PSA testing: Molecular technologies and men's experience of prostate cancer survivorship

Abstract

Although the value of the PSA (prostate-specific antigen) test as a cancer-screening instrument remains hotly contested, over the past two decades its usage has become commonplace. While most men diagnosed with prostate cancer will die with rather than of the disease, widespread PSA screening has led to an attendant increase in cancer diagnoses and the usage of aggressive treatments to ‘combat’ it. Despite the central (if controversial) role that PSA now plays in the diagnosis of prostate cancer and monitoring for recurrence, few studies have set out to explore its role in men's experiences of the disease. Drawing on ethnographic fieldwork at a prostate cancer support group in western Canada, we seek to delineate the meanings the PSA test holds for prostate cancer survivors. For many men in the study, their PSA levels were seen to provide an objective indicator of the presence or absence of cancer, with important implications for their subjective experience of cancer diagnosis and survivorship.

Keywords:

• cancer screening
• prostate cancer
• risk assessment
• perceived risk
• cancer survivorship

Notes

1. Recent research (e.g., Allagiu et al. 2009) has also begun to explore the association of high-grade prostate cancer with mutations in the BRCA1 and BCCA2 genes, which may ultimately prove valuable in helping to evaluate appropriate therapeutic options for men diagnosed with the disease.

2. Implicit recognition of this is evident in the medical joke that PSA actually stands for ‘patient-scaring antigen’ (see McLeod 2005, p. S29).

3. Although there is some evidence to suggest that the name used to describe this treatment impacts its acceptability to men, with ‘active surveillance’ viewed more positively than ‘watchful waiting’ (Donovan et al. 2003).

4. Historically, T1B cancer was only picked up incidentally as a result of resecting the prostate for other conditions such as benign prostate hyperplasia. However, with the advent of the PSA era, the incidence of such cancers picked up incidentally has decreased, in part because they are being detected through PSA screening (Jones et al. 2009). Indeed, the advent of the PSA era saw the introduction of a new category of T1 (non-palpable) cancers introduced: T1C, to deal with cancers discovered through such screening (Whittington and Vaughn 2006).

5. Because of the generally slow-growing nature of the disease, autopsy studies of men who died of causes other than prostate cancer found prostate cancer in 30% of men in their 50s, and 80% of men in their 70s (see Breslow et al. 2006).

6. It is interesting that the speaker used the term ‘proportion’ to describe a statistic approaching 50%. It seems likely that he was trying to temper his representation of overtreatment in light of the fact that virtually all of the men in the audience had chosen to treat their cancer aggressively. Indeed, at the end of the talk, few men in the audience seemed to seriously engage with the concept of prostate cancer overtreatment, and the fact that a number of them were dealing with iatrogenic side effects related to treatment for a disease that may not have affected them if left alone.

7. Much of the literature on PSA screening focuses on the need for ‘informed decision making’ amongst men seeking out the test. The finding that men still view the PSA test positively once they have been ‘informed’ of its limitations (Watson et al. 2006) can only be explained by recognising the broader cultural meanings and context of cancer.

8. It could be argued that PSA monitoring actually serves to reduce the uncertainty about disease recurrence because a continuing low PSA score reassures the prostate cancer survivor that the disease has not re-emerged. While that may be true for some survivors, our interest in this paper is the ways that PSA monitoring as a molecular technology may also serve to transform men's perceptions of the disease and their bodies.

9. Indeed, there was one man in the support group who refused treatment and refused to monitor his PSA levels after his diagnosis with prostate cancer. Other members spoke about him as an ‘enigma’. According to one man: ‘it's fine to decide against treatment but you need to be able to monitor how you are doing’. For these group members ongoing PSA testing was a critical component of ‘responsible’ cancer survivorship.