Are Prostate Cancer Screenings Necessary? The Pros and Cons

Shahmir H. Ali ABD, Dana Casciotti, PhD, Brandel France de Bravo, MPH,  and Nicholas J. Jury, PhD

Prostate cancer is the second leading cause of cancer deaths for men in the United States, after lung cancer. One in every eight men will be diagnosed with prostate cancer in his lifetime.1 Most cases are in men 65 and older, and most deaths occur in men 75 and older.2 Annual screenings would seem to be an important way to prevent prostate cancer. However, it may surprise you that many experts, including the U.S. Preventative Task Force (USPTF) does not recommend men over 70 to get screened for prostate cancer.3 For men ages 55 to 69, it doesn’t recommend for or against screening, but instead recommends talking to their doctor about whether screening is right for them.

In fact, even if screening leads to a diagnosis of prostate cancer, it often does not require any treatment. Thus, there is currently a hot debate within the medical community: are prostate cancer screenings a good idea, and if so, for which men? This article discusses the available tests and the benefits and harms of getting tested for prostate cancer.

Are Prostate Cancer Screenings Accurate?

Prostate cancer occurs when small tumors develop in the prostate gland, which is an important part of the male reproductive system. Screening can be performed quickly and easily in a physician’s office using either of two tests: a blood test, called prostate-specific-antigen (PSA) test, and the digital rectal exam (DRE), a manual exam of the prostate area.

However, prostate tests can often be inaccurate. Both the PSA and DRE result in many false positives (when the test shows a man has prostate cancer who does not have prostate cancer) and false negatives (when a test shows a man does not have prostate cancer but he actually does have prostate cancer). Using both screening methods together will miss fewer cancers but also increase the number of false positives, which then results in more testing, such as biopsies that involve inserting a needle through the rectum.  Biopsies can possibly result in medical complications.

Researchers are also trying to determine if other types of testing might be more accurate in detecting prostate cancer.  One study of more than 5,500 men examined whether the rate of change in PSA levels when a man has multiple tests over time (also called “PSA velocity”) could improve cancer detection compared to standard (single blood test) PSA and DRE screening tests.4 They found that high PSA velocity often resulted in biopsies that did not improve cancer detection.

Do Prostate Cancer Screenings Save Lives?

Even if prostate cancer tests are not very accurate, wouldn’t screening lead to earlier detection, earlier treatment, and less chance of death? Prostate cancer is often curable (90% or better) if detected early. Common treatments like surgery or radiation aim to remove or kill all cancerous cells in the prostate. If not detected and treated early, the cancer may spread beyond the prostate and can be fatal.

Experts disagree on the value of prostate cancer screening, quoting research with conflicting conclusions.  So, we examined the best research and found that whether or not prostate cancer screening saves lives depends on how exactly “screening” is defined as well as how survival is defined. For example, a study of 76,000 American men aged 55-74 found that men who screened for prostate cancer every year were not any less likely to die of prostate cancer than those receiving “usual care” (defined for most as at least one screening during the first 7 years of the study).5,6 In contrast, a different study of 182,000 European men aged 50-75 found that men who received “regular screening” (every 2-4 years, depending on the European country) were less likely to die of prostate cancer than those who did not have any screening.7,8  And yet, the men who were regularly screened did not live longer than those who didn’t, because they died of other causes.  That’s important to know, because the goal of screening is to live longer, not to prevent death from just one particular disease.

However, prostate cancer usually grows so slowly that it is often equally safe to screen only when there are symptoms, rather than screening based on PSA or DRE results.  Symptoms of prostate cancer can include urinary problems, difficulty having an erection, or blood in the urine or semen. If a man has prostate cancer without any symptoms, he may not need to be treated. In fact, experts estimate that half the men who are diagnosed with prostate cancer would not have any symptoms in their lifetime, and 80-85% would not die of the disease within 15 years of diagnosis even if they were not treated.9

That’s exactly why experts do not agree that screening with a PSA or DRE test saves lives.9 For who were diagnosed with prostate cancer, the chances of dying from the prostate cancer within 10-years of diagnosis were about 3 in 10,000 (that’s less than half of one percent) whether the men had a PSA screening or not.10 This means that although a PSA test will detect prostate cancers before any symptoms appear, often those cancers would never have become harmful. However, more research is underway using longer-term studies.10 A study published in 2018 revealed that PSA screening did not reduce the chances of dying, and had a very small impact on reducing chances of dying from prostate cancer (1 fewer deaths for every 1000 men screened for 10 years).11

Can Prostate Cancer Screenings Do Harm?

Aside from not providing no benefit to many men, prostate cancer screening may actually do some harm. These harms can include 1) inaccurate results leading to unnecessary biopsies and complications, 2) complications and high costs associated with unnecessary treatment, and 3) serious side effects from treatments (such as urinary incontinence and impotence).12 In fact, a 2018 study based on data from 721,718 men across 5 clinical trials estimated that for every 1000 men screened for prostate cancer, screening-related complications will result in 1 person being hospitalized for sepsis, 3 requiring pads for urinary incontinence, and 25 reporting erectile dysfunction.11

These serious side effects from prostate cancer treatment are the reason why many men with prostate cancer choose “active monitoring” instead of treatment.  Active monitoring usually involves visiting a doctor for a PSA test every 6 months, and a DRE at least once a year. However, even being asked to actively check on your symptoms during the years after being diagnosed with prostate cancer can have a detrimental psychological impact.  Men who were diagnosed with low risk prostate cancer who were asked to monitor their symptoms reported significantly higher anxiety than those without cancer or those currently in treatment.13

It is also important to acknowledge that the harms of prostate cancer screening are disproportionately impacting some communities more than others. A 2018 study revealed that Black men were more likely to receive a false-positive PSA test and undergo a biopsy than white men.14 For more information on racial differences in prostate cancer, read our article linked here.

The Bottom Line

Based on the current evidence, U.S. experts continue to conclude that prostate cancer screenings often provide very little benefit and can be harmful.  Doctors and scientists are searching for better tests, such as using family history of prostate cancer to influence the time and frequency of recommended PSA screenings. However, the impact of such efforts on reducing deaths from prostate cancer remains unknown, and so do the likely harms. Therefore, the best thing to do is talk with your doctor about whether getting a prostate cancer screening is truly right for you.

References

  1. Key Statistics for Prostate Cancer | Prostate Cancer Facts. Accessed June 29, 2022. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
  2. Cancer of the Prostate – Cancer Stat Facts. SEER. Accessed June 29, 2022. https://seer.cancer.gov/statfacts/html/prost.html
  3. US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901. doi:10.1001/jama.2018.3710
  4. Vickers AJ, Till C, Tangen CM, Lilja H, Thompson IM. An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection. J Natl Cancer Inst. 2011;103(6):462-469. doi:10.1093/jnci/djr028
  5. Andriole GL, Crawford ED, Grubb RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360(13):1310-1319. doi:10.1056/NEJMoa0810696
  6. Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO). Division of Cancer Prevention. Published July 1, 2014. Accessed July 19, 2022. https://prevention.cancer.gov/major-programs/prostate-lung-colorectal-and-ovarian-cancer-screening-trial
  7. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. The Lancet. 2014;384(9959):2027-2035. doi:10.1016/S0140-6736(14)60525-0
  8. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360(13):1320-1328. doi:10.1056/NEJMoa0810084
  9. Mulhem E, Fulbright N, Duncan N. Prostate Cancer Screening. afp. 2015;92(8):683-688.
  10. Barry MJ. Screening for Prostate Cancer: Is the Third Trial the Charm? JAMA. 2018;319(9):868-869. doi:10.1001/jama.2018.0153
  11. Ilic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519. doi:10.1136/bmj.k3519
  12. Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358(12):1250-1261. doi:10.1056/NEJMoa074311
  13. Ruane-McAteer E, Porter S, O’Sullivan J, Dempster M, Prue G. Investigating the psychological impact of active surveillance or active treatment in newly diagnosed favorable-risk prostate cancer patients: A 9-month longitudinal study. Psychooncology. 2019;28(8):1743-1752. doi:10.1002/pon.5161
  14. Miller EA, Pinsky PF, Black A, Andriole GL, Pierre-Victor D. Secondary prostate cancer screening outcomes by race in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial. The Prostate. 2018;78(11):830-838. doi:10.1002/pros.23540