The PSA Test: What Happens When a Test Is Wrong?

He sat in his recliner looking paler than snow, thinner than a scarecrow. Only one month had passed since I last saw him. How could a healthy, vibrant man lose so much weight in such a small time-frame?

It began shortly after Christmas. I received a call saying Dad was ill. They had taken him to the doctor who told them that Dad's PSA test result was high and that the doctor had told them that he was certain Dad had prostate cancer and that it had metastasized. He recommended biopsies of the prostate, lymph nodes and bone. Dad had seen Mom go through chemotherapy and radiation therapy when she had breast cancer. Dad wanted nothing to do with medical treatments for cancer. In fact, he refused any medical care, including having further testing to determine if he indeed had cancer.

But, in Dad's mind, he believed the medical doctor-that he had cancer and it had spread. The family believed the medical doctor as well. Everyone's life was turned upside down because of one test and one doctor's interpretation.

Little did they know that the PSA test has been shown to be an inaccurate test for prostate cancer.

The PSA test stands for Prostate Specific Antigen. It was pushed to be used as a tool to detect prostate cancer in 1987. The theory behind the test was that the prostate gland releases into the blood stream the Antigen. In those with prostate cancer, the prostate would release more PSA, in theory.

With further study, however, it was determined that too many people with elevated PSA tests didn't have cancer. In one study of 1 million men with elevated PSA levels, 75% of these men didn't have prostate cancer when a biopsy was done.

The high number of false positives has lead doctors and researchers to reconsider the use of the PSA test as a diagnostic tool for prostate cancer, and to re-think their recommendations. Dr. Thomas Stamey, a Stanford University urology professor stated that "high PSA levels are signs of an enlarged prostate and have no value as tools for cancer diagnosis" (prostatecancer.about.com). Dr. Stamey had been the main urology specialist who pushed to have the PSA test available for prostate cancer screenings in 1987.

Moreover, it is unclear if the use of the PSA test out-weighs the risks of follow-up diagnostic testing, such as biopsies, which can lead to infection, impotency and urinary incontinence.

Since the inception of the PSA test to check for prostate cancer, 14 causes were found to elevate PSA levels:

1. Enlarged prostate (called Benign Prostatic Hypertrophy, BPH)
2. Urinary tract infections
3. Stones in the prostate
4. The presence of a genetic variance-a single nucleotide polymorphism
5. Vigorous prostate massage
6. Aging
7. Infection within the body
8. Infection or inflammation of the prostate
9. Sexual activity within 5 days of the test, including masturbation
10. Race
11. A recent cystoscopy (a medical test where a scope is inserted through the penile canal to look at the bladder)
12. Large doses of some medications used to treat cancer
13. Rough handling, contamination or inadequate refrigeration of the blood sample
14. Prostate cancer

Because the most common cause of an elevated PSA test is an infected prostate gland, the new protocols for an elevated PSA is to put the man on 2 to 4 weeks of antibiotics then recheck the test to see if it dropped. The new recommendations are indicating that most men with an elevated PSA responded favorably to antibiotics, even those that had an extremely high PSA reading.

Although the higher the PSA reading the greater the indication that cancer may be present, Dr. David Bostwick, professor of pathology at Mayo Clinic, cautions men to remember that even an extremely high PSA does not necessarily mean cancer; it could be a severe prostate infection or an enlarged prostate gland.

It is also a new protocol to watch for changes in a PSA level, that one PSA reading may not be indicative of cancer. If a person's PSA level changes more than 2 points in 12 months there is a greater indication that the person may have cancer and a biopsy may be warranted for further diagnosis. Still, biopsies are recommended only after antibiotics are given and after watching for PSA changes. Biopsies are expensive, painful and not always accurate; and they have complications of their own.

Too many men have suffered through emotional distress and invasive medical procedures because of one elevated PSA reading. Men need to be informed of the new protocols for an elevated PSA. According to Dr. Isadore Rosenfeld, "America's Most Trusted Doctor," prostate cancer is very slow-growing. If you are diagnosed with an elevated PSA level, waiting 4 weeks while taking antibiotics will not cause the cancer to grow rapidly, if you have cancer. But taking antibiotics for 4 weeks may lower the PSA levels and decrease whatever symptoms you are having. When cancer is left untreated, it usually takes 7 to 15 years to spread beyond the prostate gland. Also, with prostate cancer, the man rarely has any symptoms that something is wrong. Prostate cancer is silent until the very last stages. If a man has symptoms, such as urinary frequency or pain, it is more likely that he has an infection or an enlarged prostate, not cancer.

It is possible that Dad really does have prostate cancer. Without further testing we may never know. But Dad believes it, and as long as Dad believes it, his body will respond accordingly. Dad will continue to lose weight, be tired and feel saddened by not being able to attend his son's wedding or his granddaughter's graduation. The moment the thought of cancer was put into his head, and he believed it, he was destined to die from the ideation of cancer.

If 75% of 1 million men with elevated PSA levels did not have prostate cancer (in the study), imagine the number men who are told about elevated PSA levels each day, and how many of them are told they have cancer based on that test. That is too many men. The thought of cancer is devastating to everyone emotionally-connected to the person with the diagnosis. No longer does an elevated PSA test automatically mean cancer. Always get a second opinion. And always remember the new protocols set up by University Hospitals-it could save your life.

Information About Those Who Have Studied PSA and Prostate Cancer

David Bostwick, MD, is a pathologist and professor of pathology at the Mayo Clinic in Rochester, MN and has devoted more than 17 years to the study of prostate cancer and its origins. He is the author of over 200 scientific papers on the subject.

Harry Fisch, MD, is the director of the Male Reproductive Center and directs urologic microsurgery in the Department of Urology at Columbia University Medical Center of New York Presbyterian Hospital in New York City. He is also a professor of clinical urology at Columbia University.

Thayne Larson, MD, trained at the Mayo Clinic in Rochester, MN. He is now a consultant in urology at the Mayo Clinic in Scottsdale, AZ and assistant professor at the Mayo Clinic in Rochester. In his 9 years of practice he has treated hundreds of men with prostate cancer.

Gregory MacLennan, MD, is board certified in both urology and anatomic pathology. He practiced urologic surgery for 11 years in North Dakota and has treated many men with prostate cancer.

Isadore Rosenfeld, MD, is a best-selling author of 9 books including Dr. Rosenfelds' Guide to Alternative Medicine. He is a distinguished member of the faculty at New York Presbyterian Hospital/Weill Medical College of Cornell University and is an attending physician at New York Presbyterian Hospital and Memorial Sloan-Kettering Cancer Center.