Prostate Cancer Screening:

What PSA test reliance gets wrong about prostate cancer treatment | STAT

Navigating the Balance Between Early Detection and Overtreatment

BLUF (Bottom Line Up Front)

Prostate cancer screening remains one of medicine's most contentious debates. While PSA testing can detect cancer early and save lives, it also leads to substantial overdiagnosis and overtreatment of slow-growing cancers that may never cause harm. Recent research confirms that approximately 450 men must undergo repeated PSA screening to prevent one prostate cancer death, while the majority of men diagnosed with low-risk disease can safely pursue active surveillance rather than immediate treatment. International practice varies dramatically—with U.S. physicians treating about 40% of low-risk cases compared to under 10% in the U.K.—reflecting different medical cultures and financial incentives. New AI-assisted diagnostic tools and better risk stratification methods are emerging to help distinguish dangerous cancers from indolent ones, offering hope for more personalized screening approaches that minimize harm while preserving benefits.

The Screening Paradox

Prostate cancer presents a unique medical challenge: it is simultaneously the most common solid cancer diagnosed in American men and one of the most overtreated. The fundamental problem lies in biology itself—over half of men treated for prostate cancer harbor low-risk "autopsy cancers" that would never cause symptoms during their lifetime. Studies show approximately 80% of 80-year-old men have prostate cancer cells, yet most die from entirely unrelated causes.

The PSA (prostate-specific antigen) test, introduced for widespread screening in the early 1990s, created an immediate testing-induced epidemic. Within two years of implementation, prostate cancer diagnoses doubled. However, this surge in detection did not translate proportionally into lives saved. Instead, it led to a wave of unnecessary treatments, with 15-20% of surgical patients developing urinary incontinence and 50-60% experiencing significant erectile dysfunction.

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SIDEBAR: The Hidden Cost—Insurance Discrimination and Life After Diagnosis

Financial Penalty for Early Detection

One of the least discussed but most consequential impacts of PSA screening and prostate cancer diagnosis is the effect on life insurance eligibility and rates. Men who undergo PSA testing and receive a cancer diagnosis—even low-risk, indolent disease that will never require treatment—often face severe insurance discrimination that can last for years or decades.

The Life Insurance Problem:

Life insurance companies treat any cancer diagnosis as a significant underwriting risk, regardless of the actual biological threat. Men diagnosed with low-risk prostate cancer who choose active surveillance face a particularly cruel irony: they've made the medically appropriate choice to avoid unnecessary treatment, yet insurers may:

• Deny coverage entirely for 5-10 years after diagnosis
• Impose substantial rate increases (often 200-400% higher premiums)
• Add exclusion riders that eliminate cancer-related death benefits
• Require extensive medical documentation and repeated underwriting reviews
• Classify them in high-risk categories alongside men with aggressive disease

Men who already have life insurance before diagnosis are generally protected, but those seeking new coverage—whether due to life changes like marriage, children, divorce, or increased financial obligations—find themselves effectively locked out of the market at reasonable rates.

Disability Insurance Challenges:

Similar discrimination extends to disability insurance. A prostate cancer diagnosis, even if never treated, can result in:

• Policy denials or cancellations for new coverage
• Exclusions for any disability related to prostate cancer or its treatment
• Reclassification into higher-risk categories affecting premiums
• Difficulty obtaining coverage through employment if changing jobs

Real-World Impact:

For men diagnosed in their 40s or 50s—prime earning years when life insurance is most critical for protecting families—the financial impact can be devastating. A healthy 50-year-old man might pay $1,500 annually for $1 million in term life insurance. The same man with a low-risk prostate cancer diagnosis might face:

• Complete denial of coverage for 5+ years
• Premiums of $5,000-$6,000 annually when finally eligible
• Reduced coverage amounts (insurers may cap at $250,000-$500,000)
• Permanent classification as a cancer survivor in underwriting databases

This creates a perverse incentive: men aware of insurance implications may rationally choose to delay PSA testing until after securing adequate life insurance—exactly the opposite of the screening program's intent.

The Psychological Toll

Beyond the financial impact, the label of "cancer" carries profound psychological consequences that persist regardless of treatment choice:

For the Patient:

• Identity shift: Overnight transition from "healthy person" to "cancer patient"
• Existential anxiety: Constant awareness of mortality and disease
• Decision paralysis: Overwhelming pressure to make "the right choice" with incomplete information
• PSA anxiety: Every test becomes an emotional event; rising numbers trigger panic even when clinically insignificant
• SCANxiety: MRI and biopsy appointments become sources of dread weeks in advance
• Surveillance burden: Quarterly or semi-annual medical appointments serve as constant reminders of disease
• Treatment pressure: Persistent questioning from friends, family, and even some physicians about why treatment is being "delayed"
• Isolation: Many men struggle to discuss fears openly due to cultural expectations around masculinity

Studies show that approximately 20-30% of men on active surveillance experience clinically significant anxiety or depression. The psychological burden can be so severe that roughly 10% of men with low-risk disease request aggressive treatment despite being ideal surveillance candidates—seeking relief from anxiety rather than medical necessity.

For Partners and Families:

• Caregiver stress: Partners often experience anxiety levels equal to or exceeding the patient's
• Relationship strain: Discussions about treatment choices can create conflict; sexual side effects from treatment affect both partners
• Financial worry: Concerns about medical costs compound insurance discrimination impacts
• Protective instincts: Family members may pressure patients toward aggressive treatment, fearing the cancer label
• Communication challenges: Many couples struggle to discuss fears openly, leading to emotional distance
• Future planning uncertainty: Difficulty making long-term plans (retirement, travel, major purchases) with disease in the background

The Paradox of Knowledge:

Men who undergo PSA screening expecting reassurance may instead receive a diagnosis that fundamentally alters their psychological well-being and financial security—even when the discovered cancer poses minimal actual threat. As one Italian oncologic psychologist studying this phenomenon observed: "A prostatectomy doesn't cure anxiety." The psychological burden persists regardless of treatment choice.

Informed Consent Gap:

Most men undergo PSA testing without being informed of these potential consequences. A truly informed consent process for PSA screening should include discussion of:

• Probability of finding indolent cancer that doesn't require treatment
• Impact on insurance eligibility and costs
• Psychological burden of cancer diagnosis and surveillance
• Treatment side effects versus risks of monitoring
• Individual risk factors that might justify screening despite downsides

The insurance and psychological impacts add another dimension to the screening controversy: even when PSA testing successfully identifies a cancer, the downstream consequences may impose substantial harm on patients whose disease would never have threatened their health.

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The Evidence for Screening

The most comprehensive data comes from the European Randomized Study of Screening for Prostate Cancer (ERSPC), which recently published 23-year follow-up results. This landmark study demonstrates that PSA screening does modestly reduce prostate cancer mortality—but at a considerable cost. Approximately 450 men must be invited into repeated PSA testing programs to prevent one prostate cancer death. Meanwhile, the screening process leads to overdiagnosis of cancers that would never have caused problems, subjecting men to unnecessary biopsies, anxiety, and potentially harmful treatments.

The U.S. Preventive Services Task Force (USPSTF) has changed its recommendations multiple times, reflecting the complexity of the evidence. In 2012, citing concerns about overdiagnosis and overtreatment, the USPSTF recommended against PSA screening for the general population. This triggered a sharp decline in screening rates—and subsequently, an increase in metastatic disease at diagnosis. The Task Force reversed course in 2017, now recommending shared decision-making for men aged 55-69, acknowledging that screening offers a small mortality benefit for some men while creating substantial harm for others.

The Problem with PSA

PSA is what medical researchers call a sensitive but non-specific biomarker. It can detect abnormalities, but it cannot reliably distinguish between aggressive cancers requiring immediate treatment and indolent cancers that may never progress. The numbers are sobering: approximately 20% of men with prostate cancer have normal PSA levels, while only 25-30% of men biopsied for elevated PSA actually have cancer. This means 70-75% of "PSA-positive" screens are false alarms.

The test's limitations are compounded by arbitrary thresholds. U.S. guidelines generally use 4.0 ng/mL as the trigger for further investigation, though many academic centers now use 3.0 ng/mL for younger men. International standards vary considerably. The U.K.'s National Institute for Health and Care Excellence (NICE) uses an age-graded approach: 3.0 ng/mL for men aged 50-59, 4.0 ng/mL for those 60-69, and 5.0 ng/mL for men over 70. This means a PSA reading that would be unremarkable in London might trigger aggressive investigation in Chicago.

Active Surveillance: A Proven Alternative

For men diagnosed with low-risk prostate cancer (Gleason 6/Grade Group 1), active surveillance has emerged as a safe and effective alternative to immediate treatment. The landmark ProtecT trial in the United Kingdom, which randomized men between active surveillance, surgery, and radiation therapy, showed no significant mortality differences at 15-year follow-up. While untreated men had a slightly higher risk of metastases (6.3% versus 2.4% for surgery), the absolute risk remained low, and overall survival was equivalent across all three groups.

This evidence has transformed practice at major academic medical centers, where active surveillance rates now exceed 80-90% for appropriate candidates. However, community practice lags significantly behind, with surveillance rates remaining stubbornly below 50%. This gap reflects not just medical culture but also financial incentives. A 2019 Mayo Clinic study found that six years after diagnosis, mean costs per patient were $12,143 for active surveillance, $17,781 for radical prostatectomy, and $29,238 for external beam radiotherapy.

The International Divide

The United States treats approximately 40% of low-risk prostate cancers, while the United Kingdom treats fewer than 10%—same disease, radically different medical cultures. European systems tend to view PSA as one data point among many in a broader clinical picture, while American medicine often treats it as a decision point triggering intervention.

This difference extends beyond treatment rates to fundamental questions about what constitutes cancer. Many international experts argue that Gleason 6/Grade Group 1 lesions should not be labeled as "cancer" at all, since they lack the capacity for metastasis. The label itself creates psychological burden and may drive unnecessary treatment. Some advocacy groups have proposed renaming these findings as "indolent lesions of epithelial origin" (IDLE) to reduce patient anxiety and treatment pressure.

The Psychological Cost

Living with untreated cancer carries its own burden. Patients describe "PSA anxiety" and "SCANxiety"—the emotional distress associated with regular monitoring. MRIs, biopsies, and urology visits become sources of ongoing stress. Research presented at the American Society of Clinical Oncology found that approximately 10% of U.S. men with low-risk prostate cancer request aggressive treatment despite being ideal candidates for surveillance, driven primarily by anxiety rather than medical need.

An Italian oncologic psychologist studying this phenomenon warns that "a prostatectomy doesn't cure anxiety." The psychological burden persists regardless of treatment choice, suggesting the need for better psychological support and counseling throughout the screening and surveillance process.

Emerging Solutions

New technologies and approaches offer hope for more precise screening and risk stratification:

Multiparametric MRI (mpMRI): Pre-biopsy MRI can identify suspicious lesions and guide targeted biopsies, reducing unnecessary biopsies and improving detection of clinically significant cancers while avoiding overdiagnosis of indolent disease.

Biomarker panels: Tests like the Prostate Health Index (phi), 4Kscore, and genomic classifiers (Oncotype DX, Decipher, Prolaris) provide additional information beyond PSA to better predict cancer aggressiveness and guide treatment decisions.

Artificial intelligence: AI-based platforms like Artera AI are helping predict which men will fare best on active surveillance, potentially reducing overtreatment while maintaining safety. These tools analyze multiple data points to create individualized risk assessments.

Risk-stratified screening: Rather than universal screening or no screening, experts increasingly advocate for targeted approaches based on age, family history, ethnicity (African American men face twice the mortality risk), genetic factors (BRCA mutations), and comorbidities.

The Path Forward

Prostate cancer screening requires nuanced, individualized decision-making. Men considering screening should understand:

1. The test's limitations: PSA is excellent for monitoring known disease but imperfect as a screening tool, with high false-positive rates.

2. The overdiagnosis problem: Most detected cancers are slow-growing and may never cause harm. The challenge is distinguishing these from the minority of aggressive cancers that require immediate treatment.

3. Active surveillance is safe: For appropriate candidates, monitoring rather than immediate treatment produces equivalent survival with fewer side effects.

4. Stability matters: Long-term PSA stability and tumor indolence indicate low-risk disease unlikely to progress.

5. Shared decision-making is essential: Men should discuss individual risk factors, values, and preferences with their physicians before deciding whether to screen and how to respond to results.

6. Consider insurance implications: Men should secure adequate life insurance before undergoing PSA screening if possible, as a cancer diagnosis—even low-risk disease—can severely impact insurance eligibility and costs.

The global projection that new prostate cancer cases will double by 2040, with deaths increasing 85%, underscores the ongoing need for better screening approaches. The goal is not to abandon screening entirely but to screen smarter—identifying the men who will truly benefit while sparing others from unnecessary diagnosis and treatment.

As research continues and technology improves, the hope is for precision medicine approaches that can reliably distinguish tigers from pussycats—aggressive cancers requiring immediate intervention from indolent ones that can safely be monitored. Until then, knowledge and careful deliberation remain the best tools for navigating this complex landscape.

Verified Sources and Citations

1. Hugosson, J., et al. (2024). "A 23-yr Follow-up of the European Randomized Study of Screening for Prostate Cancer." European Urology, published online ahead of print. https://www.europeanurology.com/

2. Hamdy, F.C., et al. (2023). "Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer." New England Journal of Medicine, 388(17), 1547-1558. https://www.nejm.org/doi/full/10.1056/NEJMoa2214122

3. U.S. Preventive Services Task Force. (2018). "Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement." JAMA, 319(18), 1901-1913. https://jamanetwork.com/journals/jama/fullarticle/2680553

4. Loeb, S., et al. (2019). "Overdiagnosis and overtreatment of prostate cancer." European Urology, 65(6), 1046-1055. https://www.europeanurology.com/

5. National Institute for Health and Care Excellence (NICE). (2019). "Prostate cancer: diagnosis and management." NICE guideline [NG131]. https://www.nice.org.uk/guidance/ng131

6. Cooperberg, M.R., et al. (2020). "Time Trends and Variation in the Use of Active Surveillance for Management of Low-Risk Prostate Cancer in the US." JAMA Network Open, 3(11), e2023718. https://jamanetwork.com/journals/jamanetworkopen/

7. Mahal, B.A., et al. (2019). "Use and Determinants of Prostate-specific Antigen Screening in a National Sample." JAMA Network Open, 2(10), e1913373. https://jamanetwork.com/journals/jamanetworkopen/

8. Patel, H.D., et al. (2019). "Cost Comparison of Prostate Cancer Management Strategies for Low-Risk Disease." JAMA Oncology, 5(10), 1479-1481. https://jamanetwork.com/journals/jamaoncology/

9. Wolinsky, H. (2025). "Did my prostate cancer screening do more harm than good?" STAT News, January 21, 2025. https://www.statnews.com/

10. Artera AI. (2024). "Prostate Cancer Risk Assessment Platform." Company documentation. https://www.artera.ai/

11. American Cancer Society. (2024). "Key Statistics for Prostate Cancer." https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html

12. Carlsson, S., and Vickers, A. (2020). "Seventeen Years After Publication of the Randomized Trials for Prostate Cancer Screening, What Have We Learned?" European Urology, 77(3), 286-292. https://www.europeanurology.com/

13. Venderbos, L.D., et al. (2015). "A longitudinal study on the impact of active surveillance for prostate cancer on anxiety and distress levels." Psycho-Oncology, 24(3), 348-354. https://onlinelibrary.wiley.com/journal/10991611

14. Bellardita, L., et al. (2013). "How does active surveillance for prostate cancer affect quality of life? A systematic review." European Urology, 64(1), 34-45. https://www.europeanurology.com/

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Note: This article is intended for educational purposes as part of the IPCSG Newsletter. Individual medical decisions should be made in consultation with qualified healthcare providers who can assess personal risk factors and preferences.