For decades, the Prostate Specific Antigen, or PSA test, has been the “red-headed step child” of preventive medicine. Any opportunity to denigrate it or deny its benefit or utility is fully taken advantage of. The United States Preventive Services Task Force (the USPSTF), the American Urological Association (AUA), and the American Cancer Society (ACS) all have different opinions and different stances on the subject, while the American people, primarily men, have their opinion as well.
The public perception of PSA testing is you should have one done every year after you reach the age of 50, and if it’s abnormal, you need to be concerned. You need to see a doctor, have a digital rectal exam, and have an ultrasound or MRI of the prostate looking for evidence of cancer that can be biopsied. The public has no knowledge of all the controversy swirling around the PSA and how it can lead to surgeries that may or may not be necessary leaving the patient incontinent and impotent. Regular folks are just concerned about having prostate cancer and what they can do to keep from dying from it. Their concept is that the PSA is something they can do to detect cancer before it’s too late.
People (physicians, clinical researchers) who study the pro’s and con’s of PSA testing see the subject very differently, however. Last Fall, a study called the European Randomized Study of Screening for Prostate Cancer reported that after 23 years of annual PSA testing, the men who were tested yearly were 13% less likely to die from prostate cancer than those men who were not tested. This later prompted the UK National Screening Committee, like our USPSTF, to recommend against routine PSA screening.
To better illustrate this, if 1000 men in their 50’s have a PSA, 100 will have a positive test. Thirty-four of those will have a biopsy based on a positive prostate MRI. 28 of the 34 will be diagnosed with prostate CA, and only 2 will die from the disease. There will be 20 men who are overdiagnosed and have unnecessary surgery or radiation, all prompted by aggressive PSA testing. Over treatment is common in the US because of the public perception of PSA testing.
If PSA testing were 100% effective and prevented all prostate cancer deaths, those men in the untested group who got prostate cancer would be 6 times more likely to die from some other cause than prostate cancer. That’s the concern with PSA testing—even if positive, and the patient is diagnosed with PCA on biopsy, death from prostate cancer is not a certainty. It’s a slow-growing disease that is often outpaced in severity by cardiopulmonary conditions which are the terminal event in their lives.
So, the experts are in the camp who don’t recommend routine screening with a PSA. They’re ok with a PSA every now and then, but not annually unless specific circumstances demand it. I say, what’s the big deal. If Mr. Smith wants a PSA, he should have one. It’s what’s done with the results that makes the difference in outcome. That’s where the physician has to be conservative and carefully weigh all options without preconceived bias.
Reference: Lin KW. Routine PSA Screening May Do More Harm Than Good. medscape.com 2025 December 23.
