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    PSA testing: It's not your choice, it's the patient’s

    Henry Rosevear, MDDr. RosevearI’ve been a urologist long enough that a few things have started to bother me. One of them is the way primary care doctors are using the PSA test. I realize that for most urologists reading this blog, I will be preaching to the choir, but my hope is that primary care providers will take a few minutes to consider my message as well.

    I have been practicing now for about 18 months, and I recently diagnosed my sixth patient under 70 with metastatic prostate cancer. Two of them are in their fifties. This is not a patient population that I encountered in residency and given their diagnosis and prognosis, it is a group I keep a close eye on.

    All six were some version of the same story, including a multi-year history of slowly worsening lower urinary tract symptoms that have been refractory to a variety of oral medicines. Eventually, the symptoms became unbearable and they were sent to me for further treatment. None had had either a rectal exam or a PSA in years. All had been told that rectal exams and PSA were useless, and most could even describe the U.S. Preventive Services Task Force (USPSTF) recommendations on PSA screening. Not surprisingly, all were initially surprised that prostate cancer was even on my differential and all were shocked with the final diagnosis. One of them is actively seeking legal advice.

    ALSO SEE: Drug reps: Understanding the hand that feeds you

    This raised two critical points in my mind: first, the difference between screening someone for prostate cancer with PSA and diagnosing someone with prostate cancer; and second, the proper use of PSA as a screening tool.

    Regarding the first point, I believe that once the USPSTF gave PSA screening a “D” grade, primary care providers simply stopped using it. (I could find no paper or evidence to support this belief, though in conversation with numerous primary care providers, I think this is true.) That is a mistake. Men with risk factors for prostate cancer who are exhibiting potential signs of the disease should have their PSAs checked not to “screen” them but rather to “diagnosis” them. I am unsure medicolegally how you can justify not checking a PSA in a man with a family history of prostate cancer and worsening obstructive voiding symptoms despite oral anti-BPH treatment.

    Next: PSA as a screening tool

    More from Dr. Rosevear

    Falls in the elderly: How urologists can save a life

    Attention thought leaders: How is new-onset flank pain evaluated?

    Online reputation management: Lessons from ‘Googling’ myself

    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.


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