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Should I PSA Test for Prostate Cancer? | Yes as Part of a Smart Screening Strategy

For many men, the answer can be Yes - PSA testing for prostate cancer makes sense as part of a smart screening strategy but probably should be No as part of an ordinary PSA screening strategy. Your screening strategy decision is crucial.

PSA is the prostate-specific antigen blood test measured in ng/mL that reflects prostate conditions.

PSA testing for prostate cancer is highly controversial because its use may save too few lives to justify the harms of unwarranted biopsies with risk of deadly sepsis, over-diagnosis and treatment with risks of impotence and incontinence. See our PSA Debate page in a new window with links to content on both sides of the issue - sometimes with strong emotions. However, much of this content does not provide enough analysis to help you make a highly informed decision about PSA testing for you.

Based on analysis and work with many men, we believe that the answer to the PSA testing question depends crucially on your prostate cancer screening strategy, as well as your life expectancy, age, race and risk preferences.

No - Do Not PSA Test as Part of an Ordinary PSA Screening Strategy for Prostate Cancer

For many men, the answer should be No PSA testing if they are limited to an ordinary PSA screening strategy for prostate cancer. An ordinary PSA screening strategy relies on PSA testing to trigger a prostate biopsy when a man's PSA level reaches a modest threshold level. For example, a PSA threshold for biopsy of about 3.0 was used in the definitive European screening study described in the Evidence section below. For our typical example man age 64 with 20-year life expectancy and no risk factors, we will show in three Sections:

1. The low loss of life expectancy from prostate cancer for no PSA testing.
2. The small life expectancy benefit of an ordinary screening strategy compared to the harms.
3. The strongly premature biopsy often triggered by an ordinary screening strategy.

An ordinary PSA screening strategy is incomplete because it does not use valuable new technology, does not focus on timing decisions and makes it difficult to incorporate your risk preferences into timing decisions, such as biopsy now or later.

Yes - PSA Test as Part of a Smart Screening Strategy for Prostate Cancer

For many men, the answer can be Yes to PSA testing as part of a smart screening strategy. For this strategy, PSA provides valuable early warning that triggers sequential use of new technologies, including enhanced blood tests, prostate cancer risk calculators, imaging using ultrasound and MRI, and MRI targeted fusion biopsies rather than conventional pattern biopsies. The results of new technologies provide valuable information for analysis of timing decisions that allows consideration of your risk preferences to avoid a premature biopsy.

Smart screening for prostate cancer is designed to help you balance the risks of premature biopsy with the risks of late diagnosis. In Section 4 below, we introduce smart screening that incorporates PSA testing. Using smart screening analysis, men can insist on strong evidence of increasing prostate cancer risk in order to avoid the risk of premature biopsy. Your biopsy timing should reflect your risk preferences, which may differ from other men and differ from your physicians.

See our PSA Debate page in a new window with links to content on both sides of the issue.

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Return to Prostate Smart Screening for Cancer home page.

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Example Man for Analysis and Discussion

Your prostate cancer screening strategy should depend on analysis. Your analysis depends on your life expectancy and age. Life expectancy determines your exposure to prostate cancer risk and is a function of your age and health. The longer your life expectancy the greater your exposure to prostate cancer risk. For this analysis and discussion we will use a typical example man:

• Age 64
• 20 year life expectancy, which is average for age 64 US men.

For this example man, we will assume no elevated risk factors. Note that African American men have roughly double the risk.
Where needed, we will assume a 3.0 PSA test level, which reflects the ordinary PSA threshold for biopsy used by the definitive European study of screening.

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Evidence from the European Randomized Study of Screening for Prostate Cancer

The European Randomized Study of Screening for Prostate Cancer (ERSPC) is the definitive study of prostate cancer screening with over 180,000 men considered for 13 years in the most recent results article in the Lancet. Articles about the study have been featured in the prestigious New England Journal of Medicine and other prominent medical journals. It was the study most heavily relied on by the US Preventative Services Task Force review of prostate cancer screening when it concluded that the benefits of screening often do not justify the harms.

The ERSPC studied the ordinary prostate cancer cancer screening strategy using a PSA threshold of about 3.0 to trigger a biopsy. We will use the most recently published ERSPC results in our analysis in Sections 1 and 2 below.

The ERSPC found for men with a median age at randomization of 60.2 years:

• 27% reduction in prostate cancer death from screening.
• 1 prostate cancer death averted for 781 men invited for screening (0.13%).
• 1 prostate cancer death averted for 27 men diagnosed (3.7%).

However, overall (all-cause) mortality was not statistically different for screened and not screened men. The small proportion of prostate cancer deaths could explain this result.

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1. No PSA Testing Leads to Minor Risk of Loss of Life Expectancy from Prostate Cancer

In the US, about 1 man in 39 will die of prostate cancer, or 2.6%, according to American Cancer Society statistics. This seems like a low number, which raises questions about how worried you should be about this risk if you have not been diagnosed with prostate cancer. To help answer that question, we will turn to the ERSPC study and examine the risks for men not screened for prostate cancer.

Overall Loss of Life Expectancy without Screening

For not screened men, the overall risk of prostate cancer death was only 0.8% after 13 years, which seems very low. However, most men find processing small risks of death challenging. We have learned that many men find it easier to process the corresponding loss of life expectancy from prostate cancer risk. For our example age 64 man with 20-year life expectancy, the corresponding loss of life expectancy from prostate cancer is:

• 0.18 years (2.2 months) overall loss of life expectancy from prostate cancer risk for unscreened men

This means that without screening a typical 64-year old man will lose only 2.2 months of life expectancy from prostate cancer. Moreover, these average 2.2 months of life are lost at the end when many men expect a low quality of life (age 84 for the example).

Probability of Prostate Cancer Diagnosis without Screening

​The overall loss of life expectancy for unscreened men (2.2 months) is so low, in part, because the probability of prostate cancer diagnosis without screening is so low:

• 6.8% probability of diagnosis of prostate cancer without screening.

This low probability means that 93.2% of men won't be diagnosed and won't have to worry greatly about prostate cancer. The question then becomes: What is the loss of life expectancy for the few not screened men later diagnosed with prostate cancer?

"If Cancer" Loss of Life Expectancy if Prostate Cancer Is Diagnosed without Screening

For not screened men later diagnosed with prostate cancer, the "If Cancer" risk of prostate cancer death was nearly 10% after 13 years. A 10% risk of death 13 years after diagnosis is concerning but low compared with the most deadly other cancers, such as pancreatic. The most deadly other cancers kill most men a few years after diagnosis. For our example man with 20-year life expectancy, the corresponding loss of life expectancy is:

• 2.6 years "If Cancer" loss of life expectancy from prostate cancer risk for unscreened men later diagnosed with cancer.

This means that without screening only 6.8% of 64-year old men will lose 2.6 years of life expectancy from prostate cancer. Again, these average years of life are lost at the end when many men expect a low quality of life (age 84 for the example).

Many men consider these risks low compared to the potential harms and are reluctant to consider PSA screening for prostate cancer. The next section shifts the focus to the potential benefits and harms of PSA testing with an ordinary biopsy threshold.

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2. PSA Testing with Ordinary Biopsy Threshold Saves Lives at High Human Cost

The ERSPC studied the ordinary prostate cancer screening strategy using a PSA threshold of about 3.0 to trigger a biopsy. We examine the net benefit of prostate cancer screening in terms of reduction in prostate cancer death.

Overall Increase in Life Expectancy from Screening

The overall reduction of prostate cancer death risk from screening was only 0.2% after 13 years, which seems very low. Screening reduced the death risk after 13 years from 0.8% shown above for no screening to 0.6% for screening. For our example man with 20-year life expectancy, the corresponding increase in life expectancy from screening is:

• 0.05 years (2.6 weeks) overall increase in life expectancy from prostate cancer screening.

This means that for a typical 64-year old man screening increases life expectancy by only 2.6 weeks. As above, these average 2.6 weeks of life are gained at the end when many men expect a low quality of life (age 84 for the example). Many men find that 2.6 weeks of additional life expectancy are not worth the hassle and risks of ordinary prostate cancer screening. However, ordinary prostate cancer screening may look better as a form of "insurance" if we look at biopsies, which are the step in the screening process that triggers serious consequences.

Probability of Biopsy for Screened Men

Ordinary prostate cancer screening produces many biopsies with the risk of deadly sepsis and potential for over-diagnosis, treatment and side effects that include impotence and incontinence. For the ERSPC screened group of men:

• 27.7% of men were biopsied in the screening group.

Many men are concerned that starting ordinary prostate cancer screening will lead to a greater than 1 in 4 chance of a biopsy (27.7%) with its consequences. Let's take a look at the life saving benefits.

Increase in Life Expectancy for Screened Men Who Are Biopsied 

The "If Biopsy" reduction of prostate cancer death risk was only 0.72% after 13 years, which seems low. For our example man with 20-year life expectancy, the corresponding screening increase in life expectancy from screening is:

• 0.17 years (2.0 months) increase in life expectancy for men who were biopsied in the screening group.

This means that for a typical 64-year old man a biopsy after screening increases life expectancy by only 2.0 months. As above, these average 2.0 months of life are gained at the end when many men expect a low quality of life (age 84 for the example). Many men find 2.0 months of additional life expectancy from a biopsy are not worth the hassle, risk of deadly sepsis and potential for over-diagnosis, treatment and side effects that include impotence and incontinence. However, a biopsy after ordinary prostate cancer screening may look better as a form of "insurance" if we look at diagnosis, which is the major consequence of a biopsy triggered by an elevated screening PSA.

Probability of Prostate Cancer Diagnosis with Screening

Ordinary prostate cancer screening produces many diagnoses with the risk of over-diagnosis, treatment and side effects that include impotence and incontinence. For the ERSPC screened group of men:

• 10.2% probability of diagnosis of prostate cancer with screening.

Many men are concerned that starting ordinary prostate cancer screening will lead to a greater than 1 in 10 chance of a diagnosis (10.2%) and its consequences. Let's take a look at the benefits if prostate cancer is diagnosed.

"If Cancer" Increase in Life Expectancy if Prostate Cancer Is Diagnosed with Screening

The "If Cancer" is diagnosed reduction of prostate cancer death risk was only 1.97% after 13 years, which seems low. For our example man with 20-year life expectancy, the corresponding screening increase in life expectancy is:

• 0.46 years (5.5 months) increase in life expectancy for men who were diagnosed in the screening group.

This means that for a typical 64-year old man a diagnosis and treatment after screening increases life expectancy by only 5.5 months. As above, these average 5.5 months of life are gained at the end when many men expect a low quality of life (age 84 for the example). Many men find 5.5 months of additional life expectancy are not worth the hassle, risk of over-diagnosis, treatment and side effects that include impotence and incontinence.

Many Men Reject Ordinary Prostate Cancer Screening Because of Low Life Expectancy Benefits

After considering this analysis, many men might reject ordinary prostate cancer screening studied by the ERSPC because the increase in life expectancy benefits are too small compared to the hassle and potential harms: risk of deadly sepsis and potential for over-diagnosis, treatment and side effects that include impotence and incontinence.

Ordinary prostate cancer screening saves lives but at a human cost that is too great for many men. Major improvements are needed to justify PSA-based prostate cancer screening. In Section 4, and throughout this website, we suggest that smart screening is available today using existing technology and analysis and can greatly reduce the harms while still saving lives.

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3. PSA Testing with Ordinary Biopsy Threshold Leads to Premature Biopsy

Ordinary prostate cancer screening with a 3.0 PSA biopsy threshold looks even less appealing when we examine the premature biopsy problem. Consider our example man age 64 with 20-years life expectancy, no special risk factors and a 3.0 PSA that is growing slowly to suggest slow growth in prostate cancer risk (20% per year). You can learn more about our analysis on our Biopsy Delay page and our Sample Report page, which open in new windows.

Biopsy Now or Delay 1-Year

A biopsy of the prostate is the pivotal cancer screening step.  It is needed to diagnose cancer that can lead to treatment with possible life saving benefits. However, most prostate cancers are not very life threatening with little or no benefit of treatment.  

A biopsy also has negative consequences, including:

1. Discomfort and the risk of potentially life-threatening sepsis (infection).
2. Emotional costs that accompany a possible diagnosis of cancer.
3. Potential side effects of treatment if warranted, such as impotence and incontinence.

​Each screening action can be taken now (or soon) or delayed. We consider a 1-year delay that is convenient for analysis and discussion. ​

Ultimately, a 1-year delay in screening actions delays a subsequent biopsy, possible diagnosis and treatment if warranted. The consequence is a reduction in life expectancy from a delay in treatment that may allow prostate cancer to progress. The benefit of delay is deferral of the negative consequences of a biopsy, possible diagnosis and treatment. ​

Overall Reduction in Life Expectancy from a 1-Year Delay in Biopsy

For the example man, a 1-year delay can lead to:

• 0.01 year (4 day) reduction in life expectancy from a 1-year delay.

​This reduction in life expectancy from delay is insignificant for this example man. However, a 1-year biopsy delay may look worse if we examine the potential for diagnosis of prostate cancer.

Probability of Prostate Cancer Diagnosis with Screening

For the example man, the probability a biopsy will lead to a prostate cancer diagnosis is:

• 21% probability a biopsy will find cancer.

Many men are concerned that a biopsy will lead to a greater than 1 in 5 chance of a diagnosis (21%) and its consequences without enough life saving benefits. Let's take a look at the consequences of a 1-year delay "If Cancer" is diagnosed.

"If Cancer" Reduction in Life Expectancy from a 1-Year Delay in Biopsy

If the example man knew that he would be diagnosed with prostate cancer, a 1-year biopsy delay can lead to:

• 0.07 year (3.6 weeks) "If Cancer" reduction in life expectancy from a 1-year delay.

​This means that for a typical 64-year old man a 1-year delay in biopsy, diagnosis and treatment after screening reduces life expectancy by 3.6-weeks. As above, this 3.6-week reduction in life occurs at the end when many men expect a low quality of life (age 84 for the example). Many men find that a 3.6-week reduction in life expectancy is not worth the hassle, risk of over-diagnosis, treatment and side effects that include impotence and incontinence.

Many Men Would Delay a Biopsy Until the "If Cancer" Risk Reaches Much Higher Levels

​Your biopsy timing decision should be based on your assessment of risks. The decision is very personal with wide variation among men (and their spouses) and among physicians with potentially large differences between men and their physicians. For example,

• Some urologists might be more concerned about the dangers of cancer while
• Some primary care physicians might be more concerned about the side effects of biopsy, emotional costs of diagnosis and side effects of treatment.

First, we will take a look at divergent risk assessments and then will put them in the context of competing health actions.

Divergent Risk Preferences for Biopsy Timing

​Different men seem to have highly divergent assessments of the risk tradeoffs. For example:

• Many men we have worked with would wait for a 1.0-year “If-Cancer” reduction in life expectancy: 
  • They place a high value on their currently high quality of life that would be disrupted by diagnosis and treatment if warranted and 
  • Are much less concerned about losing life expectancy toward the end of life when they expect their quality of life may be low.  
• Other men might only wait for a 0.25-year “If-Cancer” reduction in life expectancy:
  • They are less concerned about disruption of their current quality of life from diagnosis and treatment if warranted and 
  • Are more concerned about losing life expectancy, perhaps because they want to see their grandchildren grow up or live as long-as their spouse.
• Few men we know would choose a biopsy now to avoid the 0.07 year "If Cancer" reduction in life expectancy from delay for this example man using an ordinary screening strategy with 3.0 PSA biopsy threshold.

Life Expectancy Reductions in Context of Other Health Actions

​Let’s put these life expectancy reductions in context. There are many things that you can do this year to feel better now and live longer, including: improved diet, exercise, and stress reduction; healthier habits (stop if a smoker); and medical evaluation and possible changes of medication - with your heart near the top of the list.

These health actions can add 1, 2, 3 or more years to your life expectancy as well as help make you feel better now.  A biopsy now with a possible diagnosis with its emotional costs and treatment if warranted with potential side effects could make you feel worse in the near-term to avoid a reduction in life expectancy from a 1-year delay. ​

Ordinary Prostate Cancer Screening Leads to Premature Biopsy for Many Men

For many men, a premature biopsy is the likely result of ordinary screening with a typical 3.0 PSA threshold for biopsy. For these men, the harms of screening exceed the small life saving benefits.

Therefore, prostate cancer screening needs to be improved dramatically to be justified for many men. Crudely, PSA thresholds could be increased substantially to reflect your risk preferences.

Alternatively, you could choose a smart screening strategy that incorporates all the best screening technology and analysis and reflects your risk preferences. We introduce smart screening for prostate cancer in the next section.

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4. Develop Your Prostate Smart Screening Strategy for Cancer

We have developed our Prostate Smart screening strategy for cancer to solve the problems of ordinary prostate cancer screening. It is - 

For men who want to lead a collaborative team effort rather than be a passive patient.

Prostate Smart analysis helps you create your strategy with your collaborative team of physicians and confidants to minimize your risks of:

> Regrettably late diagnosis of deadly cancer:

• Late diagnosis and treatment can substantially reduce your life expectancy:
  • Serious problem for men who avoid PSA testing.
  • Minimal problem with screening when many men overestimate the low risk.​

> Premature biopsy, diagnosis, treatment and side effects:

• Premature biopsy, diagnosis and treatment can lead to impotence and/or incontinence with potentially life-threatening sepsis from a biopsy triggered by elevated PSA:
  • Potential problem for men who avoid new technology and rush to biopsy with incomplete screening.
  • Serious problem for men who would prefer to delay their biopsy if they understood the risk tradeoffs, including possible low consequences of delay.

Analysis is needed to create the best personal screening strategy for you because:

• There are many factors to consider
• Men differ greatly in terms of their:
  • Data, including elevated PSA levels and prostate volume
  • Risk preferences that vary dramatically among men and physicians.

​We analyze published studies and present the implications for personal decisions. Studies are from: Mayo Clinic, Cleveland Clinic, Johns Hopkins, Memorial Sloan Kettering, NIH, NYU, UCLA, UC London, Yale and more.

Learn more about PSA-Based Prostate Smart Screening Strategy Analysis in a new window.

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Introduction to Prostate Smart Cancer Screening Strategy Analysis

Your personal smart screening strategy for prostate cancer will minimize your risks of:

• Regrettably late diagnosis of deadly cancer.
• Premature biopsy with sepsis risk, possible diagnosis, treatment and side effects, including impotence and incontinence.

Analysis is needed to create the best personal screening strategy for you because there are many factors to consider and men differ.

Prostate Smart cancer screening strategy analysis is introduced in seven sections:

1. Understand your "Underlying" "True" elevated or high PSA.
2. Take informative screening actions using new technology after elevated or high PSA.
3. Estimate your elevated or high PSA cancer risk using free risk calculators.
4. Translate your prostate cancer risk into potential loss of life expectancy.
5. Analyze your elevated or high PSA trend to inform growth rate of cancer risk.
6. Estimate your growth rate of cancer risk to inform delay decision.
7. ​Consider your potential loss of life expectancy from delay of premature biopsy.

See our Introduction to Prostate Smart Cancer Screening Strategy Analysis page that opens in a new window.

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Highlights of Prostate Smart Cancer Screening Strategy Analysis

Some very brief highlights may interest you in learning more about Prostate Smart Screening Strategy Analysis:

1. Understand Your "Underlying" "True" Elevated or High PSA

Your "Underlying" "True" elevated or high PSA is the value that your physicians should use to assess your risk with the help of prostate cancer risk calculators or rules of thumb. Adjust for WHO calibration and BPH treatment. For an elevated or high PSA, consider possible temporary infection, inflammation and prostate aggravation rather than prostate cancer as the cause.

2. ​Take Informative Screening Actions Using New Technology after Elevated or High PSA

New technology can greatly improve prostate cancer screening effectiveness compared to PSA alone. Use both cancer risk calculator technology and new cancer screening technology, including enhanced tests (Free PSA, PHI, 4Kscore, PCA3), ultrasound imaging, MR imaging and targeted biopsies.

​3. Estimate Your Elevated or High PSA Cancer Risk Using Free Risk Calculators

Prostate cancer risk calculators consider many variables and screen significantly more effectively than PSA alone.

For example using the ERSPC Risk Calculator, we focus on the Prostate Health Index (PHI) and prostate volume for men with no other risk factors. For an elevated PSA 3.0, the graph on the right plots the probability significant prostate cancer will be found by biopsy as a function of PHI for three prostate volumes estimated by digital rectal exam (DRE): small (25cc), medium (40cc) and large (60cc).

Notice that the probabilities are much higher for a small prostate (the top red curve) than for a large prostate (the bottom blue curve). The probability of cancer is lower for large prostates because they tend to produce more PSA that "explains" elevated levels of PSA.

Click to enlarge.

4. Translate Your Prostate Cancer Risk into Potential Loss of Life Expectancy

Many men find it helpful to translate risk calculator results into potential loss of life expectancy that is easier to understand and use for decision making. Worrisome probabilities from risk calculators often imply very little loss of life expectancy.

5. ​Analyze Your Elevated or High PSA Trend to Inform Growth Rate of Cancer Risk

PSA trend analysis is a rigorous way of analyzing periodic (or annual) PSA tests to extract the most information:

• Provide better early warning of rapid PSA growth to elevated levels that may indicate fast growing cancer
• Project past trends to help identify a surprise increase in PSA that may be caused by temporary prostatitis
• Estimate growth rate of PSA from cancer that may suggest the growth rate in cancer to use for analysis of biopsy delay

For example, very fast growing prostate cancers that produce fast growing PSA are relatively rare but very dangerous. PSA can grow to very high levels in a few years unless identified early. See graph at right.

In contrast, slow growing cancers that produce slow growing PSA may pose little or no threat with biopsy delay the best strategy.

Most elevated or high PSA is not caused by cancer. Prostatitis caused by infection and/or inflammation and prostate enlargement caused by benign prostatic hyperplasia (BPH) are more frequent causes of elevated or high PSA than prostate cancer. Moreover, these non-cancer conditions can cause PSA to vary up and down around an increasing PSA trend.

Click to enlarge.

6. Estimate Your Growth Rate of Cancer Risk to Inform Delay Decision

Most prostate cancers seem to be slow growing. A PSA trend provides the best estimate of prostate cancer growth because increasing PSA is associated with increasing risk of prostate cancer found by biopsy and increasing risk of death if found.

7. ​Consider Your Potential Loss of Life Expectancy from Delay of Premature Biopsy

Premature biopsy is the major risk of PSA testing!

• Biopsy for prostate cancer is the pivotal screening step with a choice between now and delay.
• Delay defers the risks of sepsis, emotional costs of possible diagnosis and potential over-treatment with risk of impotence and incontinence.
• Delay reduces life expectancy if cancer is present.  However, many men are surprised by the typically very small overall risk of delay.

Many men would choose biopsy delay because they are not very concerned about a small loss of life expectancy, often at the end of life when they they expect their quality of life to be low. They prefer delay to avoid a premature biopsy with sepsis risk, possible diagnosis, treatment and side effects, including impotence and incontinence.

See our Introduction to Prostate Smart Cancer Screening Strategy Analysis page that opens in a new window.