Should I, as a man, get tested for prostate cancer with the PSA test?

The PSA test reduces the chance of dying from prostate cancer, but the effect is modest. In the large European ERSPC study, with 23 years of follow-up, the screening group died from prostate cancer 13% less often than the unscreened group¹. In absolute numbers, that means: for every 456 men invited to screening, one death was prevented. Even a single PSA invitation led to a small reduction in prostate cancer mortality after 15 years, as shown by the British CAP study². On overall mortality, that is, from all causes combined, screening has no demonstrable effect.

There is a serious drawback on the other side: overdiagnosis. Screening produces 30% more prostate cancer diagnoses. A substantial proportion of these are slow-growing, low-grade tumours that would probably never have caused the man any trouble without screening. Yet those diagnoses lead to treatments, and treatments have side effects. Per 1,000 screened men, modelling estimates: 1 extra hospital admission due to blood poisoning after biopsy, 3 extra men with urinary incontinence, and 25 extra men with erectile dysfunction³. These are estimates, not directly measured figures, but they show that the path from a positive PSA to biopsy to treatment can cause real harm.

Whether screening is worthwhile for you depends heavily on your risk profile. Black men develop prostate cancer almost twice as often as white men (173 versus 97 cases per 100,000 in the US). Because of this, the balance works out differently for them. Hereditary factors account for more than half of prostate cancer risk. A father or brother with prostate cancer considerably increases your own risk. For men with such an elevated risk, the scales may tip more readily toward screening.

International guidelines and the American USPSTF therefore advise men aged 55 to 69 not to simply get a PSA test, but to make this decision together with their GP^4,5. That conversation covers your age, family history, and ethnicity. But also: how much weight do you place on the chance of overdiagnosis and side effects, versus the chance of a death from prostate cancer being prevented? There is no universally correct answer.

For men aged 55 to 69 with an elevated risk, there is the strongest evidence that a conversation about PSA screening is worthwhile. For men with an average risk, the benefit-harm balance is less favourable. Men over 70 are generally no longer routinely invited for screening in guidelines, because the benefit diminishes further and the risk of overtreatment increases.