Discussing the Decision to Screen for Prostate Cancer

Prostate cancer screening with PSA test should be discussed between doctor and patient

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

(RxWiki News) One test for prostate cancer — called PSA screening — has been controversial since it was first introduced. While the debate on prostate cancer screening continues, a recent review offers some insight on making the decision to get screened.

This new clinical review has reiterated that while the PSA (prostate-specific antigen) test is still recommended for men starting at around age 50, perhaps it shouldn't be.

Based on their research, the authors of this review recommended that men and their doctors should discuss the test and let the informed patient decide for himself whether to get screened for prostate cancer.

"Talk to your doctor about the pros and cons of testing for prostate cancer."

Julia Hayes, MD, and Michael Barry, MD, of Harvard Medical School in Boston, conducted this review of the current evidence on PSA testing.

These researchers did an online review of Medline and Embase from January 1, 2010 until April 3, 2013. 

Drs. Hayes and Barry found 339 articles and two large studies that addressed the evidence for and against PSA testing: The Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC).

PSA testing is a blood test that measures levels of the protein produced by the prostate gland. High levels are associated with cancer of the prostate. This test has been controversial since its inception for a variety of reasons, including that it has had high rates of "false-positive" results — meaning that the results indicate that a man may have cancer when in fact he does not. There also has been debate about whether screening may lead to unnecessary treatment, as many men live with prostate cancer rather than ever dying from it.

Most men have a PSA level of 4 nanograms/ml of blood, which is considered normal.

The PLCO trial showed that in 13 years of following men who had PSA testing, those men were no more likely to die of prostate cancer than men who had not been screened.

The ERSPC found that after 11 years of follow-up of men 55-69 years of age, for every 1,000 men screened, there was one fewer death due to prostate cancer.

While some lives may be saved by testing, when men are treated with surgery or radiation, as they are in the United States, there are often substantial adverse effects, the authors noted.

The authors noted that some of the studies suggested PSA screening and treatment of high levels could be more harmful than beneficial, but that following the men for even longer might change those findings. Nowadays, men live much longer than they used to. Men who are 50, who are screened and may have a high PSA level can now live an average of 30 years longer. These men may want to carefully consider the possible risks and benefits if their physician recommends further treatment, the authors wrote.

Testing is usually done annually in men aged 55 to 69. The risk for prostate cancer increases with age.

The risk for prostate cancer is also higher among black men and men with a first-degree relative with prostate cancer before the age of 70. For these men, screening typically begins at age 45 to 50 years.

The authors of this review suggested that physicians discuss screening with men aged 55 to 69 years, who are not high-risk, making them aware of the risk and benefits of screening and follow-up for high PSA levels. They should discuss the possibility of false-positive results, risks of biopsy, and potential diagnosis with prostate cancer unnecessarily leading to treatments with considerable adverse effects.

They also suggested that annual screening may be too frequent, and that a test every two years or so may be a better recommendation for the average patient.

Drs. Hayes and Barry concluded that “a reasonable strategy is to inform and involve men not only in the decision whether to screen but also in any subsequent decisions about biopsy and treatment.”

Their study was published March 19 in the Journal of the Medical Association (JAMA).

Dr. Hayes reported receiving royalties from UpToDate.

Dr. Barry reported receiving salary support as president of the Foundation for Informed Medical Decision Making.

Review Date: 
March 17, 2014
Last Updated:
March 19, 2014