Screening for prostate cancer using a simple blood test can indeed save lives, but according to the most comprehensive study yet, the “absolute benefit is small,” and many men may end up trading their cancer for incontinence and erectile dysfunction instead.
In a review that analyzed six trials involving nearly 800,000 men, screening with the prostate-specific antigen (PSA) test reduced prostate cancer deaths by two for every 1,000 men screened. That means 500 men must be screened to prevent one death from the disease - a benefit that only became apparent after decades of monitoring, particularly in the European randomized study of screening for prostate cancer (ERSPC), which followed men for 23 years.
“Prostate cancer screening does reduce prostate cancer mortality, although the caveat is that it takes a very extended period of time to realize that benefit,” said Prof Philipp Dahm, a urologist at the University of Minnesota and senior author of the Cochrane review. “This finding is a milestone and I think it will make a difference for a lot of policymakers.”
The UK and many other countries lack formal prostate cancer screening programs, largely because the PSA test is unreliable. It picks up life-threatening tumors but also detects plenty of benign cancers that would never cause trouble, leading men to undergo radiotherapy, surgery, or hormone therapy - putting them at risk of complications such as incontinence and impotence. The studies did not systematically assess quality-of-life impacts, but the ProtecT trial found that between 8% and 47% of men reported problems with urinary or sexual function after treatment.
Dr Juan Franco at Heinrich Heine University in Düsseldorf, the first author of the review, stressed that the results were “not a blanket endorsement of universal screening” and highlighted the “very real risks” of overdiagnosis and unnecessary treatment. “It’s important to have, ultimately, discussion with patients, and what we call shared decision making,” he said.
Prostate cancer remains one of the most common cancers in men, with more than 64,000 cases diagnosed annually in the UK, and one in eight men developing the disease in their lifetime - rising to a quarter of Black men. Last year, the UK National Screening Committee advised against screening for most men but recommended a targeted program for those with BRCA1 and BRCA2 mutations linked to more aggressive cancers. Ministers are reviewing that advice.
Dahm noted screening makes more sense for men expected to live at least another 10 to 15 years. “If you have a lot of competing medical comorbidities that are much more likely to limit your life expectancy, you just don’t have to worry about prostate cancer for the most part, because most prostate cancer is slow growing,” he said.
The review examined newer, more precise screening methods - testing for more prostate-related proteins and using MRI scans - but concluded it was too early to know if they save more lives or cause less harm. David James at Prostate Cancer Research said the review showed how screening reduces deaths, adding that “MRI-led diagnostic pathways, more targeted biopsies, active surveillance and newer biomarker tests are all changing the balance between the benefits and harms of screening.”
But Dr Ian Walker at Cancer Research UK emphasized the review’s downside: “Whilst this review does highlight that the test could save one to two lives from prostate cancer for every 1,000 men screened, it also shows that around 30 more men could be diagnosed with the disease, many of whom would never have been harmed by their disease and could go on to have unnecessary treatment with long‑term impacts like the loss of bladder control and erectile dysfunction.”
Dr Matthew Hobbs at Prostate Cancer UK summed it up: PSA screening can save men’s lives “but not nearly enough.” He called for more research and honest conversations with men about benefits and harms, admitting “this is not a simple decision.”