Prostate screening and the PSA test

Screening is not the same thing as diagnosing a symptom

Screening means looking for cancer in someone who has no symptoms of that cancer. If you already have blood in the urine, pain, or trouble passing urine, the tests a clinician orders are part of an evaluation, not a screening campaign. The National Cancer Institute’s patient summary makes that distinction and says there is no standard or routine screening test for prostate cancer.

Two tests are often discussed anyway. A PSA blood test measures a protein made mainly by the prostate. A digital rectal exam lets a clinician feel the gland. PSA can be high because of cancer, enlargement, or inflammation. It can also be normal when cancer is present. The National Cancer Institute says a PSA test or a rectal exam may find cancer early, and that it is not clear whether that early finding lowers the chance of dying from prostate cancer.

What the 2018 USPSTF statement actually says

The U.S. Preventive Services Task Force statement dated May 8, 2018, is more specific, and it is not a rule for every adult man:

• For men ages 55 to 69, the decision to have periodic PSA screening should be an individual one. The Task Force gave that choice a C grade. Men should have a chance to discuss benefits and harms and to apply their own values. Clinicians should not screen men who do not express a preference for screening.
• For men 70 and older, the Task Force recommends against PSA screening. That is a D grade.

The same statement says screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. From the trials it reviewed, PSA screening programs in men ages 55 to 69 may prevent about 1.3 deaths from prostate cancer over about 13 years per 1,000 men screened, and about 3 cases of metastatic cancer per 1,000 men. The trials did not show a reduction in deaths from all causes.

When this page was prepared, the Task Force website said the topic was being updated and pointed readers to the latest documents. Use the current page before you treat the 2018 grades as the last word. Other groups, including urology organizations, have published their own discussions of who might consider an earlier conversation. This site does not pick a winner among those documents. It refuses the older idea that every man should start the same tests at the same birthday.

Harms that belong in the same conversation

The Task Force lists harms that arrive earlier and more often than the deaths that screening might avert:

• False-positive results. In one major trial of screening every 2 to 4 years, more than 15 percent of men had at least one false-positive result over 10 years. Across reporting sites, about one in six men screened at least once had one or more false positives.
• Biopsy. Complications include pain, blood in the semen, and infection. About 1 percent of biopsies led to a complication that required a hospital stay in the evidence the Task Force summarized.
• Overdiagnosis. Follow-up of large trials suggested that 20 to 50 percent of men diagnosed through screening may have a cancer that would never have caused symptoms. Treating those cancers causes harm without a benefit.
• Treatment effects. About 1 in 5 men who have the prostate removed develop long-term incontinence that requires pads, and about 2 in 3 develop long-term erectile dysfunction. More than half of men who have radiation have long-term erectile dysfunction, and up to 1 in 6 have lasting bowel symptoms.

False-negative results matter too. A reassuring number can delay care if symptoms appear later.

Risk changes the discussion, and it does not erase the harms

Older age, Black race, and a father, brother, or son with prostate cancer are the strongest risk factors the Task Force names. Black men have a higher chance of dying of prostate cancer. The Task Force also said the evidence was inadequate to know whether the benefits of screening differ for Black men and men with a family history, or whether starting before age 55 helps those groups. A higher risk is a reason for a more careful conversation. It is not, by itself, a reason for this website to assign you a start date.

The National Cancer Institute also notes that some studies found a higher risk of death from cardiovascular disease or suicide in the weeks and months after a new prostate-cancer diagnosis. Anxiety is part of the harm of looking, not a footnote.

An old consent form is not reused here

An earlier version of this domain published a screening consent form with a different set of numbers, including a claim that one man in a thousand would avoid a prostate-cancer death over 10 years. That form is not republished. Estimates depend on the trial, the length of follow-up, and the age group. The figures in this article are the ones printed in the 2018 Task Force statement, and they should be rechecked when that statement is replaced.