reality urologist will say but like to know if I need to take a different kind of blood test called oncondolat blood test or biopsy. I think I should take another blood test. Within last three test it’s been up to four and over. Rectal exam was fine. I wonder if there’s a supplement to help with these up and down levels? Plus does a biopsy hurt and I believe your awake. Also are there certain med that would make the PSa go up
    Steve

  10. Serge Gerrard

    I am 70 , in good health but do have BPH symptoms and take medication for other conditions which aggravate my BPH. In 2013 my PSA was 5.8 and yesterday it was 143 and the free PSA was 12.1 .08%

    I can only add that for 1 week I had a bad URTI with severe coughing and no sleep + decongestants which made the BPH worse .
    I suppose I should repeat the PSA and get a biopsy ?????

    Regards,

    Serge

  11. K. Walsh.

    How long does PSA result take.?

  12. Sandy rattanavalee

    I am 64 year Asian male. The last 7 years my PSA level has been steady at 3.8/3.9 Four months aga it went up to 4.18 Should I be concerned and ask for a biopsy? I have been on Doczacosine once a day before bed time for the last 5 years.

  13. Norman Carter

    I am 85 and just had a new psa test. My level is 106. What should I be concerned about? I had radical prostectomy in 1991. My thyroid is low, my energy level is low. I just recently stopped Tekturna, blood pressure med. I also started on Eliquis, 2.5 mg twice a day. I’ve been very wobbly for some time. Been diagnosed with Afib.
    Feeling better after the medicine changes.

  14. Ronald Delavega

    Am a 60 year pld man. Been checking my PSA levels for 19 years I have always been around 3 Now am at 3.6. I had a biopsy about 6 years ago no cancer. 7 months ago I had an infection of the prostate and my PSA shut up to 6. Now an urologist says that 3.6 is too high for my age should I be concerned?

  15. Hasoka

    I’m 57 years old African who has lived in Sweden since the mid 80s. I had a psa test on April 3/2017 and the result was 5.0. I’ve been on high blood pressure medication for the past 10 years. My psa level for the 5 years have been around 3.0 and 5.0. Have never smoked and hardly drink alcohol. My doctor tells me is normal for a man of my age to have such psa levels. I’ve no problems urinating and general health is pretty good. Should I ask my doctor for a biopsy and should I be concerned about cancer?

    • Richard Hamood

      I am 63 yr white male. My last 3 test results for PSA are 4.0, 4.3 and 4.6. (After hip replacement)
      I definitely urinate more often. Avg 2 during sleeping hours. No issues urinating. No other known issues. Do I need a biopsy? Thank you

  16. My PSAT scorr 16.4 that was two weeks ago today is March 24, 2017 the previous Wednesday I had a prostate biopsy waiting for the results this Monday or Tuesday I have no problem urinating I do have a epididymis I left testicle that caused a inflammation in the prostate gland

  17. Sir my father is PSA test his result 500 his age60 yrs plese help me salusin

  18. Barry

    62 yrs old, high PSA for yrs ! Had cancer test 4 yrs ago- no cancer ! Harder to urinate these days but no major problems . What should I do ?

  19. Rose

    Rose
    My dads psa test has been shooting soo high.just a month ago it was 690 but today is reading 1400.how can we help? because he is on medication and diet

    • cathy

      Does he take iron or vitamins that contain iron? If on cholesteral med does he drink grapefruit juice? My husband had a very high psa and they were going to take everything. He made them retest in three weeks. He discontinued iron contents and grapefruit juice. His psa dropped to the level of a 20 yr old man.

  20. Bob

    I am a healthy 58 year old 6 foot 1 and 170 lbs. Do not smoke or drink. Very few enviro hazards in life time. My 23 and me genetic scoring for prostate cancer based on gene region, SNP, Genotype came in at 20.4 out of 100 men similar will get prostate cancer with the average is 17.4. My father who lived to 97 got prostate cancer at 92. Treated with electron conformal beam and did not die from prostate cancer. My PSA has always been below 1 and last year 2014 Nov it was 1.94, this year test 2.76 Dec 2015 but on retest it was 2.35. DRE showed normal size and no noduals, Brooke Army Medical Center plans a prostate biopsy this Thursday. I have had low flow pressure for years before increases and an increased need to urinate but I am on hydro clorothorozide Hyzaar 20/100
    I did the PSA screen Individualized Risk Assessment by Dr Thompson UT Health Science Center and it shows a 30 percent risk of detectable cancer and a 10 percent chance of high grade cancer. Thursday will be a rough day for me. Should I be worried? Based on your assessment above, under age 60 and 25 times more likely to die from this, I’m not even sure why I should be working anymore to plan for a life I will never see anyway. Your thoughts?

  21. Mark

    I am 57 years old and have had my PSA tested annually for the past 5 years (always below 1). I had understood the risk of having a high PSA and not having cancer, but I did not realize the opposite was also true until reading this article: that one can have a low PSA and still have prostate cancer. Seems to make the test even less useful and is giving me cause to reconsider my decision for annual PSA testing.

  22. Steven Stumpf

    I have high psa # since started to check. some 12 -13 years ago 12 ,13.5 15 six month ago 16.4 now 15.7 I’m a strong big bones man with no over wait. I fill myself healthy, even I fill some time
    My age. I’m working full time. Should I concern about cancer?
    Thank you, B.R. Steven Stumpf

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