A prostate-specific antigen (PSA) test is a blood test that measures the amount of circulating PSA. PSA is a protein made by prostate cells. When the PSA is ‘high’, there is an increased likelihood that it is elevated because of the presence of prostate cancer. Other benign conditions ‑ like infection or benign growth of the gland – can also lead to an elevated PSA.

PSA tests in men with no other signs or symptoms can therefore help detect prostate cancer early. But the tests can also miss cancers (in males whose PSA levels aren’t high), give false positives (in males who have high PSA but no cancer) and cause “over-diagnosis” by detecting cancers that otherwise would never be found or ever put the man’s health at risk.

And so, this mix of benefits and risks has led to some mixed and consequently confusing messages about the use of the PSA test for prostate cancer screening.

In 2012, the US Preventative Services Task Force and the Canadian Task Force on Preventive Health Care (CTFPHC), both issued new guidelines against PSA Screening tests after two large studies suggested that there’s no survival advantage to having PSA screening tests over not undergoing screening. In contrast, a similar study in Europe found that there is a survival advantage in men who undergo PSA screening.

Earlier this year, the US task force who made the initial recommendation against PSA screening revisited their recommendations given the increasing evidence that there may in fact be a more significant survival difference in men that are screened versus those that are not. As a result, the US task force released the following statement: “We are softening our opposition to the PSA test”, and they now suggest every male discuss PSA screening with their physician.

So should you get a PSA screening test? As is usually the case with these kinds of questions, the answer is: that depends.

The problem isn’t the test itself, says Dr. Danny Vesprini, a radiation oncologist and researcher at Sunnybrook.

“We know that the test works in determining elevated PSA levels, which may be a sign of prostate cancer,” he said. “The problem isn’t the test, or the ‘overdiagnosis’ of early prostate cancers; it’s the ‘overtreatment’ of low-grade disease that can be found using this method of screening.”

That’s the peril of the PSA test – what if you get diagnosed with prostate cancer when really you have a very low-grade cancer that will really never go on to cause you any problems or risk your life, and then get treated aggressively for that cancer?

“This really should be a discussion about overtreatment, not about the efficacy of the PSA test,” Dr. Vesprini said. “We know Active Surveillance is an appropriate and effective way to manage low-grade prostate cancer in most men, so we need to educate people about that.”

Active Surveillance is an evidence-based management approach that aims to improve quality of life by reducing aggressive treatment, which can result in side effects including erectile dysfunction, as well as problems with urinary or bowel control.

Patients are carefully monitored on an ongoing basis. Those who are re-classified as ‘higher risk’ over time, based on rapid rise in PSA or grade progression on repeat biopsy, are offered intervention through surgery, radiation or hormonal therapy (or a combination of these treatment options).

“So, we should acknowledge the PSA screening tests will likely over-diagnose men but then we should use Active Surveillance rather than aggressive treatments for the men with low-grade cancer,” Dr. Vesprini said.

Dr. Laurence Klotz, urological oncologist at Sunnybrook, agrees.

“The risk of overtreatment associated with PSA testing can be largely addressed by adopting conservative management, or Active Surveillance, for those men with more favourable cancers,”  he said. “This has been demonstrated to be safe in large, long-term studies. The concept is that men found to have aggressive cancers benefit a great deal by early detection, which is associated with a high cure rate. The men found to have non-significant cancers, that don’t pose a threat, can avoid treatment. This combination approach is very effective.”

Males in the high-risk groups – those with a family history of prostate cancer, those of African / Caribbean descent, or males with a BRCA gene mutation – should definitely get PSA screening starting at age 40.

“The best thing every man can do is talk to your doctor about the pros and cons of you as an individual getting the PSA test,” Dr. Vesprini said. “What does it mean for you? What will it mean if you are diagnosed with a low-grade cancer? What are the implications of being diagnosed from a medical, psychological and/or social/economic point of view? Very importantly, what are your risk factors? In a nutshell, ask your doctor about the risks and benefits of the screening as it pertains to you and your value system. For many the risk of ‘overdiagnosis’ is worth it to ensure that they do not go on to develop more aggressive, life threatening disease.”

More resources:

Learn more about BRCA gene mutation.

Familial Prostate Cancer Clinic at Sunnybrook.

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Oh, the Pap test. ~cue crossed legs and sweaty palms~

But, the discomfort certainly doesn’t seem so bad when you consider a Pap screening test — where a doctor collects cells from the inner part of your cervix — is the only way to find early cell changes that might lead to cervical cancer.

To figure out why a timely Pap test is so important, I talked to Dr. Lisa Del Giudice, family physician on the Sunnybrook Academic Family Health Team and Regional Primary Care Lead, Toronto Central Regional Cancer Program.

What’s a Pap test looking for?
A Pap test is looking for abnormal cells — cancer or pre-cancer — in the cervix. Sometimes other gynecological cancers can be detected during a Pap test.

A Pap test isn’t the same as a test for sexually transmitted diseases (STDs).

“Sometimes an STD can be picked up on a Pap, but it is not really the appropriate way to test for STDs,” Dr. Del Giudice says. “The appropriate STD tests can be done at the same time if there is any concern in this regard.”

How can it help prevent cervical cancer?
In 2015, about 640 women were diagnosed with cervical cancer in Ontario and about 150 women died from the disease, according to Cancer Care Ontario. Cervical cancer is almost entirely preventable with regular screening, appropriate and timely follow-up of abnormal results.
“The Pap test can find the abnormal cells or high-risk human papillomavirus (HPV) early so that next steps can be taken or the patient can be screened more often,” Dr. Del Giudice says. (Some HPV can lead to the abnormal cell changes and cause cancer).

How often should I have it?
It is recommended that women aged 21 to 69 have a Pap test every three years if they are or have ever been sexually active. Sexually active doesn’t just mean sexual intercourse — oral and digital contact also count. Women who have sex with women should have regular Pap tests.

Research suggests that smoking puts you at higher risk for cervical cancer. If you smoke and are sexually active, be extra certain to book your Pap test every 3 years.

“If you’ve had a total hysterectomy (uterus and entire cervix removed) then you no longer need to undergo Pap screening. But, if your cervix was left partially intact you still do. Same if you’ve had your ovaries removed — you should still have regular Pap tests,” Dr. Del Giudice explains.

Who can do the Pap test?
A Pap test can be done at your family doctor’s office. If you don’t have a doctor, you can get a test done at a walk-in clinic or sexual health clinic.

What happens if the Pap test ‘finds something’?
If your doctors sees an abnormality (something that looks like it could be cancer or pre-cancerous cells), they may want to repeat the test, or do further testing to high-risk HPV and/or refer you to a gynecologist for a colposcopy (a test that takes a bigger sampling of your cervix to check for and to remove pre-cancerous or cancer cells.

Any tips for making it a little less uncomfortable?
If you’ve had a painful Pap test in the past, mention it to your doctor. All women are different – your cervix might tilt to the front or back or side. Ask your doctor to note any tilt in your file (so you both can avoid the whole poke-around-down-there-trying-to-find-the-right-of-way next time)

For post-menopausal women, talk to your doctor about possibly applying topical estrogen for one to two weeks before your Pap test.

You can take an Advil a half hour before the test. And try your very best to take a deep breath and relax. (Easier said than done, but try!)

If during the test you are in pain, ask your doctor if you can tip your pelvis up to reposition (by putting your hands under your bum).

I can’t remember if my last Pap was two years ago or three – but I think it’s definitely worth a call to my family doctor (or a look in my MyChart!) to see if it’s time to book one. I think I can stand a few moments of discomfort knowing it’s for a potential lifetime of better health.

The post Is it time for your Pap test? appeared first on Your Health Matters.

It’s not the happiest news. Experts published in the most recent edition of the Journal of the American Medical Association suggest cancer is poised to become the leading cause of death worldwide. That’s despite major strides forward in cancer treatment and prevention.

That said, there is a lot you can do as an individual to reduce your risk. That includes things like healthy eating, staying active and being screened, when indicated. Cancer screening is something most of us will experience, and it simply means you’re being checked. If something suspicious is found, your doctor will likely order a biopsy, a sample of tissue taken for closer examination. And while you wait at home, worrying and wondering, what happens behind the scenes is something you simply have to see.

At Sunnybrook Health Sciences Centre, thousands of such tissue samples are sent to our state-of-the-art pathology lab every year. When I walked in for the first time, I was amazed by the process. It’s something patients usually never get to see. But if you click on my video link, I’ll walk you through every step and introduce you to our Chief of the Department of Anatomic Pathology, Dr. Mahmoud Khalifa.

Step one is receiving the sample, processing it into the system with a unique patient code number. A technician then sits at a table, cutting it into smaller pieces that will fit into a special color-coded cassette. The one-inch cassette is porous to allow different chemical solutions to pass through, the purpose being to dry out the tissue during overnight processing.

Once that’s complete, the sample moves on to a so-called embedding station, where it’s removed from the cassette and covered in liquid wax. The wax is then allowed to harden on a small black cold plate. You might wonder, why wax? The reason is that the wax suspends the tissue sample, allowing for the next step in this intricate process: cutting. Picture the meat slicer you find at the grocery store. Well, that’s what happens to the tissue suspended in wax: it’s sliced like salami so different depths of the sample can be examined. Then, these thin sheets of wax are placed to float in a small water bath, where the technologist can literally scoop up what they need onto a glass slide. These glass slides are labeled with the patient’s specific code to eliminate any mix-ups.

Once the section is on the slide, it needs to be stained so the pathologist can do their job. Pathologists are physicians who have specialized training and examine tissue, blood or other body fluids to help diagnose diseases, blood disorders and infections. The staining process takes about one hour, and the pink color allows for the cells to be viewed under the microscope to check for cancer. Sunnybrook has one of the most up-to-date staining systems in the country. By laying the glass slides flat, it virtually eliminates the risk that cells from one slide will contaminate another. In short, cutting the chance of receiving a false-positive result.

After staining, another technologist matches the slides with a pathology report before they are sent on. Sunnybrook is also a leader here, having teams of pathologists who specialize in each type of cancer. And that’s an added benefit to patients, especially in more complex cases.

Our hospital has one of the most robust quality assurance programs in Canada. And the bottom line for patients is simple: when they get a result, they can rest assured that every step has been taken to make sure it’s accurate.

I hope you’ll check out my video. It’s a story you won’t see anywhere else.

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