Harms of PSA screening outweigh benefits for most men, says American College of Physicians

BMJ 2013; 346 doi: (Published 09 April 2013) Cite this as: BMJ 2013;346:f2232
  1. Michael McCarthy
  1. 1Seattle

Men aged 50 to 69 years should have prostate specific antigen (PSA) tests only after discussing with their physicians the “limited potential benefits and substantial harms of screening for prostate cancer,” say new guidelines published on 9 April by the American College of Physicians.

“Only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test,” said David Bronson, president of the college.

“For most of these men, the harms will outweigh the benefits,” he added.

Men who have an average risk for prostate cancer, who are younger than 50 years, men older than 69 years, and those with a life expectancy of less than 10 to 15 years after diagnosis should not be screened with the PSA test, according to the new guidelines, which appear in the current issue of the journal Annals of Internal Medicine.1

Although about one in six (17%) men will develop prostate cancer in their lifetime, most prostate cancers are slow growing and do not cause symptoms, the guidelines say. Overall, only three in 100 (3%) men die of the disease.

Testing, however, is common, and studies have found that up to a third of men screened for prostate cancer reported that they were unaware they were being tested. And many who were aware that they were being tested did not have an adequate discussion of the benefits and harms, the guidelines say.

Among the risks of PSA testing are high false positive rates causing anxiety; unnecessary additional testing and biopsies with their attendant complications, such as pain, bleeding, and infection; overtreatment for slow growing cancers that would have never caused health problems; and treatment complications, which include urinary incontinence and erectile dysfunction.

Men who might be at higher risk—such as African Americans and those with a first degree relative diagnosed with prostate cancer, especially if diagnosed before age 65—should be informed of the potential benefits and risks of prostate cancer screening beginning at age 45, the guidelines say.

For men at higher risk, those who have multiple family members diagnosed with prostate cancer before 65, these discussions should begin at age 40.

“The PSA test is not ‘just a blood test.’ It is a test that can open the door to more testing and treatment that a man may not actually want and that may actually harm him.” the guidelines say. “Thus, each man should have the opportunity to decide for himself whether to have the PSA screening test.”

The new guidelines are based on a review of four guidelines for prostate cancer screening developed in the United States by the American College of Preventive Medicine, American Cancer Society, American Urological Association, and US Preventive Services Task Force.

In drawing up the statement, the authors followed the AGREE II (appraisal of guidelines, research, and evaluation in Europe) method, which considers a guideline’s scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

In addition to the advice for physicians, the guidelines include talking points to help them explain the benefits and harms of prostate cancer screening and treatment.


Cite this as: BMJ 2013;346:f2232