PSA Screening Controversies: Why Shared Decision-Making Matters for Prostate Cancer

Why PSA Screening Is So Controversial

Every year, millions of men get a simple blood test called PSA to check for prostate cancer. It’s quick, cheap, and widely available. But here’s the problem: for every life it saves, it can trigger a chain reaction of biopsies, anxiety, and treatments that don’t actually help - and sometimes make things worse.

The test measures prostate-specific antigen, a protein made by the prostate gland. A high level can mean cancer. But it can also mean a swollen prostate, an infection, even riding a bike the day before. About 75% of men with PSA levels between 4 and 10 ng/mL don’t have cancer at all. And yet, they’re often sent for a biopsy - a painful, risky procedure that can cause bleeding, infection, or hospitalization.

On the flip side, 15% of men with aggressive, life-threatening prostate cancer have PSA levels below 4.0 ng/mL. That means the test misses some of the worst cases. It’s not a perfect tool. It’s not even a good one by modern standards. But it’s the one we’ve been using for decades.

What the Studies Actually Show

Two massive studies, one in Europe and one in the U.S., looked at over 600,000 men over ten years. The European study found PSA screening cut prostate cancer deaths by 21%. The American study found no benefit at all. Why the difference? In the U.S., many men in the "no screening" group still got tested anyway. That blurred the results.

But even in the European study, the benefit came at a heavy cost. For every 1,000 men screened every year for 10 years:

• 1 to 2 deaths from prostate cancer were prevented
• 100 to 120 men had false positives and went through unnecessary biopsies
• 80 to 100 men were diagnosed with cancers that would never have caused symptoms or shortened their lives

These are the cancers that doctors call "indolent" - slow-growing, harmless tumors. But once found, they’re often treated with surgery or radiation. And those treatments? They can cause permanent incontinence, erectile dysfunction, bowel problems. Men wake up after surgery thinking they’ve beaten cancer - only to realize they’ve traded one problem for two worse ones.

Shared Decision-Making Isn’t Just a Buzzword - It’s the Only Ethical Way Forward

The U.S. Preventive Services Task Force changed its recommendation in 2018. No longer saying "don’t screen." Now saying: "If you’re a man between 55 and 69, talk to your doctor before deciding." That’s shared decision-making. And it’s not optional anymore. It’s the standard.

But here’s the catch: most doctors don’t do it well. A 2022 study found primary care doctors spend an average of just 3.7 minutes discussing PSA screening. That’s less time than it takes to check your blood pressure. Meanwhile, experts say you need 15 to 20 minutes to properly explain the trade-offs.

What should that conversation include?

• That PSA screening might reduce your chance of dying from prostate cancer by about 1 in 1,000 over 10 years
• That you’re more likely to be harmed by the test than helped - with unnecessary biopsies, anxiety, or treatment you don’t need
• That if you’re diagnosed, you might not need treatment right away - active surveillance is now a safe, proven option for low-risk cases
• That your race matters - Black men have a 70% higher risk of prostate cancer and are more likely to die from it
• That if your PSA is below 1.0 ng/mL at age 45, you may never need another test

Yet only 60% of men report ever hearing any of this. Too often, the conversation goes: "You’re due for your PSA test." Not: "Here’s what it might do to you. Here’s what it might not do. Let’s decide together."

What’s Replacing PSA? The New Tools (And Why They’re Not a Magic Fix)

There are better tests out there - but they’re not perfect, and they’re not cheap.

MP-MRI scans can show suspicious areas in the prostate before a biopsy. The PRECISION trial found using MRI first cut unnecessary biopsies by 27%. But an MRI costs $400 to $600. Not everyone can get one. And even MRI can miss some cancers.

The 4Kscore test looks at four different proteins in the blood. It’s 95% good at spotting men who won’t have aggressive cancer. But it costs $400 to $600. Most insurance won’t cover it unless you’re already in a high-risk group.

Then there’s the new IsoPSA test - approved by the FDA in 2021. It claims to be 92% accurate at finding high-grade cancer, compared to just 25% for traditional PSA. That’s a big leap. But it’s still new. Not widely available. And still not perfect.

AI is coming too. MIT researchers built an algorithm that predicts prostate cancer risk from routine blood tests. It’s 85% accurate and could cut unnecessary PSA tests by 30%. But it’s still in trials. Not in clinics yet.

So here’s the reality: PSA is still the most common first step. Because it’s cheap. Because it’s everywhere. Because we don’t have a better, affordable, widely available alternative - yet.

What Happens When Men Skip PSA Screening?

Since 2010, PSA screening rates in the U.S. have dropped from 42% to 29% among men 55 to 69. That’s a 31% decline.

And guess what happened? The number of men diagnosed with metastatic prostate cancer - cancer that’s already spread beyond the prostate - jumped by 37% between 2004 and 2013. That’s not a coincidence. It’s a consequence.

Some of those men are dying from cancers that could have been caught early. One man in his 60s, diagnosed with stage 4 cancer after skipping screening for years, told his story on a prostate cancer forum: "I thought I was fine. I didn’t have symptoms. Now I’m on chemotherapy. If I’d known, I’d have gotten tested."

Who Should Get Tested? And Who Should Skip It?

There’s no one-size-fits-all answer. But here’s what the evidence says:

• Men 55 to 69: This is the group where screening has the best chance of helping. But only if you understand the risks. Talk to your doctor.
• Men under 55: Only if you’re Black, or have a father or brother who got prostate cancer before 65. Even then, start with a baseline PSA at 45.
• Men 70 and older: The U.S. Preventive Services Task Force says the harms outweigh the benefits. If you’re healthy and active, talk to your doctor. But for most, screening is not recommended.
• Men with PSA under 1.0 ng/mL at age 45: You’re at very low risk. You may never need another test.
• Men with PSA above 3.0 ng/mL at age 50: You’re at higher risk. You need more frequent checks and possibly an MRI.

And if you’re Black? You’re more likely to get prostate cancer. More likely to die from it. Yet you’re 23% less likely to get a proper shared decision-making conversation. That’s not just a gap in care - it’s a systemic failure.

What to Do Next

If you’re a man between 55 and 69:

1. Ask your doctor: "Have we talked about the pros and cons of PSA screening?" If not, say: "I want to make an informed choice. Can we go over the risks and benefits?"
2. Ask: "What’s my baseline PSA? What’s my risk based on my race, family history, and age?"
3. Ask: "If my PSA is high, what happens next? Do I automatically get a biopsy? Or can we do an MRI first?"
4. Ask: "If I’m diagnosed, what are my options besides surgery or radiation? Is active surveillance right for me?"
5. Ask: "Can I get a decision aid - something visual - to help me understand the numbers?"

Don’t let fear or inertia make the decision for you. Don’t let a 3-minute appointment decide your future. This isn’t about whether PSA is good or bad. It’s about whether you’re making a choice - or just letting someone else make it for you.

What If You’ve Already Been Diagnosed?

Many men panic when they hear "prostate cancer." But here’s the truth: not all prostate cancers need to be treated right away. In fact, most don’t.

Active surveillance means regular PSA tests, MRIs, and occasional biopsies - not surgery. The ProtecT trial showed that after 10 years, survival rates were identical between men who had surgery, radiation, or just watched. No difference in death rates. But big differences in side effects.

If you’ve been diagnosed with low-risk cancer, ask: "Is active surveillance an option?" If your doctor doesn’t mention it, ask again. You have time. You don’t need to rush into treatment.