Prostate Cancer Screening: Should I Have a PSA Test?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Prostate Cancer Screening: Should I Have a PSA Test?
Get the facts
- Have a PSA test to check for prostate cancer.
- Do not have a PSA test to check for prostate cancer.
Key points to remember
- Experts disagree on whether PSA testing should be used to routinely screen men for prostate cancer. Talk with your doctor about your age, your health, and the pros and cons of PSA testing. He or she can help you decide.
- A high level of PSA may mean cancer. But usually it isn't cancer. It's often something else, like an enlarged prostate or an infection.
- A PSA test cannot show if you have cancer. You will need a prostate biopsy to find out if your high level of PSA is from cancer or something else.
- A PSA test may help find cancer early, when it can be cured. But many PSA tests also find cancers that are slow-growing and may never cause a problem. Some cancers grow so quickly that even regular screening cannot find them early enough.
- PSA tests aren't perfect. They may have abnormal results even when there isn't cancer (a false-positive result) or have normal results when a man has cancer (a false-negative result).
- If you have a family history of prostate cancer, your risk of getting it may be higher than average. Even if you are at a higher risk, screening may not help you live longer.
Prostate cancer is the abnormal growth of cells in the tissues of the prostate gland. It is the most common cancer in men. Most men who get it are older than 65.
Unlike many other cancers, it is usually slow-growing. For most men, this slow growth means they have time to learn all they can before deciding whether to have treatment or which treatment to have.
Early prostate cancer usually doesn't cause symptoms. When prostate cancer is found early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate. Or if the cancer is growing very slowly, active surveillance or watchful waiting is an option. As prostate cancer grows or spreads, symptoms may develop, including urinary problems (such as blood in the urine) and bone pain.
The prostate-specific antigen (PSA) test is a blood test. PSA is released into a man's blood by the cells of his prostate gland. Low amounts of PSA may be found in the blood of healthy men. The amount of PSA in the blood normally increases as a man's prostate enlarges with age. And it increases after ejaculation and after trauma to the prostate caused by such things as a long bike ride. It is also increased by inflammation of the prostate gland (prostatitis) and by prostate cancer.
The PSA test is usually done along with a digital rectal exam to screen for prostate cancer in men who have no symptoms. A PSA test may also be used to check men who have had prostate cancer to see if the cancer has come back.
A high PSA result can be the first warning sign of prostate cancer. A high PSA can signal a higher risk of getting prostate cancer in the future. But a high PSA can also be linked to other causes that aren't cancer.
The amount of PSA in the blood normally increases as a man's prostate enlarges with age. But when you have prostate cancer, your PSA level increases even more over time.
The PSA test and digital rectal exam can suggest a problem when there is not one. This is called a false-positive result.
These tests may also fail to detect a problem when there is one. This is called a false-negative result.
A PSA test alone can't tell if you have prostate cancer. This test only shows the level of your PSA. And a PSA test can't tell why your level is high.
The prostate naturally gets bigger as a man gets older. More than half of all men who are older than 50 have an enlarged prostate. This affects the PSA level, making it less accurate as a way to detect cancer.
Because several other things can make a PSA level go up—for example, ejaculation or an infection in the prostate—your doctor may advise you to have another PSA test later before you make any further decisions.
If your PSA test suggests that you may have prostate cancer, your doctor may recommend a biopsy, which is the only way to make sure that you have prostate cancer. If the biopsy finds cancer, you must decide how or whether to treat it.
Most prostate cancers that are found early are slow-growing. But a few prostate cancers grow fast. Men who have fast-growing cancers are more likely to die from prostate cancer than men who have slower-growing cancers. But PSA tests may not help men who have fast-growing cancers that have spread quickly. And doctors can't always tell which prostate cancers will grow quickly and become life-threatening. Treatments can have serious long-term side effects. They may cause health problems, including problems with your bladder, bowel, and erections. For this reason, some men choose not to have the PSA test.
In men who have not been diagnosed with prostate cancer, PSA velocity may signal that there is a problem that needs further testing. PSA velocity is measured by looking at the rate of change in PSA levels over 2 or 3 years. PSA levels rise faster in men who have prostate cancer than they do in men who have enlarged prostates.
|Outcomes||With PSA testing||Without PSA testing|
|Death from prostate cancer within next 10 years, men ages 45 to 80||7 to 8 out of 100||7 to 8 out of 100|
|Cases of cancer found||6 to 7 out of 100||4 to 5 out of 100|
|Results above normal range that are not cancer||76 to 83 out of 100 abnormal results||None|
|Problems from biopsy done after positive test||Less than 1 out of 100||None|
*Based on the best available evidence (evidence quality: borderline to moderate)
The quality of the evidence about PSA benefits is borderline.
It's easy to assume that cancer screening tests save lives. And some do. But in the case of prostate cancer screening, PSA testing has not been shown to reduce a man's risk of dying in the next 10 years.
Take a group of 100 men, ages 45 to 80. Whether they have PSA tests or not, 7 to 8 out of 100 may die of prostate cancer in the next 10 years, which means that 92 to 93 out of 100 may not. Their risk of death from prostate cancer is the same with or without PSA tests.
One benefit may be that cancer is more likely to be found with PSA testing than without. Take a group of 100 men:
- If all of them have PSA tests, testing may find 6 to 7 cancers.
- If none of them have PSA tests, 4 to 5 cancers may be found.
But this can be a mixed blessing. Some prostate cancers that are found may never have caused a problem or needed treatment had they not been found.
The quality of the evidence about PSA risks is moderate.
One risk of PSA tests is that they can suggest a problem when there isn't one. This is called a false-positive result. It can lead to more invasive testing.
Take a group of 100 men who have a positive PSA test. Only 17 to 24 of these men actually have prostate cancer. This means that 76 to 83 of them do not have prostate cancer, even though their PSA results are positive.
If your PSA test is positive, your doctor may recommend a biopsy, which is the only way to make sure you have prostate cancer.
Biopsy has its own risks. Take a group of 100 men who have a prostate biopsy. Less than 1 out of 100 will have a problem from the procedure, such as infection, bleeding, a blood clot, or problems urinating. (Out of 1,000 men who have a biopsy, 1 to 7 will have a problem from the procedure. This means that 993 to 999 out of 1,000 will not have any problem.)
Another risk is overtreatment. Overtreatment means that a cancer that would never have caused a problem is treated as if it were life-threatening, such as with surgery, radiation, or chemotherapy. Take a group of 100 men who have prostate cancer found by a PSA test: some experts believe that as many as 50 out of 100 will have treatment they never needed.1 And some of those men will have long-term side effects from the treatment.
Understanding the evidence
Some evidence is better than other evidence. Evidence comes from studies that look at how well treatments and tests work and how safe they are. For many reasons, some studies are more reliable than others. The better the evidence is—the higher its quality—the more we can trust it.
Another thing to understand is that the evidence can't predict what's going to happen in your case. When evidence tells us that 2 out of 100 people who have a certain test or treatment may have a certain result and that 98 out of 100 may not, there's no way to know if you will be one of the 2 or one of the 98.
Your chance of getting prostate cancer increases as you age. Men who are younger than 75 and who do not have serious health problems may gain the most from early detection and treatment.
Most medical experts say that men age 50 or older should talk to their doctors about the pros and cons of PSA testing so that they can make their own decisions.
Some experts worry that PSA testing for prostate cancer begins a process that can force a man to make hard decisions and can lead to other health problems that are caused by the treatment for prostate cancer. Here's what some experts say:
- The U.S. Preventive Services Task Force (USPSTF) recommends against routine PSA tests to look for prostate cancer. The USPSTF found that testing does more harm than good. Men who are tested may end up getting treatment they don't need, and those treatments can cause other problems. Few, if any, men are helped to live longer by having the test.
- The American Cancer Society (ACS) advises men to talk with their doctors about testing and treatment before deciding about testing. The ACS says that men should not be tested without learning about the risks and benefits. The ACS advises talking to a doctor about testing:
- At age 50 for men who are at average risk of getting prostate cancer and are expected to live at least 10 more years.
- At age 45 for men at high risk, such as African Americans and men who have a first-degree relative (father, brother, or son) who had prostate cancer when he was younger than 65.
- At age 40 for men at an even higher risk, such as those with several first-degree relatives who had prostate cancer at an early age.
- The American Urological Association (AUA) recommends routine shared decision making only for men 55 to 69 years of age who are at average risk for prostate cancer and who don't have any symptoms of prostate cancer. The AUA says these men should talk with their doctors about the benefits and harms of PSA testing. Then they can decide based on their personal values and preferences.
Your doctor may recommend a PSA test if he or she thinks you may have prostate cancer.
Your doctor may discuss PSA screening if:
- You are in your 50s or 60s and are in good health.
- Your doctor wants to keep track of changes in your PSA level.
- You are an African American or a Jamaican of African descent, which means that you have a greater chance of getting the kind of prostate cancer that grows and spreads.
- Your father, brother, or son got prostate cancer before age 65.
Compare your options
What is usually involved?
What are the benefits?
What are the risks and side effects?
- It's a simple blood test. A needle is used to take a sample of blood from your arm.
- A PSA test can help find prostate cancer early, while it is small and usually curable.
- Testing could lead you to hard decisions about further testing and treatment.
- Testing could lead to a diagnosis of cancer and treatments that can cause loss of bladder control and not being able to have an erection.
- You have regular checkups that don't include this test.
- You avoid testing that could lead to a diagnosis of cancer and treatments that can cause other health problems, especially loss of bladder control and not being able to have an erection.
- You may have treatable prostate cancer without knowing it.
- Sometimes prostate cancer grows quickly. If this type of prostate cancer is not found early, it can shorten your life.
Personal stories about having a prostate-specific antigen (PSA) test to screen for prostate cancer
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
I have two children who are in high school right now, and both plan to go to college. It's important to me to provide for them and ensure that they have the money they need to finish their education. If I found out I had cancer, I would try any treatment that might offer me a chance to live longer, even if it has side effects. I'm going to have the PSA test.
Eric, age 56
For me, there is still too much uncertainty about the benefits of the PSA test. I tend to stay away from things that aren't yet proved, even when I know there is a chance that we might someday find out there is a benefit. I'm willing to take that chance. Because I want to avoid the risks of inexact test results and additional tests, I'm not going to have the test.
Mike, age 62
My health is great. I still run, play tennis, and travel a lot. At my age, you start to see friends getting sick and dying of one thing or another, and it makes you start to think about your own health more. I know that the PSA test isn't perfect, but I want to have every chance I can to treat cancer early if I have it.
Jacob, age 68
I've done some reading on this subject, and I know that I'm a lot more likely to die from my heart disease than from prostate cancer. Right now I'm focusing my efforts on controlling my blood pressure and cholesterol because I know that treating those things can help me live longer and better. I know that if I had the PSA test and it was high, I would just worry and be stressed out. That's not good for my heart either!
Pieter, age 67
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to have a PSA test
Reasons not to have a PSA test
Having prostate cancer and not treating it scares me more than the urinary and erection problems that cancer treatment may cause.
I worry that I might end up with urinary and erection problems if I have prostate cancer treatment.
I would do anything to fight prostate cancer, even if the side effects of treatment affect my quality of life.
I think the additional testing and treatment that might follow a positive test result would do me more harm than good.
I want to know if I have prostate cancer.
I don't want to know if I have prostate cancer, because it may never affect my health.
My other important reasons:
My other important reasons:
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Having a PSA test
NOT having a PSA test
What else do you need to make your decision?
Check the facts
Should all men over 50 have regular PSA tests?
- YesNo, that's wrong. Although many men older than 50 have this test as part of their regular checkups, experts agree that the test isn't necessary for all men.
- NoYou're right. Although many men older than 50 have this test as part of their regular checkups, experts agree that the test isn't necessary for all men.
- I'm not sureIt may help to go back and read "Get the Facts." Although many men older than 50 have this test as part of their regular checkups, experts agree that the test isn't necessary for all men.
Is it important to think about the side effects of prostate cancer treatment when making this decision?
- YesIt's true. Prostate cancer treatment can cause loss of bladder control and not being able to have an erection. Having a PSA test could lead to a diagnosis of cancer and having to decide whether to have that treatment.
- NoSorry, that's wrong. Prostate cancer treatment can cause loss of bladder control and not being able to have an erection. Having a PSA test could lead to a diagnosis of cancer and having to decide whether to have that treatment.
- I'm not sureIt may help to go back and read "Compare Your Options." Prostate cancer treatment can cause loss of bladder control and not being able to have an erection. Having a PSA test could lead to a diagnosis of cancer and having to decide whether to have that treatment.
Can a PSA test help find prostate cancer early, when it is usually curable?
- YesYou're right. When prostate cancer is found early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate.
- NoNo, that's wrong. When prostate cancer is found early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate.
- I'm not sureIt may help to go back and read "Get the Facts." When prostate cancer is found early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate.
Decide what's next
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
How sure do you feel right now about your decision?
Use the following space to list questions, concerns, and next steps.
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
|Primary Medical Reviewer||E. Gregory Thompson, MD - Internal Medicine|
|Specialist Medical Reviewer||Christopher G. Wood, MD, FACS - Urology, Oncology|
- National Comprehensive Cancer Network (2013). Prostate cancer. NCCN Clinical Practice Guidelines in Oncology, version 1.2013. Available online: http://www.nccn.org/professionals/physician_gls/ f_guidelines.asp.
- Chou R, et al. (2011). Screening for prostate cancer: A review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 155(11): 762–771.
- Djulbegovic M (2010). Screening for prostate cancer: Systematic review and meta-analysis of randomised controlled trials. BMJ, 341: c4543.
- Hamilton AS, et al. (2001). Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: Results from the Prostate Cancer Outcomes Study. Journal of Clinical Oncology, 19(9): 2517–2526.
- Hugosson J, et al. (2010). Mortality results from the Goteborg randomized population-based prostate-cancer screening trial. Lancet Oncology, 11(8): 725–732.
- Ilic D, et al. (2011). Screening for prostate cancer: An updated Cochrane Systematic Review. British Journal of Urology International, 107(6): 882–891.
- Schröder FH, et al. (2009). Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine, 360(13): 1320–1328.
- Talcott JA, et al. (2003). Time course and predictors of symptoms after primary prostate cancer therapy. Journal of Clinical Oncology, 21(21): 3979–3986.