Study: PSA tests likely reduce risk of death from prostate cancer

A recent review published on Thursday by a prominent international science research organization suggests that prostate-specific antigen (PSA) blood testing might lower the risk of prostate cancer death. This development marks a notable shift in medical evidence that could lead to broader use of the test. 

Juan Franco, the first author of the Cochrane review and a researcher at Heinrich Heine University Düsseldorf in Germany, stated during a press conference that there is “moderate certainty” that PSA screening, which detects elevated levels of PSA as a potential indicator of prostate cancer, results in fewer disease-specific deaths. The review examined data from six trials involving 800,000 participants in Europe and North America, revealing approximately two fewer prostate cancer deaths per 1,000 men screened. 

However, the authors caution that their findings should not be seen as an unconditional endorsement of PSA screening. They recommend that men discuss the test’s advisability with their physicians. The discovery that PSA screening reduces deaths marks a substantial change from the 2013 Cochrane review, which did not find similar benefits and led to a decline in PSA screening’s popularity. 

PSA screening became a common procedure in the 1990s, but after about two decades, major medical organizations advised against its use. The U.S. Preventive Services Task Force (USPSTF) revised its guidelines to discourage PSA testing, initially for men aged 75 and older in 2008, and then for all men in 2012. 

During that period, research failed to demonstrate that screening saved lives but highlighted its drawbacks: widespread PSA testing resulted in overdiagnosis and overtreatment. Men with low-grade, slow-growing cancer, who might have lived long, comfortable lives and died from unrelated causes, faced the physical and emotional burdens of cancer diagnosis and treatment. 

Prostate biopsies pose a high risk of infection, and surgeries to remove tumors can result in erectile dysfunction, while radiotherapy and other aggressive treatments may have significant side effects. Considering that half of the prostate cancers diagnosed in the U.S. do not require aggressive treatment and are better monitored, the risk of worsening patients’ health while attempting to treat them is substantial. 

The new review, compared to the 2013 version, includes more long-term data, particularly from the ERSPC (European Randomized Study of Screening for Prostate Cancer) study, with follow-up lasting up to 23 years. It supports the idea that PSA screening has a role, provided it is conducted judiciously. “This study is timely because I think it provides sufficient evidence to support that screening could be beneficial if it is offered appropriately to those who are most likely to benefit, and it could actually save lives,” said Simpa Salami, a professor of urology at the University of Michigan. 

While PSA screening should be applied carefully, Salami noted, it is now less likely to trigger a series of interventions. “We are doing better now in selecting patients for biopsy,” Salami explained. “In the past, we would biopsy anyone with just an elevated PSA, but now we have other tools to further refine who should get a biopsy: We have biomarkers in urine, we have biomarkers in blood, we have MRI imaging to facilitate biopsies,” he said, “such that we are actually maximizing the detection of high-grade prostate cancer and minimizing the detection of low-grade prostate cancer.”

The review itself does not provide guidelines or treatment recommendations and does not immediately alter screening practices. However, as the results are analyzed, it is crucial to consider them in the context they were gathered. Otis Brawley, a professor of oncology and epidemiology at Johns Hopkins University’s Sidney Kimmel Comprehensive Cancer Center, emphasized the importance of understanding what it means that PSA testing reduces disease-specific mortality. 

“In the United States, there are a whole bunch of people who think that means, ‘Oh, if I get a PSA [test], I am doing something to save my life,'” Brawley said, but the participants in the studies who saw benefits didn’t just get their levels tested once. They consistently monitored their PSA levels and worked with their doctors over time to interpret the results and decide on further action. 

“It is not what is commonly done in the United States, which is getting your PSA drawn from a van parked at a state fair, a van in the parking lot of a church, or at a football party where it’s, ‘Come on in, see the game, and get your PSA drawn,'” Brawley said. Without consistent medical care and accurate follow-ups, PSA screening alone would not deliver its potential benefits, he noted. 

“I think the appropriate thing within the doctor-patient relationship is that a doctor ought to offer the test to the patient,” Brawley added, emphasizing the evidence of benefits while also being clear about the risks of overdiagnosis and overtreatment. Doctors who have continuous relationships with their patients and can monitor their PSA results over time are better positioned to reduce the risk of overtreatment, he explained, because they have more data points to decide which patients need biopsies and which do not.

Brawley stressed the need for clarity regarding the benefit size of screening and its ability to prevent deaths. “If you have 15 men who are going to die from prostate cancer, screening them in a program of high-quality screening over a period of 20 years will prevent 1 of the 15 men from dying,” he said. “In the U.S., every man who dies from prostate cancer is viewed as a failure of that man to get screened, or the failure of the doctors to interpret the screening,” he said, adding that people cannot grasp that the majority of individuals destined to die from prostate cancer will still succumb to it, regardless of screening.

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