My husband has a cadre of male friends that I refer to as his “pub buddies.” They’re great guys and range from retired professionals to tradesmen. Little moss grows on any of them.
Lately, hubby came home with the message that he and his pub buddies had decided that the policy about PSA testing in Ontariois sexist and reflects a societal bias against men. After all, he says, mammography and Pap smears are paid for through public health insurance but PSA is not.
Let’s look at this. PSA testing is a blood test for something called prostate specific antigen. PSA levels are typically low in men but a number of conditions – both benign and cancerous – can increase it. Prostate cancer and benign conditions such as inflammation of the prostate (prostatitis) and enlargement of the prostate (benign prostatic hyperplasia) increase in frequency with age.
It is the position of some organizations that all men over 40 have a PSA to establish a baseline value and men over 50 consider annual or semiannual PSA monitoring. PSA testing for screening purposes (i.e., in a man with no evidence or diagnosis of prostate cancer) is covered by public health insurance in Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Newfoundland, PEI, the North West Territories, Yukon and Nunvaut. But in British Columbia, Alberta, Quebec and Ontario, the cost is only covered if there is a diagnosis, clinical signs of prostate cancer and/or other indicators of risk such as family history, own health history or race (there are differences between the provinces).
Why isn’t PSA testing routinely covered as a screening tool in all provinces? Well, the problem stems from the evidence on its effectiveness. A Cochrane Collaboration Review of the research literature found screening did not significantly reduce prostate-cancer specific mortality.1 Moreover, PSA testing didn’t do very well when they looked at the balance between benefits and risks. Benefits of screening may take up to 10 years to occur, so screening was unlikely to be helpful for men with a life expectancy less than 10-15 years (i.e., elderly men). Meanwhile, you need to consider the draw-backs or potential risk of screening.
The main problem with screening is the high rate of false-positive results. According to the Cochrane review, up to 76% of positive PSA tests are false.1 In other words, up to three-quarters of men who get a “positive” PSA test result don’t have prostate cancer. But because of their test result, they may be exposed to the risk of additional, often invasive, tests such as biopsies. To say nothing of the worry and stress of being told you may have cancer. According to the US National Cancer Institute, “most men with an elevated PSA test result turn out not to have cancer; only 25 to 35 percent of men who have a biopsy due to an elevated PSA level actually has prostate cancer” (emphasis in the original). 2
In addition, a certain proportion of tests may be false-negatives: the PSA level is in the normal range even through prostate cancer is actually present. A false-negative could lull a man into a false sense of security and encourage him to ignore warning symptoms.
If you want to learn more, the October 27, 2011, issue of New England Journal of Medicine has three editorials on the topic in response to the recent US Preventive Services Task Force recommendations (www.nejm.org). FYI, the Task Force recommended against routine PSA-based screening.
The issue is complicated and I think it’s the uncertainty in the science rather than overt sexism that is behind the current patchwork nature of PSA reimbursement across Canada. But I can certainly appreciate that on the surface – yes, it does look like men are being treated differently than women. However, I think the pub buddies need to appreciate that you can’t just order a PSA – it’s supposed to be accompanied with the dreaded digital rectal exam. Obviously, better screening tools could be helpful and that’s something only research can give us.
Take-away message/bottom line
There are significant issues with PSA testing which may help to explain why it is not routinely covered as a screening tool in all provinces. What is needed is something only research will be able to give us – a more accurate screening tool.
1 Ilic D, O’Connor D, Green S. Wilt TJ. Screening for prostate cancer. Cochrane Database of Systematic Reviews. Last assessed as up-to-date: June 10, 2009. http://www2.cochrane.org/reviews/en/ab004720.html
2 National Cancer Institute at the National Institute of Health. Prostate-Specific Antigen (PSA) Test. http://www.cancer.gov/cancertopics/factsheet/detection/PSA