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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:
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.
Return to Prostate Smart Screening for Cancer home page.
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:
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.
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:
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:
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:
"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:
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.
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:
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:
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:
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:
"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:
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.
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:
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:
Probability of Prostate Cancer Diagnosis with Screening
For the example man, the probability a biopsy will lead to a prostate cancer diagnosis is:
"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:
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,
Divergent Risk Preferences for Biopsy Timing
Different men seem to have highly divergent assessments of the risk tradeoffs. For example:
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.
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:
> Premature biopsy, diagnosis, treatment and side effects:
Analysis is needed to create the best personal screening strategy for you because:
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.
Return to Prostate Smart Screening for Cancer home page.