‘Prostate Screening Saved My Life’—Is That Really True In Most Cases?

Derek Raghavan, MD, PhD, FACP, FASCO, FRACP

Prostate specific antigen (PSA) screening remains one of the most controversial of “standard” medical practices. As recently as the 2026 Super Bowl, one of the more unusual TV advertisements, sponsored by a pharmaceutical company with an interest in prostate cancer treatments, extolled the virtues of PSA screening for prostate cancer. A well-intentioned patient intoned, “PSA screening saved my life!” Eminent and proven experts, like Drs Tom Beer and Ken Pienta, congratulated the company on its creative approach to this difficult problem online in LinkedIn soon thereafter. 

However, just a week earlier, Raghavan and Tannock¹ and Ian Thompson,² each with some expertise in the management of prostate cancer, had letters to the editor published in TheNew England Journal of Medicine, criticizing the content of another (this time, 23 year) follow up of the European Prostate Cancer Study.³ Their concerns were that no overall survival benefit was demonstrated by the European study, and that most reports of the success of treatment of early-stage prostate cancer underestimate the morbidity (and potential mortality) of such treatment. So, what’s the deal here, and why can the medical profession not come to a final consensus?

1. Ming Chu and colleagues at Roswell Park Cancer Institute,⁴ leveraging preliminary studies of others, provided the prostate specific antigen as a useful tool for the management of prostatic diseases. PSA is a relatively specific protein that reflects the extent of prostate tissue, both benign and malignant,⁴ and usually correlates with response to treatment.^5,6However, and particularly in previously treated cases, poorly differentiated prostate cancers may not produce much PSA, creating a discrepancy between the PSA amplitude and the extent of cancer. This situation can be confounded by the less common variant, neuroendocrine prostate cancer, which usually does not produce much PSA. Nonetheless, in the broad context, PSA is useful in the management of advanced prostate cancer, both as a parameter of early tumor response to treatment and sometimes as a prognostic determinant.^5,6

What about early-stage prostate cancer? In this setting, PSA has a fan base that views it as having a key role in early diagnosis, for clinical monitoring of patients, allowing documentation of relapse after treatment, and encouraging patients to return regularly for follow up, and this has led to the development of a series of prognostic models for use in early-stage disease (often with limited sensitivity and specificity). In some cases, these proponents are correct and PSA screening has led to individual lives saved—but at what cost, and causing how much damage to these patients and others?^2,7

In Favor of PSA Screening

Many of the urological associations⁸ and some patient advocacy groups have taken positions justified as follows:

• Screening allows early detection of many cancers and thus saves lives;
• The proportion of patients presenting earlier with prostate cancer is much higher since the introduction of PSA screening;
• Early treatment by surgical extirpation is usually curative; another controversy is whether radiotherapy is equally effective, but we won’t address that today;
• Regular PSA checks lead to early diagnosis and early treatment and thus should save lives;
• The proportion of patients suffering death from prostate cancer has reduced in the past decades since the introduction of PSA screening;
• Some randomized trials, comparing screened and unscreened, control populations have demonstrated reduction of deaths from prostate cancer or possible prolongation of disease-free interval in the screened arms;^3,9-11
• Some randomized trials that have not shown benefit were heavily flawed in design or execution, particularly due to patient-directed crossover;¹²
• Thus, they claim that screening with PSA, often in association with digital rectal examination, must be beneficial for patients.

An Opposing View

The contrasting view, perhaps espoused most consistently by the American College of Physicians (ACP)¹⁴ and intermittently by the U.S. Preventive Services Task Force (USPSTF)¹⁵ is as follows:

• There is no randomized clinical trial that has shown overall lives being saved by PSA or equivalent screening programs,^3,9-12 although overall survival has been the sine qua non of successful screening in cancers of breast, colon, and lung; so why drop the bar of success for prostate cancer alone?
• The ProtecT trial, from the United Kingdom, a cluster randomization study of different clinical practice sites, involving 82,429 patients who underwent PSA testing, failed to show either tumor-specific or overall survival benefit in a real-world setting.¹⁵
• Some randomized trials have shown a deficit in survival, particularly among older screened men.¹⁰
• Most studies have not shown true overall benefit for the population from current prostate screening protocols; furthermore, many published studies have underestimated the toxicities of treatment, including radical surgery, radiotherapy and androgen deprivation therapy (ADT).
• There have been many other advances in the management of prostate cancer in the same time period, which could easily explain improvement in survival.
• As a result, the ACP¹⁴ and USPSTF¹⁵ has previously recommended against routine prostate screening strategies with the currently available tools, although the USPSTF has softened its stance, simply advising discussion between doctor and patient,¹⁶ hardly a glowing example of taxpayer value!

How I See This Chaos

This has led to confusion and concern that lives will be lost because of this negative stance. As I see it, the following important points apply:

• Prostate cancer is a remarkably heterogeneous disease, and there clearly is a very common type that will coexist in men for many years, and which poses no threat to their longevity or lifestyles unless disrupted by the consequences of aggressive post-screening treatment; that stated, we need to be very much aware of the much more dangerous variants that can progress rapidly and even cause death and should be focusing our attention and resources on managing them.
• In my clinical practice, I have lost count of the number of patients that I have been referred who were initially diagnosed by PSA screening, were clinically staged as T1-2N0M0 (i.e. early-stage disease), were treated early and aggressively by radical prostatectomy or radiotherapy (sometimes accompanied by ADT), and who have relapsed with biochemical recurrence or metastatic disease—viz. failure of PSA screening, often at physical or financial cost, and clearly no panacea.
• We certainly need to increase education of men (and their families) about the existence of prostate cancer, its symptoms and presentations, the availability of treatment, and key facts relating to the debate about screening and the respective potential toxicities of treatment.
• We should be emphasizing for some of our clinical colleagues that there is a major difference between population-based PSA screening and the use of PSA in assisting in the diagnosis and management of a male with symptoms of prostatic disease, and that results obtained from the latter situation do not apply to PSA screening of asymptomatic men.
• In tumors where screening is of unequivocally proven benefit (e.g. mammography for breast cancer, colonoscopy for colon cancer, low-dose CT scanning for lung cancer), there is both a stage shift at presentation, an increment in cancer-specific survival and, most importantly, a significant and clinically relevant increase in overall survival; this has never been shown in the randomized trials of prostate screening, despite lengthy follow-up;
• Cancer-specific death rates, in isolation, do not provide sufficient benefit to support routine population-based screening as they may well mask an increment of morbidity or mortality in other areas (eg, the consequences of hormonal manipulation or the complications of surgery or radiotherapy);
• The absolute number of deaths from prostate cancer each year in the United States, since the introduction of widespread prostate screening, has not reduced as dramatically as implied by much of the rhetoric in support of PSA screening—25,943 deaths from prostate cancer in 1989,¹⁷ 28,170 deaths from prostate cancer in 2011,¹⁸ and 33,500 deaths in 2025;¹⁹ what has changed rapidly is the denominator of cases, implying the discovery of a large reservoir of incidental cases;
• The USPSTF appears to have made its decisions based on studies that did not address, in any meaningful way, African Americans nor men with family histories of prostate cancer; responsible clinicians need to be particularly careful in framing their decisions on screening for Black males and men with a family history.

Working Through This Morasse to a Solution

When trying to come up with a rational health policy on prostate screening, there are several important points to consider:

• Perhaps most importantly, most of the protagonists on each side of the argument are genuinely advocating for their positions, based on how they understand the data.Members of several advocacy groups believe that lives have been saved by the process of screening; unfortunately many of them have been convinced by their clinicians that this concept is true, when actually many have had “curative” treatment for a condition that was not likely to threaten their lives. In some cases, some may claim that lives have been saved long before this heterogeneous disease had time to declare itself. Some advocacy groups may have been influenced by the pharmaceutical industry, providing them with potentially biased and rhetorical information, ie, companies that have stood to profit from increased numbers of men being diagnosed with some form of prostate cancer—and treated.
• Sadly, some of the professional advocates for screening and subsequent treatment (particularly concerning low-grade prostate cancer) may be influenced simply by the profit motive.
• The USPSTF, allegedly experts in their field, have certainly contributed to the confusion by reversing their published opinions and advice, sometimes without even the benefit of new evidence.
• Many of those who oppose routine screening are physicians who have seen the proportion of men who have been screened and undergone early and active treatment, often with considerable morbidity (incontinence, impotence, complications of early ADT, financial expenditure), and who have nonetheless relapsed clinically or with rising PSA.These physicians argue that many trials that have studied the utility of PSA screening have failed to show the overall survival benefit that characterizes successful screening for other tumors. 
• In similar Western societies (e.g. Australia, New Zealand), where PSA screening has not been implemented as frequently by government or the medical profession, the death rates from prostate cancer are similar to those in the United States.

In the days when I ran cancer institutes, I really did not appreciate faculty members coming to me to complain about a problem unless they also had given some thought to potential solutions. Trying to be consistent, I think it appropriate to suggest how I might tackle this problem going forward, rather than simply complaining about it.

• First, I think it is important for learned medical societies (e.g. American Urological Association, American College of Physicians, American Society of Clinical Oncology, American Association of Cancer Research, Society of Urologic Oncology) and government health agencies to come together to take a stringent evidence-based position, seemingly a unique concept in recent times for some government committees. My personal preference would be to have the NCI host a meeting of experts of different persuasion and try to come up with a consensus approach; having addressed the data dispassionately, and without political overlay, these organizations should initiate public education campaigns explaining reality to the lay public (including politicians and influencers), addressing the true benefits and drawbacks of screening, the existence of relatively benign forms of prostate cancer that do not require urgent treatment, accurate and honest descriptions of the complications and costs of treatment, and, importantly, the difference between screening of asymptomatic patients and investigating patients with symptoms suggestive of prostate enlargement. This could include an enduring online resource (website), endorsed and supported by the key organizations, and updated if convincing new data were to be published;
• We need to acknowledge what we really do not know from the available data— specifically we have scanty structured information on the benefits and drawbacks of PSA screening for the Black community (in many published series known to have more advanced presentation and worse outcomes) and men with a family history.
• I do not believe that it will be possible to conduct randomized clinical trials addressing this question in the United States today, but it may be possible for collaborative studies of extant data from the published randomized trials to explore the absence of overall survival benefit and the characteristics of those patients successfully or unsuccessfully screened to inform the design of future screening proposals.

Whereas it is unlikely that these steps alone will fix the problem, at least our profession could then take comfort in acting responsibly and providing accurate information on which potential patients and the community can act, allowing reason to supervene over well-intended emotion.

DISCLOSURE: Dr. Raghavan reported no conflicts of interest.

REFERENCES

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Dr. Raghavan is an oncologist at the Veterans Administration Health Care Center, Charlotte; Emeritus Professor at Wake Forest School of Medicine; and External Advisor at Henry Ford Health and Michigan State University Cancer Collaboration.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or Conexiant.