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 group. That sounds impressive, but in absolute numbers it means that for every 456 men invited, one death from prostate cancer was prevented. The British CAP study confirms this: even a single PSA invitation led, after 15 years, to a small but measurable reduction in prostate cancer mortality. On overall mortality from all causes combined, screening has no demonstrable effect, as several large studies show.

Set against this is a serious drawback: overdiagnosis. Screening produces 30% more prostate cancer diagnoses, a considerable proportion of which consist of slow-growing, low-grade tumours that would in all likelihood never have caused health problems for the man if he had not been screened. Those additional diagnoses do lead to treatments, with side effects as a consequence. Per 1,000 screened men, model-based estimates are: 1 extra hospital admission for sepsis following biopsy, 3 extra men with urinary incontinence, and 25 extra men with erectile dysfunction. These are model-based estimates, not directly measured figures, but they show that the chain from a positive PSA to biopsy to treatment can cause real harm to men who would never have experienced any trouble from their tumour.

Whether screening is worthwhile for you personally depends strongly on your risk profile. Black men have almost twice the risk of prostate cancer as white men (173 versus 97 cases per 100,000 in the US), which means the balance between benefit and harm is different for them. More than half of the prostate cancer risk is determined by hereditary factors: a father or brother with prostate cancer substantially increases your own risk. For men with such an elevated risk, the scales may tip more readily toward screening.

Both international guidelines and the American USPSTF therefore recommend that men between the ages of 55 and 69 do not simply undergo a PSA test, but decide together with their general practitioner. In that conversation, personal factors are addressed: age, family history, ethnicity, and also how much weight you place on the risk of overdiagnosis and side effects versus the chance of preventing a death from prostate cancer. There is no universally correct answer; that is precisely why the decision is so personal.

In practical terms: for men aged 55 to 69 with an elevated risk, such as Black men or men with first-degree relatives with prostate cancer, there is the strongest evidence that a conversation about PSA screening is worthwhile. For men with average risk, the benefit-harm balance is less favourable and screening is not an obvious choice. Men above the age of 70 are generally no longer routinely invited in guidelines, because the benefit diminishes further and the risk of overtreatment increases.