The silent epidemic: the pros and cons of screening for prostate cancer | Well actually | The Guardian
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Breaking the Silent Epidemic: New Developments in Prostate Cancer Screening and Detection
A Comprehensive Update for the Informed Prostate Cancer Patient Support Group
Executive Summary
Recent high-profile diagnoses, evolving screening guidelines, and groundbreaking research trials are reshaping the landscape of prostate cancer detection and early intervention. As one survivor's story illustrates the life-saving potential of timely screening, new evidence from major European trials and updated professional guidelines are refining our understanding of optimal screening strategies.
The Wake-Up Call: A Personal Story and National Reminder
The ongoing debate over prostate cancer screening gained renewed urgency following former President Joe Biden's May 2025 diagnosis with aggressive, metastatic prostate cancer (Gleason score 9). Biden's case—discovered after urinary symptoms led to the finding of a prostate nodule—represents the approximately 8% of prostate cancer cases diagnosed after the disease has already metastasized to other organs.
This diagnosis serves as a stark reminder of what Ed Manning, a 67-year-old technology executive and jazz pianist, describes as prostate cancer being "the Silent Epidemic". Manning's own near-miss with late-stage disease—his PSA of 17 led to timely detection just months before the cancer would have spread beyond the prostate—underscores the critical importance of screening discussions between patients and physicians.
Current Screening Guidelines: A Complex Landscape
The prostate cancer screening landscape remains nuanced, with different organizations offering varying recommendations:
U.S. Preventive Services Task Force (USPSTF)
For men aged 55-69 years, the USPSTF recommends individual decision-making about PSA screening after discussing benefits and harms with healthcare providers. Men 70 and older should not be routinely screened. The task force estimates that PSA-based screening may prevent approximately 1.3 prostate cancer deaths per 1,000 men screened over 13 years.
American Cancer Society (ACS)
The ACS recommends screening discussions begin at age 50 for average-risk men, age 45 for high-risk men (including African Americans and those with first-degree relatives diagnosed before age 65), and age 40 for men with multiple affected first-degree relatives.
American Urological Association (AUA)
The 2023 AUA guidelines recommend that clinicians may begin screening between ages 45-50 for average-risk individuals, with earlier screening (ages 40-45) for high-risk populations including Black men, those with germline mutations, and those with strong family histories.
Breakthrough Research: The PROBASE Trial Findings
The German PROBASE trial, involving over 46,000 men, is providing unprecedented insights into optimal screening strategies for younger men:
Key Findings from PROBASE
Men with baseline PSA levels below 1.5 ng/mL at age 45 have very low prostate cancer risk over the next five years, with only 0.45% developing PSA levels ≥3 ng/mL upon retesting after five years. Among 45-year-old men screened, the overall prostate cancer prevalence was only 0.2%, with just four cases of aggressive cancer (Grade Group ≥3).
Revolutionary Screening Interval Recommendations
European researchers suggest that men with PSA levels under 1.5 ng/mL could safely extend screening intervals to five years, potentially affecting millions of men across Europe. This finding challenges current guidelines and could significantly reduce healthcare costs while maintaining safety.
MRI Integration in Young Men
PROBASE research shows that multiparametric MRI in 45-year-old men with elevated PSA can help avoid detection of low-risk cancers in up to 71% of cases and prevent unnecessary biopsies in up to 68% of cases, though MRI interpretation is more challenging in younger men.
The Screening Controversy: Benefits vs. Harms
Documented Benefits
Studies comparing screened and unscreened populations show a 50% cancer-specific mortality decrease when PSA testing is widely used. Memorial Sloan Kettering researchers note that PSA screenings have reduced deaths significantly more than the commonly cited 1 in 1,000 figure, with some studies suggesting closer to 10 in 1,000 men benefit.
Known Risks and Limitations
Potential harms include false positives (occurring in over 15% of men over 10 years), unnecessary biopsies (with 1% requiring hospitalization for complications), and overtreatment leading to incontinence (affecting 1 in 5 men post-surgery) and erectile dysfunction (affecting 2 in 3 men post-surgery).
Current estimates suggest 20-40% of screen-detected prostate cancers may never have caused harm, with overdiagnosis rates varying by age, PSA levels, and cancer grade.
The Screening Decline and Its Consequences
Since the 2012 USPSTF recommendation against routine screening, there has been a concerning 5% annual increase in men diagnosed with advanced prostate cancer. Dr. Samuel Washington from UCSF reports that in 2023, only about 38% of men between 50 and 64 were screened for the disease.
Emerging Technologies and Improvements
Advanced Testing Options
New tests like the 4Kscore (developed at Memorial Sloan Kettering) and MRI scans are helping determine when biopsies are truly necessary, reducing unnecessary procedures while maintaining detection accuracy.
Treatment Advances
Dr. Clifford Gluck notes that advances including high-intensity focused ultrasound (HIFU) and improved surgical techniques make screening "a far more favorable proposition" by reducing treatment-related side effects.
Special Populations and Risk Factors
High-Risk Groups
African American men face 70% higher risk than other races and should begin screening discussions at age 45. Men with BRCA1/BRCA2 mutations, family history, or other genetic predispositions may benefit from even earlier screening.
Older Adults
Medical professionals generally don't screen men in their late 70s or 80s, as they're more likely to die of other conditions. However, Biden's case illustrates that aggressive cancers can still develop in this population.
The Biden Effect: Renewed Focus on Screening
Biden's diagnosis has sparked renewed discussion about screening practices. The American Cancer Society notes this case serves as "a reminder about the tragic impact of prostate cancer in the US, where about one in eight men will be diagnosed over their lifetime".
Medical experts emphasize that Biden's advanced diagnosis would be considered unusual for someone screened regularly, potentially indicating the cancer had been present for years.
Medicare Coverage and Access
Medicare Part B covers annual digital rectal exams and PSA blood tests for men over 50, with patients paying 20% of Medicare-approved amounts for DRE and nothing for PSA tests.
Expert Recommendations and Future Directions
Current Best Practices
Leading medical organizations recommend PSA testing only after comprehensive discussion of risks and benefits. A baseline PSA for all men aged 40-45 is suggested, with annual testing reasonable for higher-risk men starting at 45.
Shared Decision-Making
Most countries have adopted policies requiring PSA testing decisions be made through "shared decision-making" between patients and providers, though experts acknowledge this process can be challenging given time constraints in primary care.
Looking Forward: The Future of Screening
As the PROBASE trial continues through 2034, and with new technologies like PSMA PET scans and genetic risk scoring becoming more available, the landscape of prostate cancer screening continues to evolve. The key message remains clear: informed discussion between patients and healthcare providers, taking into account individual risk factors, remains the cornerstone of effective prostate cancer screening strategy.
For prostate cancer survivors and those at risk, these developments offer both hope for more precise screening methods and a sobering reminder of the importance of staying engaged with evolving screening recommendations.
Sources and Citations
- Manning, E. (2025). "The silent epidemic: the pros and cons of screening for prostate cancer." The Guardian. Available at: theguardian.com
- Centers for Disease Control and Prevention. (2025, February 11). "Should I Get Screened for Prostate Cancer?" https://www.cdc.gov/prostate-cancer/screening/get-screened.html
- European Association of Urology. (2024, April 6). "Five-year interval is safe for prostate cancer screening, research shows." ecancer. https://ecancer.org/en/news/24526-eau-2024-five-year-interval-is-safe-for-prostate-cancer-screening-research-shows
- Centers for Disease Control and Prevention. (2025, August 4). "Screening for Prostate Cancer." https://www.cdc.gov/prostate-cancer/screening/index.html
- U.S. Preventive Services Task Force. (2018, May 8). "Prostate Cancer: Screening Recommendation." https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
- Medicare.gov. "Prostate cancer screenings." https://www.medicare.gov/coverage/prostate-cancer-screenings
- NPR. (2025, May 21). "PSA tests to screen for prostate cancer. What age makes sense to get one?" https://www.npr.org/sections/shots-health-news/2025/05/21/nx-s1-5405613/prostate-cancer-psa-test-age
- David, M. K., & Leslie, S. W. (2024, September 10). "Prostate-Specific Antigen." StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557495/
- National Cancer Institute. "Prostate-Specific Antigen (PSA) Test." https://www.cancer.gov/types/prostate/psa-fact-sheet
- Memorial Sloan Kettering Cancer Center. (2024, December 6). "Myths About PSA Tests and Prostate Cancer Screening." https://www.mskcc.org/news/myths-about-psa-tests-and-prostate-cancer-screening
- Jain, M. A., Leslie, S. W., & Sapra, A. (2023, October 26). "Prostate Cancer Screening." StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK556081/
- De Vrieze, M., Al-Monajjed, R., Boschheidgen, M., & Albers, P. (2024). "Prostate Cancer Screening in Young Men." Journal of Personalized Medicine, 14(8), 818. https://pmc.ncbi.nlm.nih.gov/articles/PMC11355119/
- Boschheidgen, M., Albers, P., et al. (2024). "Multiparametric Magnetic Resonance Imaging in Prostate Cancer Screening at the Age of 45 Years: Results from the First Screening Round of the PROBASE Trial." European Urology, 85(2), 105-111. https://www.europeanurology.com/article/S0302-2838(23)03158-5/fulltext
- Boschheidgen, M., Albers, P., et al. (2023, October 18). "Multiparametric Magnetic Resonance Imaging in Prostate Cancer Screening at the Age of 45 Years: Results from the First Screening Round of the PROBASE Trial." PubMed. https://pubmed.ncbi.nlm.nih.gov/37863727/
- UroToday. (2024). "EAU 2024: Risk Adapted Screening for Prostate Cancer in Europe: PSA Only - the PROBASE German Screening Trial in Young Men." https://www.urotoday.com/conference-highlights/eau-2024/eau-2024-prostate-cancer/150980-eau-2024-risk-adapted-screening-for-prostate-cancer-in-europe-psa-only-the-probase-german-screening-trial-in-young-men.html
- Krilaviciute, A., et al. (2022, June 1). "A randomized trial of risk-adapted screening for prostate cancer in young men-Results of the first screening round of the PROBASE trial." PubMed. https://pubmed.ncbi.nlm.nih.gov/35076933/
- UroToday. (2024). "EAU 2024: Challenging EAU Guidelines on Prostate Cancer Risk Definition in the Screening Setting: Insights from the PROBASE Trial." https://www.urotoday.com/conference-highlights/eau-2024/eau-2024-prostate-cancer/150991-eau-2024-challenging-eau-guidelines-on-prostate-cancer-risk-definition-in-the-screening-setting-insights-from-the-probase-trial.html
- Krilaviciute, A., et al. (2024). "Risk-adjusted Screening for Prostate Cancer-Defining the Low-risk Group by Data from the PROBASE Trial." European Urology, 86(6), 493-500. https://pubmed.ncbi.nlm.nih.gov/38749854/
- Krilaviciute, A., et al. (2023, March 1). "Adherence to a risk-adapted screening strategy for prostate cancer: First results of the PROBASE trial." PubMed. https://pubmed.ncbi.nlm.nih.gov/36121664/
- Moore, C. M. (2023, November 13). "When Is It Too Early To Start Prostate Cancer Screening? Reflections on the PROBASE Study Using Magnetic Resonance Imaging for Men Aged 45 Yr with Elevated Prostate-specific Antigen." PubMed. https://pubmed.ncbi.nlm.nih.gov/37968189/
- American Urological Association. (2023). "Early Detection of Prostate Cancer: AUA/SUO Guideline." https://www.auanet.org/guidelines-and-quality/guidelines/early-detection-of-prostate-cancer-guidelines
- Medical University of South Carolina. (2025). "Hollings Cancer Center urologist on what Biden's cancer diagnosis means." https://web.musc.edu/about/news-center/2025/05/20/hollings-cancer-center-urologist-on-what-bidens-cancer-diagnosis-means
- VCU Health. (2025, May 21). "How common is prostate cancer for men President Biden's age?" https://www.vcuhealth.org/news/how-common-is-prostate-cancer-for-men-president-bidens-age/
- NPR. (2025, May 19). "Biden has prostate cancer. How treatable is it?" https://www.npr.org/2025/05/19/nx-s1-5403446/biden-metastatic-prostate-cancer-diagnosis-survival-rate
- PBS NewsHour. (2025, May 19). "What to know about Biden's prostate cancer diagnosis." https://www.pbs.org/newshour/health/what-to-know-about-bidens-prostate-cancer-diagnosis
- CBS News. (2025, May 19). "Biden diagnosed with 'aggressive form' of prostate cancer, his office says." https://www.cbsnews.com/news/joe-biden-diagnosed-prostate-cancer/
- NBC News. (2025, May 21). "Biden's prostate cancer may have gone undiagnosed for years based on severity, doctors say." https://www.nbcnews.com/health/health-news/bidens-prostate-cancer-diagnosis-unusual-not-unheard-doctors-say-rcna207640
- NBC News. (2025, May 19). "Former President Joe Biden diagnosed with aggressive form of prostate cancer." https://www.nbcnews.com/politics/joe-biden/former-president-joe-biden-diagnosed-prostate-cancer-rcna207571
- STAT News. (2025, May 21). "I've reported on presidents' health for 53 years. No public evidence suggests Biden's doctors mishandled prostate cancer testing." https://www.statnews.com/2025/05/19/biden-cancer-analysis-by-lawrence-altman-physician-reporter-presidential-health-expert/
- University of Colorado Cancer Center. (2025, May 22). "What Joe Biden's Prostate Cancer Reveals About Diagnosis, Treatment." https://news.cuanschutz.edu/cancer-center/joe-biden-prostate-cancer
- American Cancer Society. (2025, May 18). "Former President Biden Diagnosed with Aggressive Prostate Cancer." https://pressroom.cancer.org/Joe-Biden-Prostate-Cancer-Statement
- American Cancer Society. "American Cancer Society Recommendations for Prostate Cancer Early Detection." https://www.cancer.org/cancer/types/prostate-cancer/detection-diagnosis-staging/acs-recommendations.html
- American Cancer Society. "Prostate Cancer Screening Guidelines." https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/prostate-cancer-screening-guidelines.html
- NewYork-Presbyterian. "New prostate cancer screening guidelines released." https://www.nyp.org/patients-and-visitors/advances-consumers/issues/new-prostate-cancer-screening-guidelines-released
- U.S. Preventive Services Task Force. (2018, May 8). "Prostate Cancer: Screening Recommendation." https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
- Medscape. "Prostate Cancer Guidelines: Prostate Cancer Screening, Prostate Biopsy, Risk Stratification, and Staging, Genetic Testing." https://emedicine.medscape.com/article/2259453-overview
- Cancer Treatment Centers of America. (2024, March 8). "Prostate Cancer Screening and Guidelines." https://www.cancercenter.com/cancer-types/prostate-cancer/diagnosis-and-detection/screening-guidelines
- American Cancer Society. "Cancer Screening Guidelines | Detecting Cancer Early." https://www.cancer.org/cancer/screening/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html
- American Urological Association. (2023). "Early Detection of Prostate Cancer: AUA/SUO Guideline." https://www.auanet.org/guidelines-and-quality/guidelines/early-detection-of-prostate-cancer-guidelines
- FORCE (Facing Our Risk of Cancer Empowered). "Are you at high risk? Guidelines for prostate cancer screening." https://www.facingourrisk.org/info/risk-management-and-treatment/screening-and-risk-reduction/by-cancer-type/prostate/screening
- American Cancer Society. "5 Years After Routine PSA Testing Stopped Being Recommended." https://www.cancer.org/research/acs-research-highlights/prostate-cancer-research-highlights/screening---early-detection-prostate-cancer-studies/five-years-after-guidelines-recommend-against-prostate-cancer-screening.html
- The silent epidemic: the pros and cons of screening for prostate cancer | Well actually | The Guardian
This article was compiled for the Informed Prostate Cancer Patient Support Group (IPCSG) newsletter. For questions about this content, please contact your healthcare provider or the IPCSG leadership team.
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