For years, the question of whether men should routinely have a PSA blood test to screen for prostate cancer has been one of medicine’s most debated arguments. Now, the most comprehensive review of the evidence to date has shifted the dial – and the findings matter for every Australian man over 60.
A major updated Cochrane review, regarded internationally as the gold standard of medical evidence, has found that PSA screening does reduce the risk of dying from prostate cancer. That is a meaningful change from the previous version of the same review, which found insufficient evidence to draw that conclusion.
The review analysed data from six large trials involving almost 800,000 men across Europe and North America. The headline finding: PSA screening reduces prostate cancer deaths by approximately two for every 1,000 men screened. The mortality data comes from one major trial that followed 162,241 men for 23 years – one of the longest and largest studies of its kind ever conducted.
To put that in plain terms, around 500 men would need to be invited to screening to prevent one prostate cancer death. That is a modest benefit – but for the man whose life is saved, it is not modest at all.
“With new data now available, we can now say with moderate certainty that PSA screening reduces prostate cancer deaths in men with a sufficient life expectancy,” said senior author Dr Philipp Dahm from the University of Minnesota.
“This suggests that for the right patient – someone who is well-informed, has a good life expectancy, and understands the full implications of screening – there is now a reasonable evidence base to support a conversation about PSA screening.”
The researchers are emphatic that this is not a green light for every man to rush out and request a PSA test. The risk of overdiagnosis remains the central tension in this debate, and the new review does nothing to resolve it.
Screening detected around 30 per cent more prostate cancers overall – mostly at earlier stages. But for every one to two deaths prevented, roughly 36 additional cancers were diagnosed per thousand men screened. Many of those cancers are low-grade tumours that may never have caused symptoms or shortened the man’s life. Identifying them can trigger anxiety, unnecessary biopsies, and treatment side effects including sexual dysfunction and urinary problems that significantly affect quality of life.
“We want to be clear that this is not a blanket endorsement of universal screening,” said first author Dr Juan Franco from Heinrich Heine University Düsseldorf. “The decision should always be made between a patient and their doctor, with a full understanding of both the potential benefits and the very real risks of overdiagnosis and unnecessary treatment.”
The previous Cochrane review, published in 2013, found that PSA screening did not significantly reduce prostate cancer deaths. So what changed?
The short answer is time. The trials underpinning the earlier review had not yet followed participants long enough to detect a survival benefit. Prostate cancer is often slow-growing, and the benefit of catching it early may not show up in mortality statistics for 15 to 20 years after screening begins. Now that the data has matured, the survival signal has become visible.
The authors also note that the tools available to reduce the harms of screening have advanced significantly since 2013. MRI scanning and active surveillance – an approach that monitors low-grade cancers closely rather than treating them aggressively – have both improved considerably, meaning that a cancer detected by screening today is less likely to result in unnecessary treatment than it would have been a decade ago.
Early data also suggests that combining PSA testing with a newer kallikrein panel blood test and MRI may offer a more precise approach still, though it is too early to know whether this reduces deaths or harms more effectively than PSA testing alone.
Prostate cancer is one of the most commonly diagnosed cancers in Australian men, and the risk rises significantly with age. If you are over 60 and have not had a conversation with your GP about PSA testing, this new evidence gives you a good reason to start that conversation now.
The key word in that sentence is conversation. This is not a test to organise without medical guidance. Your GP can help you weigh up your individual risk factors – including family history, age and general health – against the potential benefits and harms of screening, and help you make an informed decision that is right for you specifically.
The evidence has shifted. The complexity has not.
IMPORTANT LEGAL INFO This article is of a general nature and FYI only, because it doesn’t take into account your personal health requirements or existing medical conditions. That means it’s not personalised health advice and shouldn’t be relied upon as if it is. Before making a health-related decision, you should work out if the info is appropriate for your situation and get professional medical advice.