The PSA Test: Rethinking Prostate Cancer Screening
Does PSA Screening Actually Reduce Mortality?
Prostate cancer is one of the most commonly diagnosed cancers in men, yet the role of Prostate-Specific Antigen (PSA) screening remains controversial. While early detection is often associated with better outcomes in many cancers, the reality for PSA screening is more nuanced. Despite widespread testing, data shows that routine PSA screening has not significantly reduced prostate cancer mortality. Instead, it has led to increased rates of overdiagnosis and overtreatment, raising concerns about its overall benefit.
What is PSA Screening?
PSA is a protein produced by the prostate, and elevated levels in the blood may indicate prostate cancer. However, PSA is not a cancer-specific marker—levels can rise due to benign conditions like prostatitis or benign prostatic hyperplasia (BPH).
PSA screening typically includes:
A blood test to measure PSA levels.
Imaging can be helpful if there are BPH symptoms.
The Reality of PSA Screening and Mortality Rates
A landmark 2018 study published in JAMA analyzed data from 400,000 men and found that PSA screening did not significantly reduce prostate cancer mortality after 10 years of follow-up. Additionally, the U.S. Preventive Services Task Force (USPSTF) has adjusted its recommendations over the years, now stating that PSA screening should be an individual decision for men aged 55 to 69, and is not recommended for men over 70 due to risks outweighing benefits.
Racial Disparities in Prostate Cancer
While PSA screening may not significantly reduce mortality rates across all populations, prostate cancer disproportionately impacts Black men, who have higher incidence and mortality rates than other racial groups.
Black men are 1.7 times more likely to be diagnosed with prostate cancer.
They are over 2 times more likely to die from the disease compared to White men.
Despite these risks, Black men are less likely to receive early treatment and often present with more aggressive disease at diagnosis.
This disparity suggests that while broad PSA screening may not be ideal for all men, more targeted screening strategies could benefit high-risk populations.
The Treatment Debate: Balancing Risks and Benefits
One of the biggest concerns with PSA screening is the overdiagnosis of slow-growing prostate cancers, which may never become life-threatening.
Many men diagnosed through PSA screening undergo radical treatments such as surgery or radiation.
These treatments carry significant side effects, including incontinence, erectile dysfunction, and reduced quality of life.
Studies show that nearly 50% of men diagnosed with prostate cancer through PSA screening would never have developed symptoms in their lifetime.
Active surveillance—closely monitoring low-risk prostate cancer rather than immediately treating it—is now increasingly recommended to reduce unnecessary interventions.
Testosterone and Prostate Cancer: A Misconception
For decades, medical professionals believed that testosterone fueled prostate cancer growth, leading to widespread testosterone therapy restrictions in men at risk. However, new research contradicts this assumption.
Prostate cancer rates are highest in men over 70—when testosterone levels are at their lowest.
No randomized controlled trials have confirmed a direct link between higher testosterone levels and increased prostate cancer risk.
Studies now suggest that low testosterone may even be a risk factor for more aggressive prostate cancer.
This shift in understanding has prompted a re-evaluation of testosterone therapy restrictions for aging men.
Final Thoughts: A Smarter Approach to Prostate Cancer Screening
Given the limitations of PSA screening, the focus should shift toward a more individualized approach:
High-risk populations (e.g., Black men, those with a family history) should have earlier and more frequent screenings.
Men with low PSA and no symptoms may benefit from avoiding routine screening.
More emphasis should be placed on active surveillance rather than aggressive treatment for low-risk cases.
The role of testosterone in prostate cancer should continue to be re-evaluated, as past assumptions may have led to unnecessary fears and restrictions.
In the end, the decision to undergo PSA screening should be a shared decision between patients and their healthcare providers, taking into account individual risk factors, preferences, and emerging research rather than relying on a one-size-fits-all approach.
Sincerely,
Dr. Hutson
Meet the Author
Dr. Lauren Hutson is an experienced Primary Care Provider with degrees in Neuroscience and Biology from University of Texas at Austin. She completed her residency at Baylor Scott and White, Texas A&M, and has a strong focus on preventive care and chronic illness management. During the pandemic, she provided critical care as a Hospitalist in New Mexico, exemplifying her commitment to holistic, patient-centered care.
